Human Ageing, Health, Health Utilization and Policy Implications: An introduction to Behaviour and Practices

Paul Andrew Bourne

Human Ageing, Health, Health Utilization and Policy Implications: An introduction to Behaviour and Practices

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Human Ageing, Health, Health Utilization and Policy Implications: An introduction to Behaviour and Practices

Paul Andrew Bourne Director Socio-Medical Research Institute

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©Paul A. Bourne, 2011 First Published in Jamaica, 2011 by Paul Andrew Bourne 66 Long Wall Drive Stony Hill, Kingston 9, St. Andrew National Library of Jamaica Cataloguing Data Human Ageing, Health, Health Utilization and Policy Implications: An introduction to Behaviour and Practices

Includes index ISBN Bourne, Paul Andrew All rights reserved. Published , 2011 Cover designed by Paul Andrew Bourne

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List of Acronyms and Initials
AARP AIDS BMI CI DALE DHEA DNA ED et al GDP HSB JADEP JSLC kg LFS LFS LSMS m MOH NHF OR American Association of Retired Persons Acquired immunodeficiency syndrome Body Mass Index Confidence Interval Disability Adjusted Life Expectancy Dehydroepiandrosterone Deoxyribonucleic acid Enumeration District Others Gross Domestic Product Health Seeking Behaviour Jamaica Drug for the Elderly Programme Jamaica Survey of Living Conditions Kilogram Labour Force Survey Labour Force Survey World Bank’s Living Standards Measurement Study meter Ministry of Health National Health Fund Odds Ratio
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P PAHO PIOJ PSU QoL QoL RGD SD SES SPSS STATIN US UN UNDP UWI WHO

Probability Pan American Health Organization Planning Institute of Jamaica () Primary Sampling Unit Quality of Life Quality of Life Registrar General Department Standard deviation Socioeconomic status Statistical Packages for the Social Sciences Statistical Institute of Jamaica United States United Nations United Nations Development Programme The University of the West Indies World Health Organization

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Table of Contents page List of Acronyms and Initials List of Figures List of Tables Preface Acknowledgement Dedication Part I: Human Ageing Introduction 1 2 Historical Overview On Human Ageing Population Ageing and the State of the Elderly in Jamaica 47 iv ix xii xx xxv xxvi 1

Part II: Health: An introduction Introduction 3 4 Health measurement A conceptual framework of wellbeing in some Western nations

Part III: Health status: Using health data 5 6 7 Paradoxities in self-evaluated health data in a developing country

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Variations in health, illness and health care-seeking behaviour of those in the upper social hierarchies in a Caribbean society Self-reported health and medical care-seeking behaviour of uninsured Jamaicans
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8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23

Social determinants of self-reported health across the Life Course Social Determinants of Health in a developing Caribbean nation: Are there differences based on municipalities and other demographic characteristics? Health Inequality in Jamaica, 1988-2007 Hospital Healthcare Utilisation in middle-income developing country Inflation, Public Health Care and Utilization in Jamaica Self-evaluated health and health conditions of rural residents in a developing country Self-reported health and health care utilization of older people An Epidemiological Transition of Health Conditions, and Health Status of the Old-Old-To-Oldest-Old in Jamaica: A comparative analysis Happiness, life satisfaction and health status in Jamaica Dichotomising poor self-reported health status: Using secondary crosssectional survey data for Jamaica Retesting and refining theories on the association between illness, chronic illness and poverty: Are there other disparities? Modeling social determinants of self-rated health status of Hypertensive in a middle-income developing nation Comparative Analysis of Health Status of men 60+ years and men 73+ years in Jamaica: Are there differences across municipalities? Medical Sociology: Modelling Wellbeing for Elderly People in Jamaica Health Determinants: Using Secondary Data to Model Predictors of Wellbeing of Jamaicans The changing faces of diabetes, hypertension and arthritis in a Caribbean population
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24

Health status of patients with self-reported chronic diseases in Jamaica 658

Part IV: Psychology of Ageing 25 Ageing and the Mind

Part V: Mortality 26 27

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Impact of poverty, not seeking medical care, unemployment, inflation, selfreported illness, and health insurance on mortality in Jamaica Decomposing Mortality Rates and Examining Health Status of the Elderly in Jamaica 755

Part VI: Policy Framework 28 29

Agenda setting, Development of legislation, Implementation and Policy Modification Major Health Determinants: Are they ignored in the way in which Caribbean Health Services are organized? 780

Part V: Health Insurance Coverage 30

Determinants of self-rated private health insurance coverage in Jamaica 805

Part VI: Poverty, Wealthy and Health 31

Health Disparities and the Social Context of Health Disparity between the Poorest and Wealthiest quintiles in a Developing Country

Part VII: Old-to-Oldest Elderly 32 Good Health Status of Old-to-Oldest elderly People in Jamaica: Are there difference in rural-urban area?

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Glossary
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List of Figures
Figure 1.1: Selected regions and their percent of pop. 65+ years Figure 2.1: Ranked Order of the five leading causes of mortality in the population 65 yrs and older, 1990 Figure 2.2: Leading causes of self-reported morbidity in the population of seniors, by gender in Barbados and Jamaica. Figure 2.3.: Percentage distribution of 5 main causes of deaths by age: 2002-2004 Figure 3.1: The relation between health policy and health, and the roles of health determinants Figure 10.1: Percentage of Men Seeking Medical Care by Percentage of Men reporting Illness Figure 10.2: Percentage of People Seeking Medical Care by Prevalence of Poverty Figure 10.3: Percentage of Men Seeking Medical Care by Percentage of Men reporting Illness Figure 10.4: Percentage of Women Seeking Medical Care by Percentage of Women reporting Illness Figure 10.5: Percentage of people Seeking Medical Care by Percentage with Health Insurance Figure 10.6: Ownership of Health Insurance and Prevalence of Poverty Figure 11.1: Public-Private Health Care Utilisation in Jamaica (in %), 1996-2002, 2004-2007 Source: Taken from Jamaica Survey of Living Conditions, various issues Figure 11.2: Remittances By Income Quintiles and Jamaica (in Percent): 2001-2007 Source: Extracted from the Jamaica Survey of Living Conditions, 2007 Figure 12.1: Inflation By Public Health Care Utilization Figure 12.2: Inflation by Private Utilization Care Figure 12.3: Cost of Medical care for Public and private health Care Figure 12.4: Public and private health Care Utilization Figure 12.5: Visits to Public Health Care Facilities and the Number of Reported Illness/Injury Figure 12.6: Health Insurance Coverage and Inflation Figure 12.7: Incidence of Poverty and Inflation, 1988-2007 ix

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34 36 55 254 255 256

257

258 259

283

284 299 300 301 302 303 304 305

Figure 12.8: Public Health Care Utilization and Incidence of Poverty Figure 12.9: Private Health Care Utilization and Incidence of poverty Figure 12.10: Illness/Injury and Inflation Figure 12.11: Cost of Public and private health Care Cost and Inflation Figure 12.12: Seeking Medical Care By Inflation Figure 12.13: Seeking Medical Care and Incidence of Poverty Figure 12.14: Seeking Medical Care and Health Insurance Figure 14.1. Caribbean Elderly population as a percentage of total population Figure 14.2. Jamaica Elderly population as a percentage of total population Figure 14.3. Percentage of population 80+ years with health insurance coverage, 2002 and 2007 Figure 15.1. Diagnosed health conditions, 2002 and 2007 Figure 15.2. Self-reported illness (in %) by Income Quintile, 2002 and 2007 Figure 16.1: Percentage change in elderly population by five year age groups, 1991-2001 Figure 19.1. Health seeking behaviour (in %) by marital status and sex Figure 26.1. Not seeking medical care (in %) by Year Figure 26.2. Annual Mortality (No. of people) in Years Figure 26.3. Not Seeking Medical Care (in %) by Prevalence of poverty rate (in %) Figure 26.4. Not Seeking Medical Care (in %) by Unemployment rate (in %) Figure 26.5. Not Seeking Medical Care (in %) by Illness/Injury (in %) Figure 26.6. Mortality (No of people) by Not Seeking Medical Care (in %) Figure 26.7 Prevalence of poverty rate (in %) and Unemployment rate (in %) Figure 26.8. Not Seeking Medical Care (in %) by Health Insurance Coverage (in %) Figure 26.9. Mortality (No. of people) by Prevalence of Poverty (in %) Figure 26.10. Mortality (No. of people) by Unemployment rate (in %) x

306 307 308 309 310 311 312 367 367 375 429 430 432 533 714 715 716 717 718 719 720 721 722 723

Figure 26.11. Prevalence of poverty rate (in %) by Inflation rate (in %) Figure 26.12. Not Seeking Medical care (in %) by Inflation rate (in %)

724 725

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List of Tables
Table 2.1: Observed & Forecasted Percentage of Elderly 65 years or over in Selected Regions, and the World Countries: 1950, 1975, 2025 and 2050. Table 2.2: Observed & Forecasted Percentage of Elderly 60 years or over in Selected Regions, and the World Countries: 1950, 1975, 2025 and 2050. Table 2.3: Characteristics of the Three Categories of Elderly, and Ageing transition 15 18 14

Table 2.4: Percentage of Estimated or Projected Populations of Selected Caribbean Nations, 1980, 2000, 2005 and 2020 24 Table 2.5: Total Fertility Rate for Selected Caribbean Nations, Caribbean, and Latin American: 1950-1955 to 2045-2050 Table 2.6: Life Expectancy at Birth of both Sexes for Selected Caribbean Nations, the Caribbean, and Latin American Table 2.7: Life Expectancy at Birth of Jamaicans by Sex, 1880-2004 Table 2.8: Jamaica: Selected demographic variables, Labour Force Participation (in %). Table 5.1 Socio-demographic characteristic of sample by sex of respondents Table 5.2 Socio-demographic characteristic of sample by educational level Table 5.3 Socio-demographic characteristic of sample by self-reported illness 27 28 30 118 119 120 26

Table 5.4 Stepwise Logistic Regression: Good self-rated health status by sociodemographic, economic and biological variables 121 Table 5.5 Table 5.5. Stepwise Logistic Regression: Self-reported illness by sociodemographic and biological variables Table 6.1. Demographic characteristics of sample Table 6.2. Particular variables by social hierarchy Table 6.3. Logistic regression: Moderate-to-very good health status by particular variables Table 6.4. Logistic regression: Self-reported illness by particular variables 122 143 144 145 146

Table 6.5. Logistic regression: Self-reported health seeking behaviour by particular variable 147
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Table 7.1: Socio-demographic characteristics of sample Table 7.2: Sociodemographic characteristic by Sex Table 7.3. Health status by Self-reported dysfunction Table 7.4. Ordinary Logistic Regression: Correlates of Good Health Status of Uninsured Jamaicans

167 168 169 170

Table 7.5. Ordinary Logistic Regression: Correlates of Medical Care-Seeking Behaviour of Uninsured Jamaicans 171 Table 8.1: Good Health Status of Jamaicans by Some Explanatory Variables Table 8.2: Good Health Status of Elderly Jamaicans by Some Explanatory Variables Table 8.3: Good Health Status of Middle Age Jamaicans by Some Explanatory Variables Table 8.4: Good Health Status of Young Adults Jamaicans by Some Explanatory Variables Table 9.1: Demographic characteristic of sample Table 9.2: Self-rated health status By Sex Table 9.3: Diagnosed Self-reported illness By Sex Table 9.4: Typology of Self-reported Diagnosed Illness By Sex Table 9.5: Diagnosed Self-reported illness By Age group Table 9.6: Self-rated Health Status by Age group Table 9.7: Predictors of Self-rated Health Status of Jamaicans Table 9.8: Predictors of Self-rated Health status of men in Jamaica Table 9.9: Predictors of Self-rated Health status of women in Jamaica Table 9.10: Predictors of Self-rated Health Status of Jamaicans in Urban Areas Table 9.11: Predictors of Self-rated Health Status of Jamaicans in Other towns Table 9.12: Predictors of Self-rated Health Status of Jamaicans in Rural Areas Table 10.1: Life Expectancy at Birth of Jamaicans by Sex: 1880-2004 Table 10.2: Inflation, Public-Private Health Care Service Utilization, Incidence of Poverty, Illness and Prevalence of Population with Health Insurance (in per cent), 1988-2007
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189 190 191 192 216 217 218 219 220 221 222 223 224 225 226 227 249

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Table 10.3: Seeking Medical Care, Self-reported illness, and Gender composition of those who report illness and Seek Medical Care in Jamaica (in percentage), 1988-2007

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Table 10.4: Public Health Care Visits (using the JSLC, data) and Actual Health Care Visits (using Ministry of Health Jamaica, data), 1997 and 2004 252 Table 10.5: Self-reported Health Status per 1,000 by Population, Men and Women; Sex-Ratio of Self-reported Health Status, and Female to Male Ratio of Self-reported Health Status, 1989-2006 Table 11.1 Discharge, Average Length of Stay, Bed Occupancy and Visits to Public Hospital Health Care Facilities, 1996-2004 Table 11.2 Inflation, Public-Private Health Care Service Utilisation, Incidence of Poverty, Illness and Prevalence of Population with Health Insurance (in per cent), 1988-2007 Table 11.3 Hospital Health Care Utilisation (Using Jamaica Survey of Living Conditions Data) By Income Quintile (%): 1991-2007 Table 11.4 Demographic Characteristic of Sampled Population, n=1,936 Table 11.5 Public Hospital Health Care Facility Utilisation by Area of Residence (in percentage), n =1,936 Table 11.6 Public Hospital Health Care Facility Utilisation By Per Capita Population Income Quintile (in per cent), N=1,936 Table 11.7.1 Descriptive Statistics of Negative Affective Psychological Conditions and Per capita Income Quintile Table 11.7.2 Multiple Comparison of Negative Affective Psychological Condition by Per Capita Income Quintile Table 11.8.1 Descriptive Statistics of Total Positive Affective Psychological Conditions and Per Capita Income Quintile Table 11.8.2 Multiple Comparisons of Positive Affective Conditions by Per Capita Income Quintile

253

285

286

287 288

289

290

291

291

292

292

Table 11.10 Logistic Regression: Predictors of Public Hospital Health Care facility utilisation in Jamaica 293

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Table 11.11 Public Hospital Facility Visits (using the JSLC and Ministry of Health Jamaica) By 1997 and 2004 294 Table 12.1: Inflation, Public and private health Care Service Utilization, Incidence of Poverty, Illness and Prevalence of Population with Health Insurance (in per cent), 1988-2007 Table 12.2:Annual Inflation in Food and Non-Alcoholic beverages and Health Care Cost, 2003-2007 Table 12.3: Percentage of Households Receiving Remittances By Region, 2001-2005 Table 12.4: Percentage of Households Receiving Remittances By Quintile, 2001-2005 Table 12.5: Mean Patient Expenditure ($) on Health Care in Public and Private Facilities in the Four-Week Reference Period, JSLC 1993-2004, 2006 Table 12.6: Purchased medication and Seeking Medical Care (Per Cent), 19-2006 Table 12.7: Distribution of Poverty By Region (Per cent), 1997-2007 Table 12.8: Distribution of Elderly Population (ages 60 years and older) By Region (Per Cent), 1997-2007 Table 13.1. Demographic characteristics, 2002 and 2007 Table 13.2: Self-reported health conditions by particular social variables Table 13.3. Health care-seeking behaviour by sex, self-reported illness, health coverage, social hierarchy, education, age and length of illness, 2002 and 2007 Table 13.4. Stepwise Logistic regression: Social and psychological determinants of self-evaluated health, 2002 and 2007 Table 13.5. Stepwise Logistic regression: R-squared for social and psychological determinants of self-evaluated health, 2002 and 2007 Table 14.1. Sociodemographic characteristic of sample Table 14.2. Diagnosed health conditions by area of residence Table 14.3. Health status by area of residence Table 14.4. Health status by self-reported illness, 2007

328

329 330 331 332 333 333 334 345 347 349

351

352 389 390 391 392

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Table 14.5. Health status by gender Table 14.6. Health status by gender Table 14.7. Health status by health care-seeking behaviour Table 14.8. Health status by health insurance coverage Table 14.9. Diagnosed health conditions by health care seeking behaviour Table 14.10. Health status by Annual total expenditure, 2007 Table 14.11. Self-reported health conditions by total expenditure, 2002 and 2007 Table 14.12. Self-reported health conditions by medical care expenditure (public and private health care expenditure), 2002 Table 15.1. Socio-demographic characteristics of sample Table 15.2. Self-reported illness by sex of respondents, 2002 and 2007 Table 15.3. Self-reported illness by marital status, 2002 Table 15.4. Self-reported illness by marital status, 2007 Table 15.5. Self-reported illness by Age cohort, 2002 and 2007 Table 15.6. Mean age of oldest-old with particular health conditions Table 15.7. Diagnosed Health Conditions by Aged cohort Table 15.8. Self-reported illness (in %) by health status Table 15.9. Health care-seeking behaviour and health status, 2007 Table 15.10. Health care-seeking behaviour by health status controlled for aged cohort Table 15.11. Logistic regression on Good Health status by variables Table 17.1. Socio-demographic characteristic of sample, n = 6,783

393 394 395 396 397 398 399 400 418 419 420 421 422 423 424 425 426 427 428 486

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Table 17.2. Very poor or poor and moderated-to-very poor self-reported health status of sexes (in %)

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Table 17.3. Odds ratios for very poor or poor and moderate-to-very poor self-reported health of sexes by particular variables 488 Table 17.4. Odds ratios of poor health status by age cohorts Table 18.1: Demographic characteristic of sample, 2002 Table 18.2. Particular variable by social hierarchy, 2002 489 510 511

Table 18.3. Self-reported injury, normally go if ill/injured, why didn’t seek care for current illness, length of illness and number of visits to health practitioner by social hierarchy, 2002 512 Table 18.4. Logistic regression: Self-reported illness by particular variables Table 18.5. Logistic regression: Self-reported chronic illness by some variable Table 19.1. Sociodemographic characteristics of study population, n = 206 Table 19.2. Sociodemographic characteristics and health care utilization by self-rated health status Table 19.3. Sociodemographic characteristics and health care utilization by Population Income Quintile Table 19.4. Logistic regression: Variables of self-rated health status 513 514 534 535

536 537

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Table 20.1: Life Expectancy at Birth of Jamaicans by Sex: 1880-2004 Table 20.2: Seeking Medical Care, Self-reported illness, and Gender composition of those who report illness and Seek Medical Care in Jamaica (in %age), 1988-2007 Table 20.3 Number of older men (60+ years) and difference over each year in Jamaica: 1990-2007 Table 20.4 Sociodemographic characteristics of sample (n =1,432): Men 60+ years Table 20.5 Logistic regression: Variables predicting good health status of men 60+ years And 73+ years in Jamaica Table 21.4.: Profile of the surveyed respondents: Variables used in Wellbeing Model Table 21.1: Life Expectancy at Birth of Jamaicans by Sex: 1880-2004 Table 21.2: Jamaica: Selected demographic variables, Labour Force Participation (in %)

560

561

562 563

564 575 587 588

Table 21.3: Growth Rate of Selected Age Group and for Total Population of Jamaica, using Census data: 1844-2050 589 Table 21.5: Wellbeing Equation of the Jamaican Elderly Table 22.1: Percentage and (count) of Marital Status by Gender of respondents Table 22.2: A Multivariate Model of Wellbeing of Jamaicans Table 22.3: Decomposing the 39.3% of the variance in Wellbeing of Jamaicans, using the squared partial correlation coefficient Table 23.1: Operational definitions of particular variables Table 23.2. Demographic characteristic of sample, 2002 and 2007 Table 23.3. Self-reported diagnosed chronic illness by sex of respondents, 2002 and 2007 Table 23.4: Particular demographic and health variable by diagnosed chronic illness, 2002 and 2007 Table 23.5. Age of respondent by particular chronic illness, 2002 and 2007 Table 24.1: Socio-demographic characteristics of sample Table 24.2: Diagnosed chronic recurring illness by age group 590 604 605 606 627 628 629 630 631 653 654

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Table 24.3: Diagnosed chronic illness by social class Table 24.4: Crowding, income and annual consumption expenditure by diagnosed chronic disease Table 24.5: Logistic regression: Predictor of poor health status of patients who reported chronic disease Table 26.1. Annual Inflation in Food and Non-Alcoholic beverages and Health Care Cost, 2003-2007 Table 26.2. Inflation, Public-Private Health Care Service Utilization, Incidence of Poverty, Illness and Prevalence of Population with Health Insurance (in per cent), 1988-2007 Table 26.3. Seeking Medical Care, Self-reported illness, and Gender composition of those who report illness and Seek Medical Care in Jamaica (in percentage), 1988-2007 Table 27.1: Socio-demographic characteristic of the respondents Table 27.2: Age-specific death rates by older ages and crude death rate, 1998-2007 Table 27.3: Life expectancy at birth of Jamaicans by sex: 1880-2004 Table 27.4: Mortality sex ratio by older ages and population, 1998-2006 Table 27.5: Health status by Age group Table 27.6: Diagnosed (chronic) illness by age cohort Table 27.7. Poor health status of elderly Jamaicans by some explanatory variables Table 30.1: Demographic characteristic of sample by area of residence Table 30.2: Good health status by social standing (Per capita population quintile) Table 30.3: Good health status by age group Table 30.4: Logistic regression: Private health insurance coverage by some variables

655 656

657

711

712

713 748 749 750 751 752 753 754 801 802 803 804

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Preface
Ageing is not a recent issue in the world as it goes back centuries, to the beginning of human existence. The ageing reality was first studied by Denise Eldemire-Shearer (formerly, Denise Eldemire) in Jamaica in the early 1990s. While Denise Eldemire-Shearer’s pioneering work (PhD thesis in 1993) evaluated the epidemiology of ageing in Jamaica, it failed to explore the association between ageing and self-rated health status, social determinants of health among the aged population, the relationship between self-reported illness and self-rated health, and many of the subsequent works (quantitative and qualitative inquiries) equally did not research those critical issues in the discourse of ageing studies. Despite the works having left a gap in the literature, they provided a comprehensive understanding of ageing, meaning of ageing from a non-medical perspective and an understanding of aged Jamaicans which have aided in the formulation of countless Ageing Policies. The pursuit of truth which is critical to science, albeit social or pure, means that academics CANNOT behave as though the gap is filled and nothing is left to research in the discipline of Ageing Studies as this is not the case. By failing to evaluate self-rated health status among the aged as well as social determinants of health of this cohort, the pursuit of truth dictates that scientific inquiry is needed in those areas. An established gap in the literature on Ageing Studies symbolizes the importance of further research as these can provide germane rationale for future policy formulation and intervention programmes. In 2003 a workshop proceedings on ‘Ageing well: A life course perspective’ addressed plethora of germane issues (such as Active ageing: WHO perspectives; Caribbean Ageing and Policy Implications; Psychological Dimensions of Ageing; Age-friendly primary Health Care:
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Ministry of Health’s Perspective; Surgery in the Elderly: A prospective Study in a Developing Country; Surgery in the Elderly: What, Where and How: Reducing Clinical Complications for Diabetes and Hypertension in the Older Population; Diagnostic and Management Approaches to Dementia) but none of the articles pursuit the truth of Self-rated Health, Health Care Utilization, social determinants, particularly among the aged – people 60+ years old). In the entire publication (Ageing Well…) there was an absence of critical empirical studies on the aged population that could aid policy makers with crucial information for effective policy planning and intervention programmes. Although those topic pursued by the various scholars were vital to the general health of the elderly, more research on different tenets of the aged are unavoidable and cannot continue unresearched when data are able that could aid policy formulation and understanding of this aged cohort. In 2005 an entire text on ‘Health Issues in the Caribbean’ edited by Owen Morgan two articles and/or studies appeared on ageing, one by Denise Eldemire-Shearer and Yvonne Stewart. Again like early publication in 2003 none of the articles inquired the self-rated health and ageing as well as health care utilization among the elderly. If science is about the pursuit of truths, principles of verifications, logic, precision, then the absence of systematic inquiry on ageing and health, ageing and health care utilization, will not advance the understanding of the aged in Jamaica, for policy planning and evaluations. Although science continues unabated in our world, we are failing to provide truths in health literature, particularly on the aged. The elderly is a growing group that ignorant of information will not help understanding the population. In development planning, ageing and population ageing cannot be excluded for other matters (such as growth and development, inflation, unemployment, chronic illness and standard of living).

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The current text fills the gap in the literature by systematically exploring health measurement, health and ageing, ageing and health care utilization, particularly among aged Jamaicans. Knowledge cannot be expounded upon by unresearched phenomena, supporting the purpose of this book to enhance the revolutionary nature of science in explaining what is, ageing and self reported health. The structure of this book, therefore, substantially reflects an expansion of Denise Eldemire-Shearer’s pioneering work, current works by Janet LaGrande, Chloe Morris and Eldemire-Shearer. The difference of this work is a gradual progression of a useful framework for understanding ageing, health and ageing, health care utilization and ageing in Jamaica. The book commences with an overview of ageing, definitions of health, determinants of health, health care utilization and disparity in health of the aged males and females in Jamaica. This book is written for audiences of health care practitioners, academics, health and applied demographers, gerontologists, social workers, sociologists, students of sociology and demography, policy formulators, health care administrators, psychologists (applied and clinical), elderly, and general readers who wish to understanding the phenomena expounded upon in this volume. Econometric tools are used throughout this text that may challenging for some readers, but the author tried to thoroughly explain these issues in a matter than can be grasped by all readers, with or without statistical skills. In producing this work, it makes use of data from secondary cross-sectional surveys, previously published works in the age of health, health care utilization, ageing, and health and ageing to illustrate and demonstrate the practices and behavior of the aged in Jamaica. Like Karl Pearson, the author somewhat subscribe to the proposition that good health is inherited rather than nurtured by a particular socio-physical milieu, but also thinks that this may not necessarily be the care among the aged. These thinking led to the examination of plethora of matters on

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health and health care utilization, with particular emphasis on the aged, in order to provide a comprehensive understanding of the phenomena instead of merely hold unsubstantiated positions. As a scientist the author cannot claim truths with verifications, that is the basis upon which many of the inquiries emerge and new positions are formed. Ageing is a reality that is highly dreaded in many societies, because people believe it is the slowing and closing of life’s gift. Ageing is a part of the life’s trajectory, which means that there is nothing to fear or be apprehensive about as it is certain at the beginning of life that there is a high probability ageing will occur. Ageing is sometimes refers as ageism (ie. a negative reality) primarily because of the observation of many who are elderly. Ageing does not commence at 60+ years, it begin at birth and continues throughout life. Some seek a panacea for ageing; they desire its disappearance because of its perceived negatives, mythologies and misnomers. Ageing gracefully is rarely forwarded by many people in societies, even though this is aired by agencies, people fear death which account for the negative psychological dislike for ageing beyond 60 years. Empirical evidence showed that some health conditions are more likely to emerge beyond a particularly chronological age, which increases the psychological negative of ageing at 60+ years. It is not the mere onset of health conditions that pose the fear for many, but it is the increasing likeliness of morality on the introduction of those conditions. With this realty, ageing beyond a certain chronological value is not a welcoming thing for some people. The seniors years merely reflects the commulative status of earlier years coupled with the socio-physical environment, indicating that the objective is not to fear ageing but it is to mindful of those situations and how we can make amendments in order to discount poor health in the later years.

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No discourse on ageing and/or health can be completed without an examination of the health status of the fasting growing aged cohort in Jamaica, the old-to-oldest elderly. With rural poverty being twice that of urban poverty, more elderly residing in rural geopolitical zones, oldto-oldest elderly are mostly unemployable or unemployed, comorbidity increases with advanced age, we need knowledge on the health status of this people and factors that account for good selfrated health status. Chapter 32 provides a comprehensive examination of the aforementioned issues, illness affecting the old elderly versus the oldest-elderly, and the statistical association between illness, poverty and old-age. Now we have a better understanding of those factors that account for old-to-oldest elderly good health. While the data were goodly fitted for the model, the explanatory power was low of those identified predictive factors. This means that good health of this age cohort is not influenced by income or social standing, and that there is a need to examine lifestyle risk factors; disease indicators and psychological conditions as this may provide more answers to good health of Jamaicans 75 years and older. A quantitative assessment has provided use with answers; it is clear from the findings that more information is needed on this age cohort. The researcher recommends the use of qualitative methodologies to provide in-depth understanding of those factors that determine good health of this age cohort. All the chapters were carefully and deliberately chosen in keeping with the focus of human ageing, health, health utilisation and policy formulation. The majority of the chapters have some advanced statistical techniques, but the author tried to ensure that information provide will give a thorough understanding without any knowledge of advanced statistics. The author hopes that the information can commence the discourse on human ageing, policy changes, policy implementations and the rebranding of human ageing in Jamaica.

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Acknowledgements

Jamaica continues to log behind in the study of self-rated (or reported) health among the aged. Because science cannot be advanced without pursuing truths, it follows that the gaps in the literature must be met with immediacy in order to provide meanings and guidelines for policy makers and other scientists, and science. This book emerged out of a stay with my aged mother (Ms. Janet “Medda” Green), brother (Mr. Kervin Roger Smith), niece (Janet Smith), nephew (Kevin Smith) and hearing about the comorbidities experienced by the ageing uncle (Mr. Gerald Green). During the holidaying with ageing mother and being cognizant of the realities of ageing, I was awoken to the realization that ageing is process as I saw the ease with which my mother slept and work with small intervals between. Like her older brother (Mr. Gerald Green), my mother experienced comorbidities such as hypertension, heart conditions, circulatory problems and respiratory conditions, yet works assiduously in the days and awake in the nights as hungry as an unfed tiger. Ageing became a reality that I began interfacing with, but realize that it was not to be dread as both my mother and her brother were lovers of the age, say it as a time a offering some ‘good’ to the younger generation and challenging many of the stereotypes and fears of ageing, ageism was social construct that they fail to accept and one that bars the psyche for exploring further unchartered areas. This book is, therefore, a verification of the pursuit of truths on health and ageing in Jamaica, and is the inspiration of my holiday experience, family, relatives including Uncle Mr. Gerald Green. The creation of this volume is to examine many issues unresearched in the past and is totally due to the aforementioned individuals and science, the pursuit of truths.

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Dedication This volume is dedicated to Janet Green, Gerald Green, Kervin Smith, Evadney Bourne Aged people, Jamaicans, Young people

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Human Ageing, Health, Health Utilization and Policy Implications: An introduction to Behaviour and Practices

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Part I: Human Ageing

1

Introduction
For millennia, the pursuit of truths on longevity (human ageing) were primarily centered around 1) lifespan, 2) biology (including genetic and embryology), 3) morbidity and comorbidity 4) functionality (physical and cognitive), 5) mortality, and 6) changes in population structure and composition. The majority of those issues were embedded in the biomedical model. The theories that emerged during the earlier years substantially addressed cause of biological ageing (including functional ageing). Because it was long established that ageing was associated with increased health conditions and mortality, many studies were geared toward pathogens and finding the curse for morbidities. Those gave rise to plethora of demographic and epidemiological studies on life expectancy, which was in keeping with a logical assessment of human ageing, using empiricism. For centuries, there have been a gradual development of empirical works outside of the historical undercurrents of human ageing (lifespan, life expectancy, longevity, genetics, embryology, mortality, and morbidities), these have given currency to inquiries on social ageing (as such as happiness, lifestyle, perceptions, quality of life, health status, ageism). The perspectives of aged people extend beyond the live years to experiences (including sexuality), social programmes, and taxation. A pioneer in Jamaica who has been investigating human ageing is Denise Eldemire-Shearer (formerly Denise Eldemire). She has dedicated the majority of academic studies to the examination of human ageing issues, outside of the traditional biomedical model. Professor Eldemire-Shearer has expanded the non-biomedical studies on human ageing by including areas like health status, challenges of ageing, ageing realities, stress and employment status (as well as productivity). 2

Although Eldemire-Shearer layed the foundations for the revoluation and development in the literature on human ageing in the Caribbean, particularly Jamaica, her works were not directed towards modeling the health status, self-health conditions, and chronic disease, using econometric analyses. The use of economietric techniques, Ian Hambleton and colleagues introduced this to the study of self-rated health status of aged Barbadians. Outside of Ian Hambleton and colleagues’ study, Paul Bourne has conducted plethora of research on health of the aged. The gradual development of scientific studies on health and human ageing in Jamaica, outside of the biomedical model, has provided a more comprehensive understanding and knowledge of the elderly. This volume has not explored the cultural biases and negatives on ageing, ageism, but sought to evaluate health and ageing mainly using secondary cross-sectional survey data. The negative perspectives of ageing include 1) worthless burden, 2) can be abandoned for young people, 3) tax burden or liability including economic cost, 4) disease infected, 5) low productivity, 6) humoured and ridiculed by others, and 7) discriminated against by the society. The negative perceptions of the ageing influence the treatment of the aged. The Jamaican society is one of culture that has many things negative to ascribe about the elder. Like Jamaica, Turish men fear the onset of ageing, as they believe that during this period the economic challenge will be intensified because of the turmoil in the nation (McConatha, et al., 2004). This is not the case in societies like Japan, China, and/or Mexican Americans, Asian Americans, Kung of Botswana, Housa of Nigera as ageing carries with it a high degree of presitige and great respect (AARP, 1995; Holmes and Holmes, 1995; Kalavar, 2001; Foos and Clark, 2010; Sokolovsky, 1999). A study conducted by Wilks and Colleagues (2008), using data on Jamaicans aged 15-74

3

years old, found that 53% of men aged 65-74 years had sexual relations at least once per month compared to 4.2% of females of the same age; 18.5% of elderly males (aged 65-74 years old) reported having diabetes compared with 29.6% of elderly females of the same age; 60.5% elderly males reported hypertension and 66.1% of females. The elder is an individual who is normal, with more experiences, sexually and physically active like the young, but who have a higher probability of being influenced with health conditions than their younger aged people. Clearly peoples’ perception on ageing is culturally based and varies across society and/or cultures. Negative views on older people affect the negative attitude toward ageing and the treatment of them, but these are not of what this volume seeks to address. The text is in response to the gap in the literature on health and ageing, with the primary purpose of providing empirical studies on the phenomena in order to guide principles, theories and develop issues on adult ageing in Jamaica. Human ageing is a reality that commenes the day one is born, continues over the lifespan and end at death. Regardless of peoples’ perception of ageing, their attitude toward ageing, human ageing must be understood as the population ages. Knowledge on ageing is critical to development as are inflation, monetary policy, national debt and unemployment. Ageing, therefore, is an important phenomenon that explains current practices, behaviours and lifestyles of the past. This volume examines issues on ageing, population ageing in the Caribbean, particularly Jamaica, health status, health conditions, utilization, and hospitalization of Jamaicans, with emphasis on the elderly.

4

References
AARP. (1999). The AARP grand parenting survey. Washington, DC: Author. Bourne, P.A. 2009. Growing Old in Jamaica: Population Ageing and Senior Citizens’

Wellbeing. Kingston: Department of Community Health and Psychiatry, Faculty of Medical Sciences, the University of the West Indies, Mona Erber, Joan. 2005. Learning Inc. Aging and Older Adulthood. Canada: Waldsworth, Thomson

Foos, P.W., & Clark, M.C. (2010). Human aging, 2nd ed. Boston: Pearson Education. Holmes, E.R., & Holmes, L.D. (1995). Other cultures, elder years, 2nd ed. Thousand Oaks, CA: Sage. Kalavar, J.M. (2001). Examining ageism: Do male and female college students differ? Educational Gerontology 27, 507-513. McConatha, J.T., Hayta, V., Riesser-Danner, L., McConatha D. (2004). Turkish and US attitudes toward aging. Educational Gerontology 30, 169-183. Sokolovsky, J. (1997). The cultural context of ageing, 2nd ed. New York: Bergin and Garvey Publishers. Wilks R, Younger N, Tulloch-Reid M, McFarlane S, Francis D. (2008). Jamaica health and lifestyle survey 2007-8. Kingston: Tropical Medicine Research Institute, University of the West Indies, Mona.

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Chapter

1 Historical Overview On Human Ageing
In the earlier centuries, pandemic and pestilence destroyed millions of peoples. One such pandemic was the Oriental or bubonic plague (a rate-based disease, fleas that lived on humans and rats). In early 1330s, it exterminated many lives in Hong Kong and later spread throughout China, the continent of Asia and then to Europe. In October 1347, the pestilence was brought to Europe by a group of Italian merchants who had traveled to China on business. On their return to the ports of Sicily, many of them were found suffering from the plague and some were dead. The pestilence had traveled all the way Northern Europe to England. In August of the fourteenth century (1348), the people of England named it the ‘Black Death’. It eradicated approximately 40 million people worldwide. Some scholars argue that this

disease ‘wiped out’ about one-third to one-half of European’s and Asian’s human population (Rowland 2003), and five years it slaughtered 25 million Europeans. The disease stayed with people until it

disappeared in the 1600s. Then during the 1700s, smallpox slew an estimated 100 peoples worldwide. Following those pandemics and plagues, the discoveries of peninsulin along with proper sanitation and public health have seen a significant reduction in mortality. Whereas low mortality

6

is not synonymous with all nations – because of warfare and famine- low death rates have been the experience of a plethora of the developed societies. This reality is also happening in many developing and emerging nations. Accompanying mortality decline is the issue of the fertility transition that began in the France in the 19th century. This has spread throughout Europe, America and Canada, Japan, China, Barbados and Jamaica to name a few countries. Many developed societies are now experiencing what is referred to as ‘below replacement level fertility. This is where the society automatically replenishes itself by approximately 2.1 births per women of child-bearing age (15 – 49 years). There are societies like Barbados, Trinidad and Tobago, Japan, France, Sweden, and Canada among others that have a total fertility rate of approximately 1.6 children per woman of child-bearing age, which is an indicator of below replacement level fertility. This coupled with declining mortality further explains the next inevitable population challenge, old ages. Population ageing is not simply longer live, but is the health challenges that face not only the individual but the cost of health, the possibility of reduced economic growth, shifts in disease patterns and prevalence and the increasing pressure that it is likely to place on the working age population. The question that few Jamaicans have been asking themselves is ‘what are the scope, implications and challenges of population ageing’ within our declining state (increasingly less resources). Indicators of population ageing Demographers refer to ageing of world population as demographic ageing (or population ageing, or ageing population). There are a few yardsticks that are used in this process. One, they use the median age of the population. This is where one-half of population within a geographic space is either above or below a certain age (median age). Two, some use the proportion of the

7

human population that is 65 years (some say 60 years) and older, which is 8 – 10 %. For the purpose of this paper, I will use the latter (8 -10% of the population 60 and 65 years and older). As a demographer, the chronological valuation for old age (or ageing population) is 65 years and beyond; and so, this will be used throughout this paper except in a further cases, and when this is the case, I will specify to this end. Population ageing means longer life and not necessarily quality living. In this article, I use ageing totally in the sense of longer life. With this said, there is an indication that Jamaica’s population have been ageing, and when did this began? Another germane question that is of significance is ‘Is there a gender disparity in longer life, and which sex is likely to live longer in Jamaica?’ I will begin with life expectancy as the symbolic representation of population ageing. Implications of population ageing Furthermore, Jamaica like Montserrat and Barbados are experiencing the return of some of those people who migrated in the 1950s-1960s, who are elderly along with the continuous negative migration of young people, thereby increasingly expanding the population ageing in those societies. This is an explanation of the population ageing occurring within many of the Caribbean nations. Therefore, many Caribbean countries began experiencing population ageing in 1960s but it has recently begun to be of concern because of the emphasis of this matter on the world stage. Ageing inevitable means longer life, that affects the population composition and structure. In that as the population ages, the base of the population pyramid narrows, while the upper portion expands. If reduced fertility continues without any major catastrophe in the future, what we are likely to experience is people living longer, and the death rates at older ages will begin to naturally increase thereby changing the population age structure further. Another result

8

of this demographic ageing is increased disability that will result. Whereas technological advances have added years to people’s lives, it has not reduced ailments. So people will be living longer, but with more disability. Global life expectancy has risen from 47 years in 19501955 to 65 years and beyond in 2000-2005 and 2005-2015, which is similar for Jamaica, Trinidad and Tobago, Bahamas and Barbados (United Nations 2006:87-89; United Nations 2005: xxii: STATIN 2003). One of the probabilistic results of ageing is the reduction on the working aged and the youthful population. These provide shifts in the population pyramid as it contracts at younger ages and expand at older ages. This is reiterated in a publication of the Caribbean

Food and Nutrition Institute (1999:191) that stated, “By the year 2050, there will be older persons than children in the world, the majority of whom will be females and widowed or without a partner. The Caribbean is likely to mirror this phenomenon…” The Statistical Institute of Jamaica pointed out that those societies that were at the early stage of the demographic transition in which fertility remains high and mortality decline are now experiencing increasing in younger population. However, for those that at the late stage, where fertility is declining and mortality is stationary, the younger sector of the population is smaller than the segment 60 years and older (STATIN 2003). This is in keeping with the global perspective on demographic transition. Within the 21st century, population ageing and shifts in health status of the population are synonymous constructs, along with the deviations between living longer and living healthier. Notwithstanding these realities, scientific study on the aged population is more recent than the construct itself. Erber credited a Belgian mathematician and astronomer, Adolphe Quetelet, in 1835, for studying the different stages that men pass through during their lifetime. The work is a pivotal landmark in the study of the ageing process. As population ageing is reality in the

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Caribbean, Jamaica and other developed nations that have begun in earnest to project the like socio-economic of “greying” populations within the general setting of aged dependency, support ratios and many issues associated with demographic transition. In 1884, an Englishman named Francis Galton who was both a mathematician and medical doctor researched ‘physical and mental functioning’ of some 9,000 people between the ages of 5 and 80 years (Erber 2005:4). As mathematician like his predecessor, Adolphe

Quetelet, Galton want to measure human life span, physical and mental functioning of people. Therefore, he sponsored a health exhibition that would allow him to have data for analysis. This begs the question – what explains that fascination of man in seeking to understand ageing, and in particular, his/her intrigue with the aged and their wellbeing? Even though, the ageing process is lifelong and though this may be constructed within each society differently, many decades have elapsed since Galton’s study on the health status of people. Despite changes in human development and the shifts in world population toward demographic ageing – people living beyond 65 years (see ILO 2000; Wise 1997), the issues of the aged and their health status, in particular general wellbeing, have not taken front stage on the radar of demographers unlike many other demographic issues. This is especially true for the Caribbean. There are signs indicating that population ageing in the 21st century is affecting many industrialized societies. These societies are affected through low fertility, which speaks to the future problems of – high age dependency ratios, high support ratio, and future changes in population size and structure. Among the challenge of low fertility in industrialized nations are the difficulties that it posses for population replacement, reduced juvenile dependency, lower potential fertility, and increased old-age ratio. There are some non-demographic issues that spill

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offs of population ageing such as the consequences for future pension allocations, hospitalization expenditure for the aged. A demographer, Alain Marcoux, measured population ageing in an article titled ‘Population ageing in developing societies: How urgent are the issues?’ as a specified valuation of the general population being 60 years and older. The benchmark that was used to establish this situation is the proportion of the population who are aged 60 years and over exceeds 10%) whereas another group of scholars Gavrilov and Heuveline used 65 years and beyond that exceeds 8-10%. These include for example - Germany, Greece, Italy, Bulgaria and Japan; U.S.A; Sweden – Figure 1.1, below). Interestingly, Greece and Italy’s aged population (people 60 years and older) in 2000 stood at least 24% of the total population, which indicate completion of the fertility and mortality transition, and the high burden being placed on the working population. Those societies’ fertility decline began early and their mortality at older ages has been declining; this justifies their ageing population. The issue of the ageing of a population cannot be simply overlooked as such; a situation will affect labour supply, pension system, health care facilities, products demanded, mortality, morbidity, and public expenditure among other events. It [ageing] is not simply about mortality, fertility and/or morbidity. The phenomenon is about people, their environment and how they must coexist in order to survive, and how institutions that do exist to enhance longevity. Ageing, therefore, is here to stay. In order to grasp the complexities of this phenomenon, Lawson’s monograph adequately provides a summative position on the matter. She noted that: Actually, it is predicted (U.N) that developing countries are likely to have an older generation crisis about the year 2030, that is about the same time as most developed countries (Lawson 1996:1)

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This demographic transition is not only promogated by Lawson, but is concurred on by Cowgill who believed that come the next half-century (2030), there is strong possibility this transition will plague developing nations. This is no different for the developed nations. Three centuries ago, the issue of ageing would not constitute one out of twenty-five of the total population, or even more than this as is the case in the 21st Century. According to Lawson, “The world is going to have to learn to live with populations containing a much higher proportion of older people…” The speed at which a population will age (60 years and over) in countries in the Latin America and the Caribbean (shift from 8 to 15 %) will be shorter than two-fifths the duration of time it took the United States and between one-fifth and two-fifths for Western European country to attain similar levels (McEniry et al. 2005; Palloni et al. 2002). The rate of growth in the ageing populace in Latin America and the Caribbean is not only realty, but the issue is; will the elderly’s care and well-being reside squarely on the shoulders of the young? Seniors cannot be neglected as they will constitute an increasingly larger percentage of total population and sub-populations in different topography than in previous centuries. Furthermore, from all indications, in the developing world, the elderly population will continue to increase as a proportion of the globe’s population which is in keeping the world’s ageing statistics. According to Randal and German, the numbers of aged living in developing countries will more than double by 2025, “reaching 850 million”. The Caribbean is not different as according to Grell, the English-speaking Caribbean from the 1970 census revealed that between 8.8 and 9.8 percent of the populace were 60 years and older. A matter Lawson noted began in Jamaica since the 1900. From a study commissioned by the Planning Institute of Jamaica, it was noted that the globe’s population grew at a rate of 1.7 percent per annum, with the population of the seniors (60

12

years and older) growing at 2.5 percent. A point of emphasis was the monthly growth rate for the elderly in developing countries (3.3 %), with a projected population forecast of seniors for Jamaica for 2020 to be 15 percent. From the World Development Indicators report, in 2003, 6.9 percent of Jamaicans were 65 years and older. Eldemire noted that the increased aged populace in Jamaica began in the 1960’s. From statistical reports, the percent has continued to increase post-2000. STATIN in ‘Demographic Statistics, 2004’ reported that 10 percent of Jamaica’s population are 60 years and older, which is supported by Eldemire contrary to the viewpoints of Gibbings. Despite the indecisiveness to reach consensus on a definition of ageing from the United Nations’ perspective on the elderly, ‘old age’ begins at 60 years while demographers conceptualize this variable as ages 65 years and older. “Where ‘Old age’ begins is not precisely defined, the unset of older age is usually considered 60 or 65 years of age” (WHO 2002, 125). Nevertheless, this project is a partial fulfillment of a demography degree, and so will subscribe to demographic conceptualizations, primarily. Whereas, some developing countries will begin to experience this come 2030 most societies would have been exposed to this by 2050.

U.S.A Sw eden

Major Area, region and country

Germany Italy Europe Japan India China Latin America and the Caribbean Af rica World 0 10 20 30 40

Percentage of the Elderly (65+ years) 1950 2000 2050

Figure 1.1: Selected regions and their percent of pop. 65+ years Source: United Nations 2005: World Population Prospects: The 2004 revision (page 20)

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Chapter

2 POPULATION AGEING and the STATE
of the ELDERLY In Jamaica
Introduction Ageing is not a recent phenomenon; it goes back centuries. Currently, the differences are pace and level. The distinction here is, pace denotes the rate of growth per annum; and level represents the percentage of the population who are experiencing a certain event. These concepts will be made clearer with the use of various illustrations throughout this paper. As in 2007, it is estimated that the percentage of people 65 years or over is estimated to be 7.5% and come 2050, the figure is projected to reach 16.1%, which is a 115% increase in 43 years. On the contrary, between 1950 and 2007, the percentage of people ≥ 65 years rose by only 2.2%. (Table 1.1). However, by 2030, 1 in every 8 (12.5% of the globe’s population) humans will be 65 years and older, and this is coming from 6.9% in 2000. But there is a discourse as to whether or not ‘old age’ begins are 60 or 65 years; hence, we will present the figures as if we were using 60 years. Thus, if we are to use 60 years and older, the trends are relatively similar to those for ages 65 year or over. As in 1950, the world’s population aged 60 years and older was 1 in 15 (8.2%); but in 2007, the figure rose to 1 in 9 (10.7%), and the projected 21.7 percent (or 1 in 5) by 2050 (United Nations, 2007:72) (Table 2). Based on percentages, the world’s elderly population (≥ 60 years) between 1950 and 1975 increased by 0.4%. However, between 1975 and 2007, the percentage of ‘old people’ rose by 2.1% but for 2025-2050, the increase is expected to be 6.6%. Insert Table 2.1. Presently, China, United States, Germany, India, Sweden, Italy, and Japan have in excess of 50 percent of the world’s population who are 65 years or older. But, does population-- ageing stop with those societies only? The yardstick for measuring an ageing population is having 810% of the population reaching at least 65 years. As of 2025, the Caribbean will have an

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estimated 11.4% of its population ≥ 65 years. Statistics show that the percentage of Caribbean population ≥ 65 years is more than that for the combined of Latin American and the Caribbean (See Tables 2.1, 2.2). “Since population ageing refers to changes in the entire age distribution, any single indicator might appear insufficient to measure it” (Gavrilov, and Heuveline, 2003:3), which appears to have befallen many Caribbean states. This is evident in the political landscape of Caribbean nations as the issue of demographic ageing has not taken on as a serious issue as debt burden, inflation, unemployment, crime and international relations. The rationale for this delay is embedded in perception that critical as that time. But this position is far from the truth. For the reason that, apart from the demographic transition that is taking place globally and equally within the Caribbean, there is another aspect to this phenomenon. As the implications of ageing range from pension schemes problems, higher health care costs and initiatives. These do not cease there, as there are two important issues that we have yet to address, how we will be dealing with production and productivity within the context of an ageing nation (‘shrinking labour force because of ageing’; ‘possibly the bankruptcy of social security systems’). One medium has written that two-thirds of people ≥ 65 years are alive today (BRW, 1999), which strengthens the issue of taking population ageing to the forefront of national debate. Thus, it is clear that population ageing is a global phenomenon; but what is the extent of this in Caribbean states? To further comprehend this phenomenon or to explain this unbounded demographic reality; I will contextualize this paper within a global framework, with particular emphasis on selected Caribbean and more so on Jamaica. Insert Table 2.2 Ageing Defined. Ageing is a significant but neglected dimension of social stratification and the life-course is an essential component of the analysis of status (Turner 1998:299) “Where ‘Old age’ begins is not precisely defined, the onset of older age is usually considered 60 or 65 years of age” (WHO 2002:125). The indecisiveness to reach consensus on a definition of ageing in spite of the United Nations’ perspective on the elderly, which is chronological ageing that begins at 60 years, yet demographers and many statisticians continue to conceptualize this variable as beginning at age 65 years (Lauderdale 2001; Elo 2001; Manton and Land 2000; Preston et al. 1996; Smith and Kington 1997; Rudkin 1993). This moot point

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will not be settled in this paper, but what will happen here is that the various perspectives will be presented to the readers. As a demographer, however, I will primarily be using the chronological age of 65 years and older to present the commencement of ‘old age’ (or ageing). But one should keep in mind (as Turner date outlines) that ageing is a ‘social stratification’ which is neglected within the discourse of social stratification. In medieval times, Thane (2000) notes that ‘old age’ were defined as 60 years and older. She justified this by forwarding an argument for the established age. In medieval England, men and women ceased at 60 years to be liable for compulsory service under labour laws or to participate in military duties. Ancient Rome, on the other hand, ‘old age’ began from early 40 to 70 years, with 60 years being “some sort of annus climactorius”. Demographers see the seniors the elderly or the aged (old people) - as individuals 65 years and older, and not an individual who is 60 years of age. Western societies use 65 years and older to represent the elderly (seniors) as this is the period when people become fully eligible for Social Security benefits. Irrespective of the commencement age of the elderly, there is a wholesale agreement that the aged at the beginning of the next generation will be a real social challenge. One scholar emphasized that there is no absoluteness in the operational definition of the “elderly” (Eldemire 1995:1). She commented that from the World Assembly of Ageing (which was held in Vienna in 1982), the “elderly” is using the chronological age of 60 years and older ‘as the beginning of the ageing process’. Jamaica having signed the Vienna Declaration of Ageing, which defines ageing to begin at 60 years, Eldermire questioned academics and other scholars for their rationale in using 65 years. I will now classify the ageing in two main categories, (1) chronological and (2) biological ageing. Chronological ageing Within the study of demography, the elderly begins at the chronological age of 65 years – using the unit of analysis of time, based on the number of years and months that has elapsed since birth (Erber 2005; Iwashyna et al. 1998; Preston, et al. 1996; Smith and Waitzman 1994). However, based on the monographs from other scholars (such as - Marcoux 2001; Eldemire 1997; PAHO and WHO 1997; Eldemire 1995; Eldemire 1994; Barrett 1987), the issue of the aged begins at 60 years. Hence, the issue of the aged continues to battle from non-

standardization. For those who use 60 years, they adopt this value because of the World

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Assembly on Ageing (in Vienna, Austria: July-August 1982), which postulates that ageing begins at the chronological of 60 years. The Canadian statistical agency used age 65 years as the dividing line between “young” and “old” (Moore et al. 1997, 2; Smith and Waitzman 1994; Preston, et al., 1996). The issue of using the chronological age of 65 years to measure older adulthood according to one academia comes from the minimum age at which the Social Security System begins disbursing payment for pension to people living with the United States (Erber 2005:12). It is argued that in 1935, the U.S. government modeled this from the German’s retirement system. This explains the use of 65 years of age by many scholar, practitioners and non-professionals ever since. This approach subdivides ageing into three categories. These are (i) young-old (ages 65 through 74 years), (ii) oldold (ages 75-84 years) and oldest-old (ages 85 years and beyond). However, is there a difference between biological and chronological ageing? Biological ageing Organisms age naturally, which explains biological ageing. This approach emphasizes the longevity of the cells, in relation to the number of years the organism can live. Thus, in this construction, the human body (an organism) is valued based on physical appearance and/or state of the cells. Embedded in this apparatus is the genetic composition of the survivor. This occurs where the body’s longevity is explained by genetic components. Gompertz’s law in Gavriolov and Gavrilova (2001) shows that there is a fundamental quantitative theory of ageing and mortality of certain species (the examples here are as follows – humans, human lice, rats mice, fruit flies, and flour beetles (, Gavriolov and Gavrilova 1991). Gompertz’s law went further to establish that human mortality increases twofold with every 8 years of an adult life, which means that ageing increases in geometric progression. This phenomenon means that human mortality increases with the age of an adult, but that this becomes less progressive in advanced ageing. Thus, biological ageing is a process where the human cells degenerate with years (the cells die with increasing in age), which is explored in evolutionary biology (see Charlesworth 1994). But studies have shown that using evolutionary theory for “late-life mortality plateaus”, can fail because of the arguably the unrealistic set of assumptions that the theory uses to establish itself. Reliability theory, on the other hand, is a better fitted explanation for the ageing of humans than that argued by Gompertz’s law as the ‘failing law’ speaks to deterioration of human

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organisms with age (Gavrilov and Gavrilova 2001) as well as a non-ageing term. The latter based on Gavrilov and Gavrilova (2001) can occur because of accidents and acute infection, which is called “extrinsic causes of death”. While Gompertz’s law speaks to mortality in ageing organism due to age-related degenerative illnesses such as heart diseases and cancers, a part of the reliability function is Gompertz’s function as well as the non-ageing component. When the biological approach is used to measure ageing, it may be problematic as two different individuals with the same organs and physical appearance may not be able to perform at the same rates, which speaks to the difficulty in using this construct to measure ageing. Nevertheless, this construct is able to compare and contrast organisms in relation to the number of years, a cell may be likely to exist. Erber (2005) argues that this is undoubtedly subjective, as we are unable within a definite realm to predict the life span of a living cell (Erber 2005:9). Interestingly, the biological approach highlights the view that the ageing process comes with changes in physical functioning. The oldest-old categorization is said to be the least physical functioning compared to the other classification in chronological ageing. The young-old, on the other hand, are more likely to be the most functioning as the organism is just beginning the transition into the aged arena (Erber 2005; Brannon and Fiest 2004). In order to avoid such pitfalls in constructions that may arise with the use of the biological approach, ergo, for all intent and purposes, given the nature of policy implications in effective planning, the researcher is forwarding the perspective that seniority in age commences at age 65 years – using the chronological ageing approach. In summarizing the ageing transition, both chronological and biological ageing have a similar tenet; in that, as we move from young-old to oldest-old, the body deteriorates and what was of low severity in the earlier part of the ageing process becomes crucial in the latter stage. Hence, at the introductory stage of the ageing transition, the individual may feel the same as when he/she was in the working age-population, but the reality is that the body is in a declining mode. Because humans are continuously operating with negatives and positive, as he/she becomes older – using the ageing transition (65 years and older) – the losses (or negatives) outweigh the positives. This simply means that the functionality limitation of the body falls, and so opens the person up to a higher probability of becoming susceptible to morbidity and mortality. Secondly, their environment, which may not have been problematic in the past, now

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becomes a health hazard. One University of Chicago scholar summarizes this quite well in Table 2.3:

Table 2.3: Characteristics of the Three Categories of Elderly, and Ageing transition Characteristic The Ageing Transition Young-old Heath problems Physical disability Demand for medical care Low Low Low Aged Oldest-Old

Moderate High Moderate High Moderate High Moderate High Moderate High Moderate High Moderate High

Demand for public service Low Demands on children Dependency on other Social isolation Low Low Low

Source: This is taken from Essays in Human Ecology 4. Bogue 1999, 3.
1

Donald Bogue (1999) used aged (age 75 – 84 years) to refer to what this paper calls old-old

Historical Issues on Population Ageing: Global Perspectives. Ageing has emerged as a global phenomenon in the wake of the now virtually universal decline in fertility and, to a lesser extent, of increases in life expectancy (Marcoux 2001:1) In the earlier centuries, pandemic and pestilence would destroy millions of lives. An example here is, in the fourteenth century, the ‘Black Death’, killed approximately 40 million people worldwide. One scholar argues that this disease ‘wiped out’ about one-third to one-half of European’s and Asian’s human population (Rowland, 2003). As during the 1700s, smallpox killed an estimated 100 peoples worldwide. This reality explains why population ageing was not a phenomenon then, as the deaths were high and widespread. Therefore, the person was not likely to live beyond fifty years. Following those pandemics and plagues, the discoveries of peninsulin along with proper sanitation and public health have seen a significant reduction in 19

mortality. Whereas low mortality is not synonymous with all nations, low death rates have been the experience of a plethora of the developed societies. This reality is also happening in many developing and emerging nations. Accompanying mortality decline is the issue of the fertility transition that began in France in the 19th century. It is argued, that reduction in fertility is primarily a cause of population ageing today as well as a steady decline in mortality rates. Even though, the ageing process is life long and though it may be constructed differently within each society, many decades have elapsed since Galton’s study on the health status of people. Despite changes in human development and the shifts in world population toward demographic ageing – people living beyond 65 years (see ILO, 2000; Wise, 1997), the issues of the aged and their health status, in particular general wellbeing, have not taken front stage on the radar of demographers, unlike many other demographic issues. The 20th century has brought with it massive changes in typologies of diseases where deaths have shifted from infectious diseases such as tuberculosis, pneumonia, yellow fever, Black Death (Bubonic Plague), smallpox and ‘diphtheria’ to diseases such as cancers, heart illnesses, and diabetes. Although diseases have shifted from infectious to degenerate, chronic non-communicable illnesses have arisen and are still lingering within all the advances in science, medicine and technology. One demographer showing the extent of human destruction due to the Black Death mentioned that this plague reduced Europe’s population by one-quarter (Rowland, 2003:14). Accompanying this period of the ‘age of degenerative and man-made illnesses’ is life expectancies that now exceed 50 years. So while people aged 70 years and beyond in many developed and a few developing states, the question is - Are they living a healthier life – how is their wellbeing within the increases in life expectancy? Alternatively, is it that we are just stuck on life expectancies and diseases as primary predictors of wellbeing – or health status? Before the establishments of the American Gerontology Association in the 1930s and their many scientific studies on the ageing process (Erber, 2005), many studies were done based on the biomedical model (physical functioning or illness and/or disease-causing organism), (Brannon, & Feist, 2004:9). Many official publications used either (i) reported illnesses and ailments, or (ii) prevalence of seeking medical care for sicknesses. Some scholars have still not moved to the post biomedical predictors of health status. The dominance of this approach is so strong and present within the twenty first century, that many doctors are still treating illnesses

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and sicknesses without an understanding of the psychosocial and economic conditions of their patients. To illustrate this more vividly, the researcher will quote a sentiment made by a medical doctor in ‘The Caribbean Food and Nutrition Institute Quarterly, 1999. A public health

nutritionist, Dr. Kornelia Buzina, says that “when used appropriately, drugs may be the single most important intervention in the care of an older patient … and may even endanger the health of an older patient …” (quoted in the editorial of Caribbean Food and Nutrition Institute 1999:180). A demographer, Alain Marcoux, measured population ageing in an article titled ‘Population ageing in developing societies: How urgent are the issues?’ as a specified valuation of the general population being 60 years and older. The benchmark that was used to establish this situation is the proportion of the population who are aged 60 years and over exceeds 10% (Marcoux 2001:1), whereas another group of scholars Gavrilov & Heuveline (Gavrilov, & Heuveline, 2003) used 65 years and beyond that exceeds 8-10%. These include for example Germany, Greece, Italy, Bulgaria and Japan; U.S.A; Sweden (Goulding, & Rogers, 2003). Interestingly, Greece and Italy’s aged population (people 60 years and older) in 2000 stood at least 24% of the total population (Mirkin, & Weinberger, 2001), which indicates the completion of the fertility and mortality transition, and the high burden being placed on the working population. Those societies’ fertility decline began early and their mortality at older ages has been declining; this justifies their ageing population. This is not only confined to developed societies as it is spreading to the entire world. Demographic Trends: The Global perspective Globally, trends in population ageing are such that demographic ageing is seen as a fundamental phenomenon of concern both inside and outside of the intelligentsia class. I will display the issue in great detail below, as the figures will speak of the trends that we have seen more so since the 1900s. And that this progression will continue in the next 50 years. The aged persons >65 years and older in 1950 was 5.2%, and by 1995 the figure rose to 6.5%. But, during the 1950s-1960s, the 65+ age cohort rose by 0.1%, which may be marginal but it earmarks the beginning a demographic phenomenon. In 1999, persons aged 65 years and older were 410.5 million, and one year later the figure rose to 420 million, which is a 2.3 percentage increase over the previous year. In addition during

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2000 to 2030, it is estimated that aged persons >65 years, will rise from an approximated 550 million to a projected 973 million (76.9%). By 2050, the persons aged 65 years and beyond, will be some 13.8% of the world’s population. Currently, the developed nations share

disproportionately more of the aged persons >65 years, this reality is not projected to change in the future. However, by 2030, the absolute number of aged >65 years in the developing societies is expected to triple, which will not be the same for the developed nations (from 249 million in 2000 to 690 million by 2030). In summary, during 1950-2000, the elderly population (persons 65+) increased by 1.7%. However, from 2000-2050, the same aged cohort will rise by 6.9%, which denotes a 100% increase in 50 years. The statistics reveal that come 2050 most of the aged population will be residing in developing countries. In addition, by 2030 the population 65-and older in developing societies would have increased by 140 percent, which is 40% more elderly in developing nations than in the world. Importantly, the aged are on the upper end of the ageing spectrum; and this affects the population dynamics of the society. The total human population, within any geographic area, constitutes children, youth, working aged people and the elderly. With this said, the “graying” (spelling not consistent throughout) of a population is caused by fertility decline, reduced mortality and migration of the young and return of retirees coupled with increases in life expectancies. Where the elderly population outgrows the younger population, this constricts the population structure at younger ages and expanding it at older ages (Rowland, 2003:98). This is referred to as demographic transition. It is the experience of many developed countries that started with France, but has increasingly become a phenomenon for many developing nations. The demographic development of the world is not limited to the increase in persons 65 years and older but the reduction of the children population (persons 0 – 14 years). In 1950, the children population was 34.3% of the globe’s population, and in 1975 the figure rose to 36.8%, and in 2007 the United Nations (2007:72) wrote that this is expected to be 27.6% and come 2050, 20.2%. Accompanying this reduction in the children population is the increase in the median age of the world’s population. As at the state of the 1950, this was 23.9 years, it fell to 22.4 years in 1975 and is estimated to rise to 28.1 years in 2007 and project to reach 37.8 years, which is an indication of population ageing. The increase in proportion of people ≥ 65 and changes in the median age can be simply explained by mortality changes, which demographers

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use life expectancy to explain. In life expectancy at birth during 1950-1955 was 46.6%, in 19751980, 59.9 years, and 2005-2010, 66.5 years and come 2045-2050 it is expected to reach 75.1 years. In the more developed nations, currently (in 2007) estimated by the United Nations, 2007:74), 20.7% of the population are persons ≥ 60 years, 15.5% are persons ≥ 65 years, and 3.9% are persons ≥ 80 years. The life expectancy for people in these regions is more than the world’s figure, as the United Nations (2007:75) writes that during 2005-2010, it is 76.2 years. However, in Northern Europe, it is 78.7 years, Southern Europe; it is 79.1 years, Western Europe, 79.6 years, and in Northern America, 78.2 years. Thus, population ageing is indeed a global phenomenon and more so in developed nations, but what about the Caribbean and in particular Jamaica? Demographic trends: Selected Caribbean Nations Ageing inevitably means longer life that affects the population composition and structure. Due to the fact that as the population ages, the base of the population pyramid narrows, while the upper portion expands. Demographers argue that this is substantially due to the fertility transition and reduced mortality at older ages. If reduced fertility continues without any major catastrophe in the future, what we are likely to experience is people living longer, and the death rates at older ages will begin to naturally increase thereby changing the population age structure further. Global life expectancy has risen from 47 years in 1950-1955 to 65 years and beyond in 20002005 and 2005-2015, which is similar for Jamaica, Trinidad and Tobago, Bahamas and Barbados (United Nations, 2006:87-89; United Nations, 2005: xxii: STATIN, 2003). One of the probabilistic results of ageing is the reduction on the working aged and the youthful population. These provide shifts in the population pyramid as it contracts at younger ages and expand at older ages. This is reiterated in a publication of the Caribbean Food and Nutrition Institute (1999) that stated, “By the year 2050, there will be (shouldn’t more go here) older persons than children in the world, the majority of whom will be females and widowed or without a partner. The Caribbean is likely to mirror this phenomenon…” (Caribbean Food and Nutrition, 1999:191). The Statistical Institute of Jamaica pointed out that those societies that were at the early stage of the demographic transition in which fertility remains high and mortality decline are now experiencing an increase in the younger population. However, for those that are at the late stage, where fertility is declining and mortality is stationary, the younger sector of the population

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is smaller than the segment 60 years and older (STATIN, 2003). This is in keeping with the global perspective on demographic transition. I will present a graphical display of the populations of the World and the Caribbean of two age cohorts, children (0-14 years) and elderly (65+), as an indication of the similarities these demographic trends. A further subdivision of selected Caribbean nations’ proportion of children and elderly populations are presented in Table 2.4.

Table 2.4: Percentage of Estimated or Projected Populations of Selected Caribbean Nations, 1980, 2000, 2005 and 2020 1980 Country Barbados Guyana Jamaica Suriname 0-14 yrs
29.6 40.9 40.3 39.8

2000 0-14 yrs
22.5 30.2 28.3 32.4 28.6 29.9

2005 0-14 yrs 60+ yrs
18.9 29.4 31.2 30.1 21.5 27.7 13.2 7.4 10.2 9.0 10.7 10.7

2020 0-14 yrs
19.4 23.0 20.4 24.2 23.5 24.2

60+ yrs
14.1 5.7 9.3 6.3 8.1 8.6

60+ yrs
14.1 6.3 9.0 7.9 8.4 9.9

60+ yrs
19.3 11.3 12.4 9.8 13.3 14.2

34.3 Trinidad & Tobago Caribbean 36.7

Source: United Nations. 2005c: World Population Prospects: The 2004 Revision

Demographic development in the Caribbean has taken a similar path like the rest of the world (Population Reference Bureau, 2007; STATIN, 2006; United Nations, 2005c). Over the years, the movement has being such that mortality and fertility has been declining, and the population 65 years and older has been increasing proportionately more than proportion who are children (See Tables 2.5, 2.6).
.

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By the standard that if a population of aged person using ≥ 60 years exceeds 8-10% of the population, there is the issue of demographic ageing. So since 1980, countries like Barbados, Jamaica, Trinidad and Tobago and generally the Caribbean have been experiencing this phenomenon (Table 2.4). From the Table, by 2020, Barbados’ elderly population will be higher than that of the Caribbean’s average. Among the factors of population ageing are mortality and fertility. Thus, merely using the proportion of persons who are either 65+ or 0-14 years is an indicator of demographic transition but mortality and fertility are critical determinants of ageing population. According to the United Nations (2007:5), Decreasing fertility has been the primary cause of population ageing because, as fertility moves steadily to lower levels, people of reproductive age have fewer children relative to those of older generations, with the result that sustained fertility reductions eventually lead to reduction of the proportion of children and young persons in a population and a corresponding increase of the proportion in older groups (UN, 2007:5) The United Nations’ perspective has highlighted the importance of including fertility in demographic transition discourse as well as mortality. Statistics reveal that the total fertility rate (TFR) for 1970-1975 for the world was 4.49 and for 2000-2005, it fell to 2.65; whereas in Latin America and the Caribbean between 1970-1975, it was 5.05 and this was further reduced to 2.55 in 2000-2005 (United Nations 2005c, xxi). Concurrently, in 2005, total fertility in The Bahamas is 2.2, in Barbados it is 1.5, for Jamaica 2.3 and for Trinidad and Tobago, 1.6 (United Nations 2006, 87-89). Barbados and the twin islands of Trinidad and Tobago are experiencing below replacement level fertility (Total Fertility Rate – TFR of 2.1 – United Nations 2000, 4), a problem presently faced by many developed nations such as those in Southern and Easter Europe and the United States (United Nations 2005c, xxi). I have presented Table 5Table 5, for a more detailed assessment of the total fertility trends of selected Caribbean States, the Caribbean and Latin America, in an effort for us to see the trend in this phenomenon, and the implications of this for population ageing come 2050.

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Table 2.5: Total Fertility Rate for Selected Caribbean Nations, Caribbean, and Latin American: 1950-1955 to 2045-2050 Countries 195019752005202520451955 1980 2010 2030 2050 Bahamas 4.1 3.2 2.2 1.9 1.9 Barbados Belize Dominican Rep Guyana Haiti Jamaica Suriname Trinidad & Tobago Caribbean 4.7 6.7 7.4 6.7 6.3 4.2 6.6 5.3 5.2 2.2 6.2 4.7 3.9 6.0 4.0 4.2 3.4 3.6 1.5 2.8 2.6 2.1 3.6 2.3 2.4 1.6 2.4 2.4 1.8 2.0 2.1 1.9 2.5 2.0 2.0 1.8 2.1 2.0 1.9 1.9 1.9 1.9 2.1 1.9 1.9 1.9 1.9 1.9

Latin America & 5.9 4.5 Caribbean Source: World Population Ageing 2007

Another determinant of the demographic transition is mortality. The mortality statistics are used to compute the life expectancies, and so the researcher will use the latter as it is an indicator of the former. Mortality in the Caribbean has been falling and this can be seeing from the increased life expectancies, which are highly comparable with those in developed nations, which is beyond 71 years(United Nations 2007 – See Table 2.6, below).

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Table 2.6: Life Expectancy at Birth of both Sexes for Selected Caribbean Nations, the Caribbean, and Latin American Countries 195019752005202520451955 1980 2010 2030 2050 Bahamas 59.8 67.2 72.1 78.0 82.0 Barbados Belize Dominican Rep Guyana Haiti Jamaica Suriname Trinidad & Tobago Caribbean 57.5 57.7 45.9 52.3 37.6 55.8 56.0 59.0 52.2 71.4 69.7 61.9 60.7 50.6 70.1 65.1 68.3 64.5 76.4 71.7 68.6 65.4 53.5 71.1 70.2 70.1 68.7 72.9 79.2 74.0 73.8 70.6 62.2 75.0 74.7 74.1 73.2 76.8 81.4 78.0 77.7 74.2 70.1 77.7 78.1 78.5 76.9 79.5

Latin America & 51.4 63.0 Caribbean Source: World Population Ageing 2007 Demographic Trends: Jamaica

The use of life expectancy, mortality, and total fertility rates are just some of the ways with which demographic development can be shown. Instead of showing both mortality and life expectancy, for this section of the paper the researcher will use life expectancy. As mortality rates are used to calculate the life expectancy at various ages (Table 2.7). Another way of depicting population changes is through the use of a population pyramid. In this section, the researcher will use Jamaica’s population pyramid since 2000 to depict the demographic transition occurring in this society, and then percentages of the elderly people with regard to the total population. It should be noted that the nation’s population pyramid in the year 2000 showed a narrow top and a broad base. But by 2025, the population narrows at the base and begins to expand at the middle, and come 2050, note how the population contrasts at the base as we move toward an ageing population. Come 2050 and beyond, Jamaica’s oldest elderly will be substantially more females. The “graying” of the Jamaica’s population is coming, and has already made its way within the

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society.

From a demographic perspective, relatively speaking a society is said to be old

whenever the population of person aged 60 or over (and some scholars use 65 years or over) exceeds 8-10%, which is the case in Jamaica (Appendix I). This is not the only indicator as life expectancy can be used to show population ageing. Jamaica’s life expectancy at birth for males between 1879 and 1882 was 37.02 years and for females it was 39.80 years, between 2002 and 2004 males’ life expectancy rose to 71.26 years and that of the females’ to 77.07 years, which is a clear indictor of demographic ageing (See Table 2.7).

Table 2.7: Life Expectancy at Birth of Jamaicans by Sex, 1880-2004 Average Expected Years of Life at Birth Period:
1880-1882 1890-1892 1910-1912 1920-1922 1945-1947 1950-1952 1959-1961 1969-1970 1979-1981 1989-1991 1999-2001 2002-2004 Male 37.02 36.74 39.04 35.89 51.25 55.73 62.65 66.70 69.03 69.97 70.94 71.26 Female 39.80 38.30 41.41 38.20 54.58 58.89 66.63 70.20 72.37 72.64 75.58 77.07

Sources: Demographic Statistics (1972-2006)

From records of the Population Division of the United Nations, Jamaica’s population 60 years and older in 2050, using the medium (should it be median) variant, is likely to be 24% of

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the entire population, with 18.1% being 65 years and older, compared to approximately 5% being 80+ years. These shifts mean more degenerated conditions at older ages, increased disability and diminished quality of life. The disparity in gender composition speaks to the

higher morbidity in women and higher mortality for men (see Newman 2000: 8). In 2004, Jamaica’s old-aged population stood at 7.7 percent. According to WHO/SEARC (1999), India’s elderly population was 7.7 percent. During 2004-1991, the elderly population of Jamaica rose by 3.28 percent. When the elderly is strictly operationalized within a demographer’s space (65 years and beyond), on an average the elderly population grew by 3.62 percent. The data in Appendix II reveal that for every 100 working-aged of the population there are approximately 13 elderly that is dependent on them. This reality is within approximately 30 percent of the population being children. Over the same period, the number of child-to-totalpopulation grew by - 4.4 percent and by -10.08 percent for the youth. Within this context, there is a need to analyze the labour force participation of aged Jamaicans as there would be socioeconomic implications if this were to be declining in the nation. There is little debate within the public arena about the increasing decline of the labour force participation rate of aged Jamaicans. In 1980, the labour force participation rate (in %) was 46.4% and it is estimated that this to be 26.6% in 2007. This represents a 43% reduction in the number of people 65+ years who were actively involved in the labour force. When the labour force participation rate is decomposed by sexes, the figures reveal a more telling disparity. As for females, in 1980, there were 30.4% of women actively involved within the labour force, but it is estimated to be 13.8% in 2007, which is a 55% reduction in the number of employed females. With respect to males’ involvement in the labour force, it is projected to fall to 41.4% in 2007, which is coming from 65.3% in 1980. The labour force participation rate for men will fall by 23% compared to that of females that will decline by 55%. This is within the context of females living longer than their male counterparts, and that the retirement age for females is 60 years and not 65 years (Table 2.8). Therefore, if we are to extrapolate a reduced 5 years for females, the labour force participation rate will increase further by at least percentage points.

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Table 2.8: Jamaica: Selected demographic variables, Labour Force Participation (in %).
Total (% of population4)
60+ 65+ 80+ 1950 5.8 3.9 0.2 1950 6.6 4.4 0.3 1950 5.0 3.2 0.2 1950 1975 8.5 5.8 0.8 1975 9.0 6.3 1.0 1975 8.0 5.3 0.6 1975 2007 10.3 7.6 2.0 2007 10.7 8.1 2.2 2007 9.9 7.1 1.8 2007 2025 15.0 10.3 2.3 2025 16.1 11.0 2.6 2025 13.8 9.7 2.0 2025 2050 23.6 17.7 5.6 2050 25.9 19.9 6.9 2050 21.3 15.4 4.3 2050

Female
60+ 65+ 80+

Male
60+ 65+ 80+

Median age Labour Force Participation
65+ 65+ 65+ United Nations, 2007:308-309

22.2
1980 46.4 30.4 65.3

17.0
1990 37.1 23.6 53.6

24.9
2007 26.6 13.8 41.4

30.7
2010 26.6 13.1 40.7

39.3
2020 25.1 12.3 39.6

Another variable that can be used to indicate population ageing is the median age. The median age denotes a value that where one-half of the population is above or below that age. Continuing, the median age for Jamaica’s populace in 1950 was 22.2 years and it is estimated to reach 24.9 years in 2007 and come 2025 31 years, and by 2050 it should increase by another 8.6 years. It should be note here, that demographers use a median age of 30 years to indicate an ageing population. Thus, population ageing is without a doubt a Jamaican phenomenon like the National debt problem and other social issues such as crime and teenage pregnancy. Without effective population planning for the elderly, come the next four decades, the old-aged population will become a burden to the working aged-populace in respect to medical care, nursing care, pension, other social insurance and survivability cost. With this impending social reality, there is a high probability that the old-aged will be called on to provide increasingly more of their needs for themselves within the construct of limited resources from developing societies. The physiological changes with ageing such as loss of hair, wrinkling of the skin, decrease in height, and loss of teeth are not the only issue of old age but there are other critical factors that affect their wellbeing. State of the Elderly, with emphasis on Caribbean and Jamaica The Caribbean like many developed countries is now faced with the daunting task of addressing the “graying” of its population, because of mortality and fertility decline, which

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began1960s. To show that this is a challenge to geographic topography, the region launched its first forum titled ‘The Caribbean Symposium on Population Ageing’ in November 2004 in Port of Span, Trinidad and Tobago, in order to strategize about this inevitable demographic transition, which began in earnest in developed societies. This is a precursor to its predecessor which was held in Vienna in 1982 called ‘The First Assembly on Ageing’ and another named ‘Second World Assembly on Ageing’, which was in Madrid in 2002. Like the developed world, the Caribbean islands are cognizant that policy implementation and mechanism are needed to forge an equitable solution for this phenomenon. With the Symposium comes the recognition that ageing is not limited to its call but that it affects the general society, future generations and political decisions. Ergo, what is the state of the grayed population in Caribbean and more so within Jamaica. A study revealed that there is a statistical causal relationship between socioeconomic conditions and the health status of Barbadians. The findings revealed that 5.2% of the variation in reported health status was explained by the traditional determinants of health. Furthermore, when this was controlled for current experiences, this percent fell to 3.2% (falling by 2%). When the current set of socioeconomic conditions were used they account for some 4.1% of the variation in health status, while 7.1% were due to lifestyle practices compared to 33.5% that was as a result of current diseases (see Hambleton et al. 2005). It holds that importance place by medical practitioners on the current illnesses – as an indicator of health status – is not unfounded as people place more value on biomedical conditions as responsible for their current health status. Despite this fact, it is obvious from the data – using 33.5% - that there are other indicators that explain some 67.5% of the reason why health status is as it is. Furthermore, with an odds ratio of 0.55 for number of illness, there is clearly suggesting that the more people reported illness, the lower will be their health status. (See Hambleton 2005); and this was equally so for more disease symptoms – odds ratio was 0.71) Accompanying the reduction in physical functioning which is a feature of biological ageing (Erber 2005) is the fact that the Jamaican elderly spend the most number of days receiving medical care for illnesses and/or injuries (see PIOJ and STATIN 2002:4.1). In addition, they experience the highest rate of protracted illness the country, with the “… very young and the elderly being the most vulnerable” (PIOJ and STATIN 1997:45). Embedded in this finding is the poor health status of the elderly despite living longer. Essentially, this particular group is 31

suffering from ill health caused by diabetes, stress, psychiatric disorders and chronic diseases, which translates into lower quality of life while their life is prolonged (see PIOJ and STATIN 1994:22.1; 1990:20.1), which means they are living longer but suffering more - the high cost of longevity of life. A Ministry of Health (MOH) report notes that the prevalence of chronic illnesses has also increased with ageing and that this is even more pronounced for those 65 years and older, with more males than females spending more time in health care facility (MOH, 2004:75), using the discharge rate – 975.1 per 10,000 for males compared to 817.1 per 10,000 females. Interestingly, when a detailed analysis was done of the data, seniors who reside in rural areas were suffering more than their counterparts who live in other zones (PIOJ and STATIN 2000:58). A PIOJ and STATIN (1995:32) report summarizes the wellbeing status of those 60 years and older, when they say “… our 60 year olds exhibited the highest prevalence of protracted illness/injuries”. The situation is speaksof is a state of well-being for the elderly that is not in keeping with the positives of the advancement in medicine and medical technology. There is definitely a disparity between the seniors’ wellbeing reality and their lived years, which reiterates the need to measure wellbeing outside of the traditional biomedical model. From the findings of a cross-sectional study conducted by Powell, Bourne and Waller (2007) of some 1,338 Jamaicans, 19.0% of respondents perceived that their economic well-being to be ‘very bad’. In addition, when they asked, “Does your salary and the total of your family’s salary allow you to satisfactorily cover your needs”, 57.4% of them felt that this “does not cover” their expenses (Powell, Bourne and Waller 2007:29). What is the situation of the elderly seeing that this group is even more (or equally) vulnerable than other age cohorts? The answer to this is embedded within JSLC reports. The JSLC (1997) makes it clear that the aged population (22.6%) and the children (less than five years – 14.7%) reported the highest number of illness/injury, with those who resided in the rural areas being more vulnerable than those in other zones are. In order to capture the severity of the issues faced by the Jamaican aged, if we are to convert the mean number of days of reported illnesses into monetary terms, then the medical expenditure of the elderly would have helped to erode their well-being, along with the illnesses and their severity. Then, when retirement, loss of income, the cost associated with protracted ailments, and the psychological challenges associated with ageing are collated and included in the daily life of the elderly, within the context of a shrinking economy, rising prices, the poor and 32

the elderly in particular the poor aged would be more vulnerable than other age groups within this society. There is an interconnection between economics and demography. In that,

economists are concerned about human economic decisions at the micro and the macro level. The demographer, on the other hand, invests time in studying the science of human population. Therefore, while the demographer is not interested in the costing of decisions, the economist requires a thorough understanding of the principles of the human population, in an effort to effective comprehend how people within a particular geographic area are probable able to make decision. The interconnectivity is evident that at the London School of Economics, the

department of demography is a subsection. A study on the elderly published in the Caribbean Food and Nutrition Institute’s magazine Cajanus found that 70% of individuals who were patients within different typologies of health services were senior citizens (Caribbean Food and Nutrition Institute 1999; Anthony 1999). Among the many issues that the research reported on are the six major causes of morbidity and mortality identified by the Caribbean Epidemiology Centre that is of paramount importance to this discussion; the influence of - cerebrovascular, cardiovascular, neoplasm, diabetes, hypertension and acute respiratory infection (Figure 2.1). The diagram below depicts the ranked order of the five leading causes of death for people 65 and over of selected Caribbean countries in 1990.
Trinidad & Tobago St. Lucia
A cute respiratory inf ections

Monts errat

Hypertension Diabetes Neoplasm s Cardiovascular disease Cerebrovascular disease

Country

Jam aica

Guyana

Dom inica

Barbados

Baham as 0 1 2 3 4 5

Ranked Order of 5 leading causes of mortality

Figure 2.1: Ranked Order of the five leading causes of mortality in the population 65 yrs and older, 1990 Source: adopted from Caribbean Food and Nutrition Institute 1999: 222

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In seeking to explain the severity of the health status of Caribbean nationals, using Barbados and Jamaica, the Caribbean Food and Nutrition Institute (1999) presents the 5-leading causes of morbidity as reported by seniors. The data revealed that the primary cause of illnesses in Barbados and Jamaica was hypertension. In both countries, hypertension was a female phenomenon – in Barbados, females reporting 44.6% compared to 33.1% for males and in Jamaica it was 55.4% for females and 30.3% of males (Figure 2.2, below).

Stroke

Heart disease
Jamaica Female

Diseases

Arthritis

Jamaica Male Barbados Female

Dia betes

Barbados Female Barbados Male

Hyp erte nsion

0

20

40

60

Percentage

Source: Figure taken from Caribbean Food and Nutrition Institute 1999:225. Figure 2.2: Leading causes of self-reported morbidity in the population of seniors, by gender in Barbados and Jamaica.

The data in Figure 2.2 shows that hypertension and arthritis are morbidities that significantly plague both men and women in both Caribbean countries. These chronic noncommunicable diseases continue to interface within the functional lives of the elderly, which mean that they are indeed living longer but are faced with lowered wellbeing. Secondly, if they

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are poor with proper and adequate health care coverage – which could be private or public - the implications of the cost of care along with the daily living could further add stresses to the status of life experienced by the elderly. Hence, living longer although it is directly related to reduced mortality, this does not speak to the lifestyle changes and their positive influences on the wellbeing of seniors. A study conducted by Costa, using secondary data drawn from the records of the Union Army (UA) pension programme that covered some 85% of all UA, show there is an association between chronic conditions and functional limitation – which include difficulty walking, bending, blindness in at least one eye and deafness (Costa 2002). Among the

significant findings is – (i) the predictability between congestive heart failure of men and functional limitation (walking and bending). Although Costa’s study was on men, this equally applies to women as biological ageing reduces physical functioning, and so any chronic ailment will only further add to the difficulties of movement of the aged, be it man or woman. Like many developed countries, Jamaica is able to boast of its notable achievement in progress made toward advancing the health status of its populace, during the twentieth century – the postponement of death, lowering fertility, high nutrition and sanitation and more importantly the increasing life expectancy. Analyzing data on life expectancy indicate that the country’s health status is reasonably good, as the values for life span is similar to those in some First World societies – over 70 years. Nevertheless, those positives are not sufficient to outweigh the increases in chronic noncommunicable diseases - hypertension, diabetes, cardiovascular diseases, neoplasm, depression and arthritis. These diseases are on the rise in the world and are no different in Jamaica. They continue to plague those who are more so 60 years and older, of a particular socioeconomic status, and who live in rural Jamaica (Ministry of Health 2004, 133; Jamaica Social Policy Evaluation 2003; Planning Institute of Jamaica [PIOJ] and Statistical Institute of Jamaica [STATIN] 2000:58). In an article published by Caribbean Food and Nutrition Institute, the prevalence rate of diabetes mellitus affecting Jamaicans is higher than in North America and “many European countries”. (Callender 2000:67). Diabetes Mellitus is not the only challenge faced by patients, but McCarthy (2000) argues that about 30% to 60% of diabetics also suffer from depression, which is a psychiatric illness. Such a situation further complicates the woes of the elderly as they seek to balance other psychosological conditions with the diabetes and hypertension along with the stress which is frequently associated with the illness. 35

Furthermore, in attempting to contextualize the state of the Jamaican elderly, the researcher will provide a diagram depicting the five main causes of death by different age groups between 2002 and 2004. The diagram shows that while life expectancies are increasing, that mortality from non-communicable diseases such as heart diseases, cerebrovascular diseases and diabetes are indeed high for the elderly and are thereby lowering their wellbeing (Figure 2.3). In 2003, data presented by the Ministry of Health Jamaica in its ‘Annual Report’ showed that of the patients who are 65 years and older, 29.7% of them were discharged from inpatient care because of ‘circulatory system diseases’, and nutrition and endocrine ailments accounted for 12.6%. While it is true that these diseases influence physical inactivity, the conditions of coping with these as well as the cost of care undoubtedly should be aiding to lower the wellbeing status of these people.

70+ Other heart disease 60-69 Ischaemic 50-59

Age cohorts

Homocides 40-49

30-39

Diabetes

15-29

cerebrovascu lar

under 15

0

20

40

60

80

Percent dis tribution of 5 m ain caus es of deaths

Figure 2.3.: Percentage distribution of 5 main causes of deaths by age: 2002-2004 Source: Adopted from the Demographic Statistics, 2005, (STATIN 2006:x). Findings from studies by the Planning Institute of Jamaica show that while the general health status is commendable, increases in chronic illnesses are undoubtedly eroding the quality

36

of life enjoyed by people who are 65 years and older (PIOJ and STATIN 2000:58-59; 1997:45). The report revealed that, “In 2000, the survey also demonstrated the importance of recurrent (chronic) illness as the cause of ill health among the elderly” (PIOJ and STATIN 2000:58). How is the status of elderly within general setting of higher recurrence of chronic non-communicable diseases and their severity among senior citizens? Within the macho culture of Jamaica, generally, men do not seek preventative care because it is seen as weak. Such a position is learnt from the culture, which states that boys should “suppress reaction to pain” (Chevannes 2001:37).

State of the Elderly: Disparity in the Sexes Chevannes provided the explanation for this behaviour by men, that it is entrenched in social learning theory. Where the young imitates the roles of society’s members through rolemodeling of what constitutes acceptable and good roles which is supported by reinforcement (Chevannes 2001:17). The gender role of sexes is not limited to Jamaica or the Caribbean but a study carried out by Ali and Muynck (2005) of street children in Pakistan found a similar gender stereotype in that nation. It was a descriptive cross-sectional study carried out during September and October 2000, of 40 school-aged street children (8-14 years). The sample was substantially males (80%), with a mean age of 9 years (± 2 years). The methods of data collection were (i) semi-structured interviews, and (ii) a few focus group discussions. Ali and Muynck (2005) found that the sampled population would seek medical care based on severity of illnesses and financial situation. Another finding was that they referred to use home remedy. The reason being that mild ailment is not severity enough to barr them from physical functioning, which mean that they are okay; and so some morbidities are not for-hospital, which was so the case in Nairobi slums (Taff and Chepngeno 2005:421). PIOJ and STATIN (1998) report that “The difference by gender was significant, with 10.9 per cent of females reporting illness, compared with 8.5 per cent of males” (PIOJ and STATIN 1998:45), which is the case even in 2002, that is the rate was 14.6% for females and 10.4% for males, and in 2004 it was 13.6% for females and 8.9% for male (PIOJ and STATIN 2006; 2003). From statement in the JSLC 2000 “Women have traditionally utilized health care services more than men and these interactions have allowed closer monitoring and earlier diagnosis of health conditions among women” (PIOJ and STATIN 2001:58), then this begs the

37

question – Are the aggregate data reported reflecting the views of the elderly or more so the females? However, what is true is that they [men] will visit health practitioners because the states of their chronic impairments are severe. This is evident in the higher number of treated cases in some ailments over that of females – from the hospitalization discharge rate for the persons 65 years and over, the rate for men is 975.1 per 10, 000 compared to 817.1 per 10, 000 females. (Ministry of Health 2004:75, 133). The elderly, on the other hand, are more responsive to their ill-health and seek medical attention readily, but what about the psychological state of this age cohort from things such as – loss of partner, reduction in social support, fear of being victimized and so forth. As a result, it should not be surprising that the elderly Jamaicans seek more medical attention than other age cohorts, which is captured in them indicating more selfreported illnesses and injuries and a higher mean number of days spent in medical care (PIOJ and STATIN 2006; 2003; 1998). Hence, is the state of the elderly worse than that which is reported in the JSLC? It should be noted that the data presented in all the official statistics on the health status of Jamaicans are still measuring health using the old biomedical model (using reported and treated illnesses and/or injuries) - (JSLC; MOH 2004). This approach is single focused as it omits the role environment, social exclusion, fear of crime and victimization as well as depression, and stress among other factors as determinants of individuals’ wellbeing. Conclusion This paper responds to the underlining concerns of the continuous increase in population ageing in the world. The fast ageing of populations, unless managed in a proactive manner, could impose serious challenges for policy makers in the Caribbean and Jamaica. Noteworthy is that a particular level of economic development is needed in order to deal with the challenges of this demographic transition. The demographic composition and structure of future world population and subpopulation must be understood within policy framework. The challenges that are likely to arise from an ageing population on public expenditure, on pensions and health care, particularly in the absence of reforms in pensions and health services, could lead to a build-up of public debt in developing countries in specific Caribbean islands In conclusion, the graying of population is not restricted to developed societies such as Japan, Germany, Canada, China, United States and Italy to name a few, but it is a current reality for nations like Barbados, Trinidad and Tobago and Jamaica. Currently Jamaica does not see the

38

demographic transition of ageing as an issue but come 2030 or beyond, it will be a problem for many developing states including that of Jamaica. The yardstick that is used as a symbol of the impending problem in demographic ageing is if a state’s population 60 years or over is between 8 to 10 percent and beyond. The early signals of demographic ageing, in Jamaica, began as early as in the 1960s, when the society began experiencing mortality and fertility declines. With the introduction of family planning in the 1970s, the high fertility in the 1960s has been reduced by some 300%. Statistics reveal that the aged population of Jamaica is in excess of 10 percent as of 2005, within the context of an increasing decline in the population 0 to 14 years. This population (age cohort 0-14 years) stood at 40.3 percent in 1980 and in 25 years (2005), the population has being reduced to 31.2 percent. The conditions of ageing in Jamaica are not only a demographic issue but are disproportionately becoming a social, economic and political matter. In keeping with public health measure in the form of better sanitary, food and water security and quality and vaccination, mortality was cut, which is explanation for the high life expectancy of in excess of 75 years since 2004, to the best of the researcher’s knowledge, no study has sought to examine the likely socioeconomic costs of ageing come 2015 to 2050 and beyond. Despite all the gains of technology, public health, education, lifestyle behavioural practices and high life expectancy, non-communicable diseases are on the rise and continue to plague people age 60 years or over. Thus, accompanying population ageing is more ill-well senior citizens. Within this general setting, there is a need for medical research on the way forward in patient care as well as a demand exist for advanced quantitative assessment of the model, which will evaluate wellbeing of the Jamaican elderly. This will foster a comprehensive understanding of how health should be operationalized, and we then would be able to plan for ageing in more informed manner than what presently obtains in our society. One of the socioeconomic and political challenges that the Caribbean in particular Jamaica faces is the difficulty with which population ageing will become an economic cost. Population ageing does not simply mean “graying” of population (or proportionately more persons ages 60 years or older or 65+) but with living longer comes the responsibility of paying social security like pension for a longer period of time. Another issue that we have failed to address in all of this discussion is the lowered taxes that are going to be collected as a result of demographic ageing. Within the same construct is the dwindling of the children population and

39

lowered fertility, which means that come 2010 and beyond the elderly dependency ratio will be increasingly more than in previous years. These developments will mean challenges for public budgets, and health care expenditures. The reality is, demographic ageing is here in the Caribbean and equally so in Jamaica. Systems and structures are needed to addressing the new demand for this age cohort, along with the biopsychosocial state of ageing.

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Reference Ali, Moazzam, and de Muynck, Aime. 2005. Illness incidence and health seeking behaviour among street children in Pawalpindi and Islamabad, Pakistan – qualitative study. Child: Care, Health and Development 31: 525-32. Academic Search Premier, EBSCOhost (accessed February 13, 2007). Apt, N. 1999. Protection of rights of older persons In Ageing and Health: A global challenge for the twenty-first century. Proceedings of a WHO Symposium at Kobe, Japan 10-13 November 1998. Geneva: World Health Organization. Anthony, Beverley J. 1999. Nutritional Assessment of the elderly. The Caribbean Food and Nutrition Institute Quarterly 32:201-216. Barrett, V. 1987. Analysis of the Jamaica government’s policy (1981 – 1986) on institutional and community programmes for the elderly. Kingston: B.Sc. Public Administration, University of the West Indies, Mona. Bogue, D.J. 1999. Essays in human ecology, 4. The ecological impact of population aging. Chicago: Social Development Center. Brannon, Linda and Jess Feist. 2004. Health psychology. An introduction to behavior and health, 5th ed. Los Angeles: Wadsworth. Buzina, K. 1999. Drug therapy in the elderly. Cajanus 32:194-200. BRW. (1999). ‘Health care, or wealth care?’ Business Review Weekly, Vol. 27, June 11. Callender, J. 2000. Lifestyle management in the hypertensive diabetic. Cajanus, 33:67-70. Caribbean Food and Nutrition Institute. 1999a. Health of the elderly. Cajanus 32:217-240. ________. 1999b. Focus on the elderly. Cajanus 32:179-240. Charlesworth, B. 1994. Evolution in Age-structured Populations, 2nd ed. Cambridge: Cambridge University Press. Chevannes, Barry. (2001). Learning to be a man: Culture, socialization and gender identity in five Caribbean communities. Kingston, Jamaica: University of the West Indies Press. Chou, K.L. (2005). “Everyday competence and depressive symptoms: Social support and sense of control as mediators or moderators?” Aging and Mental Health 9, no.2:177-183. Academic Research Premier EbscoHost Research Databases (accessed 6 July 2006). Cowgill, Donald O. (1983). Growing Old in different Societies: Cross Cultural Perspectives. Quoted in Jay Sokolovsky. 1983. Belmont, California: Wadsworth Publishing. Eldemire, Denise (1997). “The Jamaican elderly: A socioeconomic perspective & policy implications”. Social and Economic Studies, 46: 175-193. Eldemire, Denise (1996). Older Women: A situational analysis, Jamaica 1996. New York, USA: United Nations Division for the Advancement of Women. Eldemire, Denise. (1995). A situational analysis of the Jamaican elderly, 1992. Kingston: The Planning Institute of Jamaica. Eldemire, Denise. (1994). The Elderly and the Family: The Jamaican Experience. Bulletin of Eastern Caribbean Affairs, 19:31-46. Eldemire, Denise. (1987a). The Elderly – A Jamaica Perspective. Grell, Gerald A. C. (ed). 1987. The elderly in the Caribbean: Proceedings of continuing medical education symposium. Kingston, Jamaica: University Printers. Eldemire, Denise. (1987b). The Clinical’s Approach to the Elderly Patient. Grell, Gerald A. C.

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(ed). 1987. The elderly in the Caribbean: Proceedings of continuing medical education symposium. Kingston, Jamaica: University Printers. Elo, Irma T. (2001). New African American Life Tables from 1935-1940 to 1985-1990. Demography, 38:97-114. Erber, Joan. (2005). Aging and older adulthood. New York: Waldsworth, Thomson Learning. International Labour Organization. (2000). Ageing in Asia: The growting need for social protection. Gavrilov, L. A., and N. S. Gavrilova. 2001. The reliability theory of aging and longevity. J. theor. Biol 213:527-545. Gavrilov, L. A and Gavrilova, N. S. 1991. The biology of ¸life Span: A Quantitative Approach. New York: Harwood Academic Publisher. Gavrilov, L. A., and P. Heuveline . (2003). Aging of Population. Quoted in the Encyclopedia of Population P. Demeny and G. McNicol, eds. New York: Macmillan. Goulding, M. R., and M.E. Rogers. 2003. Public Health and Aging: Trends in Aging --- United States and Worldwide. Atlanta, Georgia: Morbidity and Mortality Weekly Report 52:101106. Grell, Gerald A. C. (ed). (1987). The elderly in the Caribbean: Proceedings of continuing medical education symposium. Kingston, Jamaica: University Printers. Hambleton, Ian, R. Clarke, Kadene, Broome, Hedy, L. Brathwaite, Farley, Hennis, Anslm J. (2005). Historical and current predictors of self-reported health status among elderly persons in Barbados. http://journal.paho.org/?a_ID=138&catID= (accessed March 22, 2006). Jamaica Social Policy Evaluation. (2003). Annual progress report on National Social Policy Goals, 2003. Kingston, Jamaica: Government of Jamaica. Cabinet Office. Lauderdale, Diane S. (2001). Educational survival: Birth cohorts, period, and age effects. Demography 38:551-561. Lawson, Sylvia, C.C. (1996). “Culture and Aging: The case of Jamaican Elderly persons.” Paper presented at the Conference on Caribbean Culture, The University of the West Indies, Mona Campus – Jamaica, March 4-6, 1996. McCarthy, Frances M. (2000). Diagnosing and Treating Psychological problems in Patients with Diabetes and hypertension. CAJANUS 2000, 33:77-83. McEniry, M., Palloni, A., Wong, R., and Pelaez, M. (2005). “The elderly in Latin America and the Caribbean.” United Nations Expert Group Meeting on Social and Economic Implications of changing population Age structure, Population Division. Mexico City, Mexico: United Nations. http://www.un.org/esa/population/publications/EGMPopAge/12_McEniry_rev.pdf (accessed July 21, 2006). Manton, Kenneth G., and Land, Kenneth. (2000). Active Life expectancy estimates for the U.S. Elderly population: A multidimensional continuous-mixture model of functional change applied to completed cohorts, 1982-1996. Demography 37:253-265. Marcoux, Alain. (2001). Population ageing in developing societies: How urgent are the issues? Food and Agriculture Organization Women and Population Division.

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http://www.fao.org/sd/2001/PE0403a_en.htm (accessed February 4, 2007). Ministry of Health. Planning and Evaluation Branch. (2004). Annual Report 2003. Kingston, Jamaica: MOH. Mirkin, Barry and Weinberger, Mary B. (2001). The demography of population ageing. http://www.un.org/esa/population/publications/bulletin42_43/weinbergermirkin.pdf (accessed July 4, 2006). Quoted in United Nations Population Bulletin, Special Issue Nos 42/43, 2001. Population Ageing and Living Arrangements of Older Persons: Critical Issues and Policy Responses. Moore, E.G., Rosenberg, M. W., and McGuinness, D. (1997). Growting old in Canada: Demographic and geographic perspectives. Ontario, Canada: Nelson. Morrison, E. (2000). Diabetes and hypertension: Twin trouble. Cajanus 33:61-63. Pan American Health Organization. (1990). Adult Health in the Americas. Washington, D.C., United States: PAHO. ____________ and WHO. 1997. Health of the elderly aging and health: A shift in the paradigm. USA: PAHO and WHO. http://www. paho.org/English/GOV/CE/SPP/doc197.pdf. (accessed December 4, 2006). Peña, Manue. (2000). Opening Remarks and Greetings from the Pan American Health Organization. The Caribbean Food and Nutrition Institute Quarterly 33:64-70. Planning Institute of Jamaica. (2006). Economic and Social Survey Jamaica, 2005. Kingston, Jamaica: PIOJ. _____________. (2003). Jamaica Survey of Living Conditions 2002. Kingston, Jamaica: PIOJ and STATIN. _____________. (2001). Jamaica Survey of Living Conditions 2000. Kingston, Jamaica: PIOJ and STATIN _____________. (2000). Jamaica Survey of Living Conditions 1999. Kingston, Jamaica: PIOJ and STATIN. _____________. (1998). Jamaica Survey of Living Conditions 1997. Kingston, Jamaica: PIOJ and STATIN. Population Reference Bureau. (2007). Cross-national research on aging. Washington D.C.: Population Reference Bureau. http://www.prb.org/pdf07/NIACrossnationalResearch.pdf. Powell, Alfred. P., Bourne, Paul, and Lloyd Waller. (2007). Probing Jamaica’s Political culture, volume 1: Main trends in the July-August 2006 Leadership and Governance Survey. Kingston, Jamaica: Centre for Leadership and Governance, University of the West Indies, Mona. Preston, S.H., I.T. Elo, I. Rosenwaike, and M. Hill. (1996). “African American Mortality at Older Ages: Results of a Matching Study.” Demography, 33:193-209. Randal, J., and German, T. (1999). The ageing and development report: Poverty, independence, and the world’s people. London: HelpAge International. Quoted in World Health Organization. (2002). World report on violence and health. Geneva, Switzerland: WHO. Rowland, Donald T. (2003). Demographic methods and concepts. Oxford: Oxford University Press. Rudkin, Laura. (1993). Gender differences in economic well-being among the elderly of Java. Demography, 30:209-226. Smith, James P. and Raynard Kington. (1997a). Demographic and Economic Correlates of Health in Old Age. Demography, 34:159-170. Smith, K. R., and N. J. Waitzman. 1994. Double jeopardy: Interaction effects of martial and 43

poverty status on the risk of mortality. Demography 31:487-507. Statistical Institute of Jamaica (STATIN). (1972 – 2006). Demographic Statistics, various years. Kingston: STATIN. Taff, N., and G. Chepngeno. (2005). Determinants of health care seeking for children illnesses in Nairobi slums. Tropical Medicine and International Health 10:240-45. Thane, Pat . (2000). Old Age In English History Past Experience, Present Issues. Oxford, England: Oxford University Press. Turner, B. S. 1998. Ageing and generational conflicts: A reply to Sarah Irwin. British Journal of Sociology 49:299-320. United Nations. (2007). World Population Ageing 2007. Department of Economic and Social Affairs, Population Division. New York: UN ________. (2006). Statistical yearbook, 50th issue. Department of Economic and Social Affairs, Population Division. New York: UN ________. (2005c). World population prospect: The 2004 revision. Department of Economic and Social Affairs, Population Division. New York: UN. ________. (2003b). World population prospects: The 2002 revision Highlights. Department of Social and Economic Affairs, Population Division. New York: UN. Wise, David A. (1997). Retirement Against the demographic trend: More older people living longer, working less, and saving less. Demography, 34:17-30. World Health Organization. 2006. Elderly people: Improving oral health amongst the elderly. http://www.who.int/oral_health/action/groups/en/index1.html (accessed July 4, 2006). __________. (2005). Healthy life expectancy 2002: 2004 World Health Report. Geneva: WHO. http://www3.who.int/whosis/hale/hale.cfm?path=whosis,hale&language=english (accessed October 20, 2006) __________. (2002). World report on violence and health. Geneva: WHO. __________. (2000). World report on violence and health. Geneva: WHO. __________. (2000b). WHO Issues New Healthy Life Expectancy Rankings: Japan Number One in New ‘Healthy Life’ System. Washington D.C. & Geneva: WHO. http://www.who.int/inf-pr-2000/en/pr2000-life.html (accessed October 21, 2005). _________. (1999). World health report 1999. Geneva: WHO. __________. (1998a). Health promotion glossary. Geneva: World Health Organization. __________. (1998b. Primary prevention of mental, neurological and psychosocial disorder. Geneva: WHO. __________. (1998c). The world health report, 1998: Life in the 21st century a vision of all. Geneva: WHO.

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Table 2.1: Observed & Forecasted Percentage of Elderly 65 years or over in Selected Regions, and the World Countries: 1950, 1975, 2025 and 2050. 1950 % World Africa Latin America & the Caribbean Caribbean China India Japan Europe Italy Germany Sweden 5.2 3.2 1975 % 5.7 3.1 2007 % 7.5 3.4 2025 % 10.5 4.2 2050 % 16.1 6.7

3.7 4.5 4.5 3.3 4.9 8.2 8.3 9.7 10.3

4.3 5.4 4.4 3.8 7.9 11.4 12.0 14.8 15.1 10.5

6.3 7.8 7.9 5.4 27.9 16.1 20.4 19.6 17.6 12.4

10.1 11.4 13.7 8.1 35.2 21.0 26.4 23.9 22.1 17.7

18.4 18.9 23.6 14.8 41.7 27.6 35.5 25.4 24.7 20.6

USA 8.3 Source: United Nations, 2007

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Table 2.2: Observed & Forecasted Percentage of Elderly 60 years or over in Selected Regions, and the World Countries: 1950, 1975, 2025 and 2050. 1950 % World Africa Latin America & the Caribbean Caribbean China India Japan Europe Italy Germany Sweden 8.2 5.3 1975 % 8.6 5.0 2007 % 10.7 5.3 2025 % 15.1 6.4 2050 % 21.7 10.0

6.0 6.9 7.5 5.6 7.7 12.1 12.2 14.6 14.9

6.5 8.1 6.9 6.2 11.4 16.4 17.4 20.4 21.0 14.8

9.1 11.1 11.4 8.1 27.9 21.1 26.4 25.3 24.1 17.2

14.5 16.4 20.1 12.0 35.2 28.0 34.4 32.1 28.3 23.8

24.1 24.8 31.0 20.7 41.7 34.5 41.3 35.0 30.9 26.4

USA 12.5 Source: United Nations, 2007

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Part II: Health: An introduction

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Introduction
The historiographical view of health currently accounts for its transformation, products, measures and conceptualization. The contemporary conceptual of health dates back to the 1940s. In 1946, in the Preamble to its Constitution, the World Health Organization (WHO) wrote that health is more than the absence of diseases to physical, social and psychological wellbeing. Such a commutative perspective of health was in response to centuries of discourse on the minimization conceptualization and how the definition of health could be widened. The definition of health is important because it is a product, end and a component that is crucial to human existence and development.

The previous definition of health was a minimized one that was developed around a narrowed perspective, the antithesis of illness. In prehistoric times (10,000 BCE), health was viewed as endangerment of the body from outside sources, particularly spirits (in Jamaica is is referred to as “Duppy”). Such a narrowed conceptualization guide and formulate health care services, treatment and thinking. Simply put health and health response was primarily around the state of the human body. This belief continued into 1800-700 BCE when it was modified from the prehistoric definition to the emergence of endangerment of the gods, who send disease as a punishment for human wrongdoings. During this period, the cosmology of health was around religious interpretations, the epistemology of health was based on this religious cosmology.

Throughout the centuries the conceptualization of health has been modified to read disease, with less reference to god. However, the subculture of health was viewed as a gift from god, and that illness was a indicator of punishment. The definition of health, therefore, grew into the absence of illness, a narrow one but this guided intervention programmes. It was during the

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period of Galenian in Ancient Rome (130 CE – 200 CE) that health was viewed as the absence of pathogens, such as bad air or body fluids that cause disease. This led to a mechanical approach to the study of health and restoration of health, by extension the preservation of life.

The Ancient Romains believed that health was a positive illness – meaning that the cure for disease could result in healthy bodies (humans). This perspective embodies the biomedical model, the causal link between between disease and ill-health and the absence of illness and wellness. Such a viewpoint exclusively surrounds illness, the biological component, and not health, which heralded a mechanistic approach to studying and viewing health. The ushering of the biomedical approach to the study of health was a cross over of empiricism, logic, verification, reliability (consistency) and gradual development to health and health. Illness which was objectively measured supported a pure science approach, but excluded the other tenets that constitute a human. Humans are multidimensional beings, indicating that physical is a single component of whole person. People are, therefore, mind, body and social beings and any definition of health must constitute all these elements before we can state that we are addressing the concerns of humans.

Although the cosmology of humans is that of mind, body and social beings, the biomedical approach to health, health study and health measurement in still dominant. During the 20th century, while the biomedical model reins supreme, infectious diseases such as smallpox, yellow fever, tuberculosis, cholera and malaria ravished many lives and people wanted cures for those conditions. In response to finding cures, the association between illness and disease was critical as this enveloped the continuation of life outside of illnesses. The infectious diseases accounted for low life expectancy, and providing a cure for those health conditions

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would mean extending life and sharing all forms of development.

Following the epidemiological transition from infectious diseases to chronic health conditions (such as heart disease, hypertension, diabetes, arthritis, respiratory ailments), it began a discussion on the relevance of the biomedical model (Stone, 1987). The biomedical model was questioned by scholars as they sought a new paradigm that would be in keeping with multidimensional aspect of humans. Questionning the relevance of the biomedical model, fuelled plethora of propositions that final yield a biopsychosocial model that developed by Dr. George Engel. Engel’s explanations of curing mental health was totally in keeping with the broaden definition offered by the WHO.

It was not before the 1800ss (the time of Freud in Austria, late 1800s) that health was recognized as being influenced by emotions and the mind. Despite this recognition by Freud, health as a long history of the predominance of a narrowed perspectives, the absence of illness, that drove the pharmacological and medical technology industries. Those industries have spent billions of dollars on finding cures for particular ailments and health conditions, and in return have invested trillions of dollars on medicine, tools and approaches for addressing illness. The pharmacological and medical technology industries have a dominance of biomedical model that they continue to promote as relevant inspite of its one dimensional nature in health and health care.

This part (Part II) will explore the definitions and operationalizations of health as they will provide the basis upon which we can understand Jamaicans’ views on health and health care demand, provisions and allocations.

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Reference

Bourne, P.A. (2010). Health measurement. Health 2(5):465-476.

Stone, G.C. (1987). The scope of health psychology. In G.C. Stone, S.M. Weiss, J.D. Matarazzo, N.E. Miller, J. Rodin, C.D. Belar, et al. (Eds), Health psychology: A discipline and professional (pp. 27-40). Chicago: University of Chicago Press.

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Chapter

3 Health Measurement
Jamaicans are not atypical in how they conceptualize health and/or how they address patient care as the antithesis of diseases or dysfunctions (health conditions). In the 1900s and earlier, Western Societies were using the biomedical model in the measurement and treatment of health, health attitudes and the utilization of health services. This approach emphasizes sickness, dysfunction, and the identification of symptomology or medical disorders to evaluate health and health care. Such an approach places significance on the end (. genetic and physical conditions), instead of the multiplicity of factors that are likely to result in the existing state, or issues outside of the space of dysfunctions. Notwithstanding the limitations of the biomedical approach, it is still practiced by many Caribbean societies, and this is fundamentally the case in Jamaica. The current paper is an examination of health measurement, and provides at the same time a rationale for the need to have a more representative model as opposed to the one-dimensional approach of using pathogens in measuring health. Owing to the importance of health in development, patient care and its significance for other areas in society, this paper seeks to broaden more than just the construct, as it goes to the core of modern societies in helping them to understand the constitution of health and how patient care should be treated. Thus, it provides a platform for the adoption of the biopsychosocial model, which integrates biological, social, cultural, psychological and environmental conditions in the assessment of health and the outcome of research, by using observational survey data.

1. INTRODUCTION
The construct of health is more than a concept. It is a “leading characteristic of the members of a population...” [1] and, ergo, it plays a direct role in the images of health and health care. Among the plethora of reasons for the importance of health are not merely the images created by the construct, but also its contribution to the production of different tenets of human existence – illness, morbidity, comorbidity, disability, mortality, life expectancy, wellbeing, and so on, as well as the guide that it affords for health interactions and interventions. In addition to the aforementioned issues, it is of germane significance in aiding us to understand many of the things that we see. The definition of this single term ‘health’ is important, as a precise use of the 52

construct fashions and connects other important applications such as growth and development, productivity, health care and people’s expectations of health care professionals. One scholar, in helping us to understand the meaning of a construct, says that “without a well-defined construct, it is difficult to write good terms and to derive hypotheses for validation purposes” [2]. Embedded in Spector’s argument is the ‘theoretical abstraction’ of the construct, and how we may use it for outcome research. In this paper, the author will review the existing literature and identify particular measures of health, examining how these differ from the WHO’s conceptual definition of health [3]. At the same time, within the limitations of the biomedical model, the study will evaluate the usefulness of the biopsychosocial model in health and how the image of health influences the health care of people. 1.2 Image of Health Health, however, is more than a ‘theoretical abstraction’. There is an ‘objective reality’ to this construct. It explains life, and life is an objective reality. Furthermore, health is a valuable tool that ‘drives’ health policies and influences the determinants of health care. Then there is the issue of health care and how this is planned for, as well as the role that health plays in the development of a society. Health, wellbeing and poverty are well documented in developmental economics by scholars such as Amartya Sen, Paul Streeten and Martin Ravallion as having critical roles in understanding human development (or the lack of it). The fascination with health and wellbeing in developmental studies is primarily because of the direct association between development and health. Jamaica is not atypical in how its people conceptualize health and/or how they address patient care. In the 1900s and earlier, western societies used the biomedical approach in the measurement and treatment of health [5]. The biomedical approach emphasizes sickness,

dysfunction, pathogens, and disability and medical disorders in the construction of health. This approach places importance on the outcome (or the end) instead of the multidimensional conditions that are likely to result in the existing state. Notwithstanding the limitations of the biomedical approach, it is still practiced by many Caribbean societies, and this is fundamentally the case in Jamaica. This is atypical in many Western nations, as contemporary demographers still use the antithesis of illness and disability to write about health [6-8]. Rowland wrote that “Measures of population health are of general interest to demographers, sociologists, geographers and epidemiologists. Interdisciplinary concerns here include comparing national

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progress through the epidemiologic transition, and identifying social and spatial variations within countries in patterns of disease and mortality” [5]. The United States has left many Caribbean societies behind in how they conceptualize health and treat health care. As early as the commencement of the 20th century [4], the United States shifted their focus from negative wellbeing (antithesis of diseases) to positive wellbeing. The antithesis of diseases assumes a bipolar opposite between health and diseases. Embedded in this bipolar thinking is that for one to be healthy, he/she must not be experiencing any symptomology of dysfunctions. Hence, the health of people is measured by mortality or morbidity statistics. Health, however, is more than just the antithesis of diseases to positive psychology, inclusive of socio-cultural conditions and the environment. Positive wellbeing encapsulates the biomedical model in addition to psychological, socio-cultural and environmental conditions. The name that Engel gave to this new approach is the biopsychosocial model. The current paper is a discourse on the limitation of the biomedical model, which will provide a rationale for the need to have a more representative model as against this onedimensional approach to the measurement of health. Traditionally, health was conceptualised as the ‘antithesis of diseases’ [4]. Using the antithesis of diseases, this construct utilizes a minimization approach or a negative perspective, adopted by western societies, which saw health as the absence of dysfunctions, morbidity conditions or comorbidity. “This definition of health has been largely the result of the

domination of the biomedical sciences by a mechanistic conception of man. Man is viewed by physicians primarily as a physio-chemical system” [9]. With this thinking, health professionals’ evaluation of patient care and diagnostic treatments is based primarily on the identification of any symptomology of dysfunctions. Hence the standard that is used in the evaluation of health is the established norm of any deviation from diseases. Rather than conceptualizing health and stating its determinants, this approach uses the identification of symptomology to measure health. Therefore, life expectancy is used here as a measure of health. This assumes that once an individual is alive, it is because there are no dysfunctions to cause death. Embedded in this association is the influence of dysfunctions on health, but there are no other determinants of health except the various symptomologies of diseases. Outside of diseases, there are other determinants of health. Based on the biopsychosocial model that George Engel [10, 11] developed, he proposed an approach to the treatment of the

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health care of psychiatric patients that included biological, social and psychological conditions. Such a conceptual framework, unlike the biomedical sciences, introduces and identifies factors that are responsible for the health, and by extension the wellbeing, of a population. One scholar cites that “the states of health and disease [are] the expressions of the success or failure experienced by the organism in its efforts to respond adaptively to environmental changes” [12]. Again, when health is defined as the antithesis of diseases its determinant is solely biological, but this is clearly one-dimensional, and many scholars have shown that health is, in fact, multidimensional, and composed of biopsychosocial and environmental conditions. Another aspect to health is the positive association between the determinants of health and health care policies. Health care policy makers use the determinants of health as the benchmark that directs their planning. Therefore, when health policies are too narrow, the health determinants which fashion a population’s health care will take a minimal approach, as this is based on the image of health. One scholar puts it succinctly, “…health policies affect health through their effects on health determinants” [13], which speaks to the importance of ‘good’ hypotheses in the schema of things. It should be noted that the hypotheses allow us to derive the possible determinants of health, which would be used to evaluate the effectiveness of the health policy, and so show how they affect health (Figure 3.1).

Health Policy

Determinants of Health – Biological conditions

Health

Figure 3.1: The relation between health policy and health, and the roles of health determinants

The goal of the policy is to decrease the incidence of chronic diseases, high risk sexual behaviour/violence and injury through the adaptation of appropriate behaviours by the population and particularly young children, adolescents and young adults [14]. The general conceptualization of health in Jamaica is the “antithesis of diseases”. This explains why many people emphasize health care for morbidity conditions, genetics, or physical 55

functioning (their biology). Another indicator of the usage of this perspective can be seen in how data are collected on health in Jamaica and/or in the wider Caribbean. Such a situation highlights the minimization or substantially negative approach in the construct of health. Despite the title of the Ministry of Health’s ‘National Policy for the Promotion of Healthy Lifestyle in Jamaica’, throughout the paper the MOH [14] emphasizes mortality, diseases, dysfunctions and reproductive health, which highlights Jamaicans’ perspective on health. This is also evident in the Planning Institute of Jamaica which is responsible for policy, along with the Statistical Institute of Jamaica, collecting information on health by way of (1) preventative (behaviour modification), curative (surgical procedures, visits to health practitioners), restorative (physical rehabilitation), and palliative (. pain management) measures, and ownership of health insurance. Thus, the hypotheses that arise from the collected data are in keeping with the narrowed definition for which the data was initially gathered by the research design exercise. The

hypothesis of the presence of pathogens such as poor air being the cause of diseases, or classification of ill-health, is ancient, within the context that health has been expanding from mere physical functioning for some time. This hypothesis assumes that a person who does not have an ailment (or disease condition) is healthy, which is categorically false, as health psychologists have shown that psychological conditions do influence wellbeing [4]. This

perspective dates back to Galen in Ancient Rome (. 130 CE – 200 CE). A point is even more forcefully made in a study by two economists, which found a strong direct relationship between happiness and wellbeing [15]. Other researchers found an association between ‘positive and/or negative’ mood(s) and wellbeing [16]. This paper is in two parts, designed: (1) to provide detailed evidence that will support the rationale for an expanded concept which looks at health and wellbeing, and (2) to illustrate the purpose and significance of the expanded model that Engel termed the biopsychosocial model. This paper however is not arguing for a

biopsychosocial hybrid model, which would include biological, economic, social, cultural, psychological and ecological conditions.

2. P HYSICAL F UNCTIONING Caring for patients suffering from ill-health has a long history, which dates back to the Agrarian societies. During those earlier periods, man in his quest to address health conditions did so primarily from the standpoint of physical functionality. Based on the annals of time, the

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literature showed that people would treat biological dysfunctions and sometimes the ‘spirit’ in their pursuit of making man healthier. This approach dates back as far as ancient Rome (. 130 CE – 200 CE). Despite the WHO offering us a better way in the pursuit of happiness and wellness, man continues to return to the biomedical model of health. One of the reasons for the continued acceptance of the use of the biomedical model is the dominance of technology in this process. As technology is still primarily intended to address physical dysfunctions and the absence of pathogens, many studies conducted in early societies have not only linked the concept of health to medical conditions and by extension health care, but have served as another important indicator in determining lifespan. In 1884, an Englishman named Francis Galton who was both a mathematician and medical doctor researched the ‘physical and mental functioning’ of some 9,000 people between the ages of 5 and 80 years [17]. Galton wanted to measure the human life span in relation to the physical and mental functioning of people, so he sponsored a health exhibition that would allow him to collect data for analysis. Health was traditionally defined as the “antithesis of diseases”, which explains the predominance of physical functioning in policy making and health care, and justifies Galton’s wanting data on the physical functioning of people. The 20th century has brought with it massive changes in the typologies of dysfunctions, where deaths have shifted from infectious diseases such as tuberculosis, pneumonia, yellow fever, Black Death (. Bubonic Plague), smallpox and ‘diphtheria’ to illnesses such as cancer, heart disease and diabetes [14]. Although diseases have shifted from infectious to degenerate, chronic non-communicable illnesses and science, medicine and technology have expanded since then, and the image of health in contemporary Jamaica still lags behind many developed nations. Morrison [18] titled an article ‘Diabetes and Hypertension: Twin Trouble’ in which he establishes that diabetes mellitus and hypertension have now become problems in Jamaicans and in the wider Caribbean. This situation was equally corroborated by Callender [19] and Steingo [20] at the 6th International Diabetes and Hypertension Conference, which was held in Jamaica in March 2000. They found that there is a positive association between diabetic and hypertensive patients - 50% of individuals with diabetes had a history of hypertension [19, 20]. Prior to those scholars’ work, Eldemire [21] found that 34.8% of new cases of diabetes and 39.6% of hypertension were associated with senior citizens (. ages 60 and over). Accompanying this period of the ‘age of degenerative and man-made illnesses’ are life expectancies that now exceed 57

50 years. Before the establishment of the American Gerontology Association in the 1930s and their many scientific studies on the ageing process [17], many studies were done based on the biomedical model, . physical functioning or illness and/or disease-causing organisms [4]. Many official publications used either reported illnesses or the prevalence of seeking medical care for measuring sicknesses. Some scholars have still not moved to the post biomedical predictors of health status. The dominance of this approach is so strong and present within the twenty-first century, that many doctors are still treating illnesses and sicknesses without an understanding of the psychosocial and economic conditions of their patients. To illustrate this more vividly, the researcher will quote a sentiment expressed by a medical doctor in ‘The Caribbean Food and Nutrition Institute’s Quarterly [22]. A public health nutritionist, Dr. Kornelia Buzina [23], says, “When used appropriately, drugs may be the single most important intervention in the care of an older patient … and may even endanger the health of an older patient …” This proposition highlights the paradox in biomedical sciences as well as showing the need to expand the image of health beyond this negative approach to it. Within the context of the WHO’s definition and growing numbers of studies that have concluded that health should be a multidimensional construct, in 2007 a group of medical practitioners used physical functionality and dysfunctions to treat an elderly patient who was suffering from a particular health condition [24]. The researchers put forward an examination of a 74-year old man who with “...a long history of ischaemic heart disease, presented with increasingly prolonged episodes of altered consciousness” [24]. The physicians cite the

argument that “many elderly patients may have more than one cause for this symptom” [24], which summarizes their perspective and reliance on understanding medical disorders in the dispensing of patient care. Throughout the study, the scholars and medical practitioners did not seek to evaluate the psychological, social, and environmental conditions and their possible influence on the current state of dysfunction of the elderly patient. Despite the seeming

complexity of the result of the detailed inquiry into the neurological conditions of the patient, and the keen medical examination of the patient, his medical condition continued for years unabated. This emphasises the dominance of the biomedical model, and it goes beyond this single study, as a review of publications in the West Indian Medical Journal – a medical journal in Jamaica – from 1960-2009 revealed a few studies that have gone beyond the use of the 58

biomedical approach to the examination of patient care. In seeking to treat the 74-year old patient, the medical practitioners examined and reevaluated various medical problems. Thus, owing to the thinking of this group of researchers, they used ‘multiple medications’ in the treatment of the patient’s condition. It was clear from the perspective of the scholars that what guided their intervention were the biomedical sciences (. physical functionality or dysfunctions). In this case, health is the ‘antithesis of diseases’. It is the narrow definition of health – negative health (. biomedical approach) – which explains the image of health and health care for those scholars and researchers. Apart from the reasons for the use of diagnosed conditions, life expectancy and other physical issues are utilized in examining health, because of the precision in using them to evaluate health as against other approaches that are more holistic and broader in scope. 2.2 Health measurement The narrow definition of health is the “antithesis of diseases” which Longest [13] says is the “…absence of infection or the shrinking of a tumour” which can be called dysfunctions (see [1, 4]. As we mentioned earlier, the ‘antithesis of diseases’ idea dates back to Galen in Ancient Rome. It was widespread in the 1900s, and so medical professionals used this operational definition in patient care. Another fact during this time was that technology was fashioned in this regard, addressing solely physical dysfunctions. This definitional limitation may be a rationale for the World Health Organization, nearing the mid-1900s, declaring that health is the “state of complete physical, mental, and social wellbeing, and not merely the absence of diseases or infirmity” [3]. It should be noted that this conceptual definition which is in the Preamble to the constitution of the WHO which was signed in July 1946 and became functional in 1948, according to one scholar, from the Centre of Population and Development studies at Harvard University, is a mouthful of sweeping generalizations. According to Bok [25], the definition offered by the WHO is too broad and difficult to measure, and at best it is a phantom. Other intelligentsia point to the WHO’s definition as a difficulty for policy formulation, because its scope is ‘too broad’ [26]. The question is “Is the conceptual definition formulated by WHO so broad that those policies faced difficulty in formation”, and by extension should we regress to a pre-1946 conceptualization of health because a construct is difficult to operationalize today? Undoubtedly, health extends beyond diseases and is tied to cultural and psychological elements,

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personal responsibility, lifestyle, environmental and economic influences as well as quality nutrition [27-41]. Those conditions are termed determinants of health [26]. The WHO’s perspective must have stimulated Dr. George Engel to pursue a modification of the narrow approach to the health and health care debate. Dr. Engel was a psychiatrist who formulated the construct called the biopyschosocial model in the 1950s. He believed that when a patient comes to a doctor, for example for a mental disorder, the problem is a symptom not only of actual sickness (biomedical), but also of social and psychological conditions [10, 11]. He therefore campaigned for years for physicians to use the biopsychosocial model for the treatment of patients’ complaints, as there is an interrelationship between the mind, the body and the environment. He believed so deeply in the model, convinced that it would help in understanding sickness and providing healing, that he introduced it into the curriculum of Rochester medical school [42, 43]. Medical psychology and psychopathology was the course that Engel introduced into the curriculum for first year medical students at the University of Rochester. This approach to the study and practice of medicine was a paradigm shift from the biomedical model that was popular in the 1980s and 1990s. The Planning Institute of Jamaica and the Statistical Institute of Jamaica employ the biomedical model in capturing the health status and/or wellbeing of the populace. This approach was obsolete by the late 20th century, as in 1939 E.V. Cowdy, a cytologist in the United States; expanded on how ageing and health status should be studied in the future. Cowdy broadened the biomedical model in the measurement of the health status of older adults by including social, psychological and psychiatric information in his study entitled the “Problem of Ageing” [17]. The Ministry of Health [MOH] [14], however, has published a document in which it shows that health interfaces with biomedical, social and environmental conditions. One of the reasons put forward by the MOH to help in understanding why they arrived at the aforementioned position, was the rationale behind the explanation for the changes in the typology of diseases – that is, from infectious and communicable diseases to chronic conditions. The institution cites that this is substantially because of the lifestyle practices of Jamaicans. One of the ironies within the document was in the ‘main components of the policy for the promotion of a healthy lifestyle in Jamaica’, which cites that the goal of the policy was to reduce the incidence of communicable and infectious diseases, which speaks to society’s subconscious emphasis on the biomedical model in conceptualizing health and its treatment. Embedded within the MOH’s 2004 60

publication are repetition and the focus on seeking to reduce physiological conditions that affect the individual. The MOH admits, however, that health interfaces with body and environment, which is an expansion of the biomedical model, but all indications in their document point to the biomedical science approach in the application of the policy. The institution recognized that psychological factors (for example, self-esteem, and resilience) play a role in influencing health, so much so that it included these within its ‘goal of the strategic approach’, but they were not supported in the ‘broad objectives of the strategic approach’. Critical to all of this is the acceptance that the definition of health is fundamental to the construction of those hypotheses that are used to formulate health policies. According to Longest [13], the conceptualization of health is indeed critical to all the things that rely on its definition. Longest writes: The way in which health is conceptualized or defined in any society is important because it reflects the society’s values regarding health and how far the society might be willing to go in aiding and supporting the pursuit of health among its members [13]. In Jamaica health policies are still driven by physical functioning, which is an obsolete approach to addressing health and by extension wellbeing. This limited approach to health and wellbeing means that little consideration is given to other factors such as lifestyle, psychological state, the environment, crime and violence, among others. This of course implies that Jamaica’s health policy is limited in its orientation, as it is largely driven by hypotheses that support physical functioning. 2.3 Biomedical Approach Dr. Buzina admits that wellbeing is fundamentally a biomedical process [23]. This conceptual framework derives from the Newtonian approach of basic science as the only mechanism that could garner information, and empiricism being the only apparatus to establish truth or fact. It is still a practice and social construction that numerous scholars and medical practitioners [24] continue to advocate despite new findings. Simply put, many scholarships still put forward a perspective that the absence of physical dysfunction is synonymous with wellbeing (or health, or wellness). Such a viewpoint appears to hold some dominance in contemporary societies, and this is a widespread image held in Jamaica. Then there are issues such as the death of an elderly person’s life-long partner; a senior citizen taking care of his/her son/daughter who has HIV/AIDS; an aged person not being able to afford his/her material needs; someone older

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than 64 years who has been a victim of crime and violence and continues to be a victim; seniors who reside in volatile areas who live with a fear of the worst happening, the inactive aged, and generally those who have retired with no social support, are equally sharing the same health status as the elderly who have not been on medication because they are not suffering from biomedical conditions to the extent that they need to be given drugs. Two medical doctors writing in Kaplan and Saddock’s Synopsis of Psychiatry noted that physicians are frequently caught in theorizing that normality is a state of health [44]. They argued that doctors’ definition of normality correlates with a traditional model (biomedical) that emphasizes observable signs and symptoms. Using psychoanalytic theories, Saddock and Saddock [44] remarked that the absence of symptoms as a single factor is not sufficient for a comprehensive outlook on normality. They stated, “Accordingly, most psychoanalysts view a capacity for work and enjoyment as indicating normality…” [44]. Among the challenges associated with this method (biomedical model), is its emphasis only on curative care. Such an approach discounts the importance of lifestyle and preventative care. In that, health is measured based on experiences with illnesses and/or ailments, with limited recognition being placed on approaches that militate against sickness and/or diseases. The biomedical approach is somewhat biased against an understanding of multi-dimensional man, which is not in keeping with the holistic conceptualization of health as offered by the WHO.

2.4 Biopsychosocial Approach
In the 1950s, George Engel, a physician, teamed with John Romano, a young psychiatrist, to develop a biopsychosocial model for inclusion in the curriculum of the University Of Cincinnati College Of Medicine, which measured the health status of people. It is referred to as Engel’s biopsychosocial model. Engel’s biopsychosocial model [10, 11, 43], recognized that psychological and social factors coexisted along with biological factors. It was a general theory of illness and healing, a synergy between medicine, psychiatry and the behavioural sciences [42]. Therefore, from Engel’s model, wellbeing must include factors such as motivation, depression (or the lack thereof), biological conditions (such as illnesses and diseases), social systems, cultural, environmental and familial influences on the appearance and occurrence of illness. Some scholars may argue that this paper appears to believe that only quantitative studies may provide answers to the examination of the determinants of health. This is absolutely not so,

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and we use a qualitative study to show people’s perception of what contributes to a particular medical condition. In a qualitative study that uses in-depth interviews with some 17 Malaysian men aged between 40 and 75 years old, some scholars examined the perception of these men in relation to erectile dysfunction (ED) – the sample was a convenient one of men who were suffering from ED and who were willing to speak about their condition. When the interviewers asked the participants about the possible causes of ED, many of them outlined biomedical conditions such as diabetes, hypertension, medications, past injuries, ageing and then came lifestyle practices (. smoking) and psychosocial factors [45]. Embedded in this perception is the respondents’ emphasis on pathophysiological conditions in health measurement and intervention. Although the sampled respondents do believe that psychosocial factors play a role in health status, it should be noted here that they did not itemize those conditions. This speaks to the conceptualization of health that these respondents have come to accept, and the fact that they believe that health is not limited to biomedical sciences. Using their definition of health, the study shows how culture plays a pivotal role in determining how men will seek health care irrespective of the nature of their condition. According to a number of demographers [46, 47], health has been conceptualized as “functioning ability”. These pundits categorized “functioning ability” as – (i) being able to provide both personal care and independent living but having some difficulty in performing these tasks or in getting about outside the home, (ii) having no functioning difficulties, (iii) being unable to independently provide personal care, and finally (iv) being able to provide personal care but not able to manage life in the home independently” [46]. 3.0 EXPANSION OF THE B IOMEDICAL MODEL Studies reveal that positive moods and emotions are associated with wellbeing [48] as the individual is able to think, feel and act in ways that foster resource building and involvement with particular goal materialization [49]. This situation is later internalized, causing the

individual to be self-confident, from which follow a series of positive attitudes that guide further actions [50]. Positive mood is not limited to active responses by individuals, but a study showed that “counting one’s blessings,” “committing acts of kindness”, recognizing and using signature strengths, “remembering oneself at one’s best”, and “working on personal goals” all positively

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influence wellbeing [50,51].

Happiness is not a mood that does not change with time or

situation; hence, happy people can experience negative moods [52]. Human emotions are the coalescence of not only positive conditions but also negative factors [53]. Hence, depression, anxiety, neuroticism and pessimism are seen as a measure of the negative psychological conditions that affect subjective wellbeing [54-56]. From Evans and colleague [54], Harris et al. [55] and Kashdon’s monographs [56], negative psychological conditions affect subjective wellbeing in a negative manner (. guilt, fear, anger, disgust); and the positive factors influence self-reported wellbeing in a direct way - this was corroborated in a study conducted by Fromson [57]; and by other scholars [53, 58,59]. Acton and Zodda [60] aptly summarized the negative affective of subjective wellbeing in the sentence that reads “expressed emotion is detrimental to the patient's recovery; it has a high correlation with relapse to many psychiatric disorders.” From the theologians’ perspective, spirituality and religiosity are critical components in the lifespan of people. They believe that man (including woman) cannot be whole without religion. With this fundamental concept, theologians theorize that man cannot be happy, or feel comfortable without a balance between spirit and body [62]. In order to achieve a state of personal happiness, or self-reported subjective wellbeing, some pundits put forward a construct that people are fashioned in the image of God, which requires some religiosity before man can be happy or less stressed. Religion is, therefore, association with wellbeing [63-65] as well as low mortality [66]. Religion is seen as the opiate of the people from Karl Marx’ perspective, but theologians, on the other hand, hypothesize that religion is a coping mechanism against unhappiness and stress. According to Kart [67], religious guidelines aid wellbeing through restrictive behavioural habits which are health risks, such as smoking, drinking alcohol, and even diet. The discourse of religiosity and spirituality influencing wellbeing is well-documented [68, 69]. Researchers have sought to concretize this issue by studying the influence of religiosity on quality of life, and they have found that a positive association exists between those two phenomena [70]. They found that the relationship was even stronger for men than for women, and that this association was influenced by denominational affiliation. Graham et al.’s [71] study found that blood pressure for highly religious male heads of households in Evans County was low. The findings of this research did not dissipate when controlled for age, obesity, cigarette

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smoking, and socioeconomic status. A study of the Mormons in Utah revealed that cancer rates were lower (by 80%) for those who adhered to Church doctrine [72, 73] than those with weaker adherence. In a study of 147 volunteer Australian males between 18 and 83 years old, Jurkovic and Walker [65] found a high stress level in non-religious as compared to religious men. The researchers in constructing a contextual literature quoted many studies that have made a link between non-spirituality and “dryness”, which results in suicide. Even though Jurkovic and Walker’s research was primarily on spiritual wellbeing, it provides a platform that can be used in understanding the linkages between the psychological status of people and their general wellbeing. In a study which looked at young adult women, the researchers found that spirituality affects the physical wellbeing of a populace [69]. Embedded within that study is the positive influence of spirituality and religion on the health status of women. Edmondson et al.’s work constituted of 42 female college students of which 78.8 percent were Caucasian, 13.5 percent African-American, 5.8 percent Asian and 92 percent were non-smokers. Health psychologists concurred with theologians and Christians that religion influences psychological wellbeing [74, 75]. Taylor [74] argued that religious people are more likely to cope with stressors than non-religious individuals, which explains the former’s better health status. She put forward the position that this may be done through avoidance or vigilant strategies. This response is an aversive coping mechanism in addressing serious monologue or confrontational and traumatic events. Coping strategies, therefore, are psychological tools used by individuals to problem-solve issues, without which they are likely to construct stressors and threaten their own health status. Taylor [74] said that "some religious beliefs also lead to better health practices", producing lower mortality rates from all cancers in Orthodox Christians. 4. EVIDENCE OF USE FOR BIOPSYCHOSOCIAL MODEL Even though policy makers are cognizant of the importance of healthy lifestyle practices and their influence on wellbeing [76], we continue to sideline them in understanding health status, and using this concept in the formulating of hypotheses that will drive a broader policy focus of health care for the populace. This is evident in our neglect to expand studies for policy purposes that collect data on health using the biopsychological model, meaning that policy formulators are emphasizing physical vulnerability or dysfunction to measure health status. Is there a study that has sought to use a maximization definition of health that will be able to better

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evaluate and plan for the wellbeing of Jamaicans? A study conducted in Barbados reveals that there is a statistical causal relationship between socioeconomic conditions and health status. The findings revealed that 5.2% of the variation in reported health status was explained by the traditional determinants of health (disease indicators – Table 1.1.1). Furthermore, when this was controlled for current

experiences, the percentage fell to 3.2% (falling by 2%). When the current set of socioeconomic conditions were used they accounted for some 4.1% of the variations in health status, while 7.1% were due to lifestyle practices, compared to 33.5% that were as a result of current diseases [34]. It holds that the importance placed by medical practitioners on the current illnesses – as an indicator of health status – is not unfounded as people place more value on biomedical conditions as being responsible for their current health status. Despite this fact, it is obvious from the data – using 33.5% - that there are other indicators that explain some 67.5% of the reason why health status should be as it is. Furthermore, with an odds ratio of 0.55 for number of illnesses, there is a clear suggestion that the more people reporting illnesses, the lower will be their health status [34]; and this was equally so for more disease symptoms – odds ratio was 0.71). Figure 1 above is a depiction of the use of the biopsychosocial model in the study of health status. This research was conducted in Barbados between 1999 and 2000, in which health status was predicted by a composite function of five general typologies of variables. The model shows that health status is not primarily limited to biomedical conditions – such as diseases and ailments – as has been the custom of many scholars. While different indicators as used by these researchers may not be possible in this paper because of the limitation of the secondary dataset – for example ‘current lifestyle risk factors’, ‘childhood nutrition’, ‘childhood diseases’, ‘environmental factors’, to name a few – despite the data’s shortcomings, the study emphasizes the use of a multidimensional approach in the study of wellbeing. Bourne [27], using secondary data, encapsulates George Engel’s conceptual idea of a multidimensional model which incorporates biological, social, psychological, environmental and social conditions in examining wellbeing. Wellbeing is operationally defined as material resources, illness and total expenditure of households. The sample is drawn from a nationally representative survey of 25,018 Jamaicans, some 9.3% of the sample being elderly. From a

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sample of 2,320 elderly Jamaicans (ages 65+ years), Bourne [27] found that 10 of the 14 predisposing variables explain 36.8% of the variance in wellbeing. Of the 10 statistically

significant variables, the five most important ones, in descending order, are (1) area of residence (β=0.227), (2) cost of medical care (β=0.184), (3) psychological conditions – [total positive affective conditions] - (β=0.138), (4) ownership of property (β=0.135), and (5) crime (β=0.111). Among the other factors, which are the 5 least important conditions, are negative affective conditions, marital status, educational level, average occupancy per room, age of residents, and the environment. Thus, whether or not we use Grossman’s model [77], Hambleton et al.’s model [34] or Bourne’s models [27-33] it is clear from them that wellbeing extends beyond biological conditions to include psychological, environmental, and social conditions. Another study was conducted by Bourne [30] of some 3,009 elderly Jamaicans (60 years and older), with an average age of 71 years and 10 months ± 8 years and 6 months, of which 67% (n=2,010) resided in rural areas, 21% (n=634) dwelled in Other Towns and 12% (n=365) lived in the Kingston Metropolitan Area. The mean General Wellbeing of elderly Jamaicans was low (3.9 out of 14 ± 2.3). Bourne’s model [30] identified 10 explanatory variables which explain 40.1% (adjusted R-squared) of the variance in general wellbeing. In this study he deconstructed the general model into (1) economic wellbeing and (2) physical wellbeing (proxy by health conditions). Using the same set of explanatory variables, the latter model explains 3.2% of the variability in wellbeing (proxy by health conditions) compared to 41.3% for the former model (. economic wellbeing using material economic resources). General Wellbeing was operational as material resources and functional limitation (or health conditions). Material economic resources constitute ownership of durable goods (such as motor vehicles, stereo, washing machines, et cetera); income (proxy by income quintile); and financial support (e.g. social security and other pensions). Hence, it follows that the biopsychosocial model is a better proxy for wellbeing; and that functional limitation is still not a good proxy for wellbeing as used by Hambleton et al. Grossman and even Smith and Kington [78]. Globally, regionally and especially domestically, the most popular space in research concerning wellbeing is the biomedical approach; its popularity is fuelled by the combination of the traditional operational definition of health (good physical health) and the dominance of the medical sciences in this field of enquiry. The number of studies on mortality, structural

alterations and functional declines in body systems, genetic alterations induced by exogenous

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and endogenous factors, prevalence and incidence of diseases, and certain diseases as determinants of health, clearly justifies establishing leniency towards medical science in the study of health and health care. Engel [10, 11] accredited the biomedical model that governs health care to the practice of pundits over the last 300 years. psychosocial processes are independent of the disease process. This model assumes that Engel argued for the bio-

psychosocial model that it includes biological, psychological, and social factors, which is a close match to the multi-dimensional aspect of man. With this as the base, it can be construed from Engel’s thrust behind the biopsychosocial model that the previous model is a reductionistic model. Engel’s biopsychosocial model in analyzing health emphasizes both health and illness, and maintains that health and illnesses are caused by a multiplicity of factors. Engel’s

theorizing, therefore, is better fitted for the definition of health coined by the World Health Organization. In Jamaica, only a miniscule number of studies have sought to analyze the effect of the death of a family member or close friend, violence, joblessness, psychological disorders and sexual abuse, on wellbeing, or social change on health, area of residence on quality of life and the perception of ageing and its influence on health conditions. Morrison [18] alluded to a transitory shift from infectious communicable diseases to chronic non-communicable diseases as a rationale for the longevity of the Anglophone Caribbean populace. This was equally endorsed by Peña [79], the PAHO/WHO representative in Jamaica. They argued that this was not the only reason for the changing life expectancy. Morrison summarized this adequately, when he said that: Aiding this transition is not only the increased longevity being enjoyed by our islanders but also the changing lifestyle associated with improved socioeconomic conditions [18] With the post-1994 widened definition of health as put forward by the WHO, people are becoming increasingly cognizant of the fact that socio-cultural factors such as geographical location, income, household size and so on, as well as several psychological factors, explain wellbeing; hence the new definition of health has coalesced biomedical variables and sociocultural and psychological variables in the new discourse on wellbeing. Stressors may arise from within the individual or outside his/her environment. One such external stressor that may affect the individual is the death of loved ones. Response to the mortality of close family members may be more traumatic, depending on expectancy or non-

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expectancy. Bereavement influences the incidence of mortality. This may result in exhaustion of the individual's 'adaptive reserve'. The person’s body wears down and becomes highly vulnerable to morbidity and even death. Rice put forward a study that contradicted an association between bereavement and mortality. He wrote that "Fathers who lost sons in war had lower mortality rates than those who lost son in accidents" [75]. Despite that study, Rice quoted other studies [80] that showed the impact of stress on human physiology. He argued that it is suppression during and after bereavement that creates the stressors, which become potent devices for mortality and morbidity. Lusyne, Page and Lievens’ [81] study finds that there is an association between bereavement and mortality. However, this is more likely to occur in the short-run (. during the first 6 months after the death of the spouse). As there are a number of confounding situations which in the long-run could offset the likelihood of mortality, such as remarriage, social support from other family members, grandchildren and so on, bereavement may not necessarily be a constant in one’s life. Nevertheless, Lusyne, Page and Lievens affirm with other studies that the loss of a long-time partner may result in the death of the living spouse. The explanations given for this eventuality are – (i) role theory as the surviving partner may find the role played by the other partner too stressful and so (ii) may not be able to adapt to the new role alone; this is more a male phenomenon [81]. The Planning Institute of Jamaica and Statistical Institute of Jamaica collect data on illhealth, and questions are asked based on visits to health practitioners, healers and pharmacies, injuries, ailments, ownership of health insurance, duration of the disease or illness, cost of treatment for ailments and injuries, and mental disability. Those questions are clearly derivatives from the biomedical model, as they seek to address physical functioning without equally emphasizing culture, lifestyle behaviour, depression, stress, fatigue, trust for others, perception of one’s position in current society and the likelihood of one’s place in the future, religiosity, time periods, HIV/AIDS of family members or the individual and how it is likely to influence the his/her health and wellbeing, social involvement in various institutions, and issues on positive affective conditions.

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5. CONCLUSION In sum, any definition of the construct of health must be multidimensional in nature. Such a definition must include (1) personal and environmental conditions, (2) social factors, (3) psychological conditions, (4) diagnosed illness, and (5) self-determination of wellbeing. If health is solely based on illnesses (biomedical model), we would have failed in our bid to operationally define a construct that is comprehensive enough to encapsulate all the tenets that would capture man in his complex milieu. Health is not simply a construct. It plays a critical role in the formulation of policy for health care, and in the development of the society. Thus, if we emphasize only the biomedical approach to the study of health, its underpinnings could only be symptomology. This approach fails to capture issues outside of the mechanistic structure of man’s conception of biomedical sciences. Concurringly if health care professionals were to use as their premise dysfunctions to indicate health, which is the deviation from the norm, this image of health would affect policy formulation and intervention programmes which are geared towards this narrow conceptualization. But this approach lacks are clear characteristics outside of illnesses that will encapsulate wellness, wellbeing, and healthy life expectancy in a multidimensional human. Thus, the biomedical model relies on illness identification to capture health and this fashions the health care system, which also limits health coverage outside of this negative view of health. This is undoubtedly suboptimal, and does not account for health. The health services in the Caribbean, and in particular Jamaica, are best described as medical services, as they are still fundamentally structured around the biomedical model which is embedded as the image of health, and not psychosocial, economic and ecological wellbeing. Although the WHO as early as the 1940s provides a definition of health that is comprehensive and complex, some scholars believe that it is elusive and by extension immeasurable. There are merits to the argument of those academics, but the emphasis should not be the difficulty of how operationalizing the construct labels it ‘elusive’. Instead the goal should have been for

researchers and academics alike to formulate a working definition of the conceptual framework created by the WHO. Thus, when Grossman in the 1970s moved away from the difficulty posed by the WHO’s conceptual framework, he developed an econometric framework that laid the foundation for the measure of this seemingly ‘elusive’ construct. Other scholars have built on the initial theoretical model introduced by Grossman, and Bourne in particular has added

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psychological and environmental conditions to the already established factors of the health model. The constitution of the World Health Organization (WHO) states that “Health is a state of complete physical, mental and social well-being and not merely the absence of diseases or infirmity”, [3]. Hence, any use of morbidity statistics, dysfunctions, sickness, diseases or illhealth to conceptualize health is limited, and by extension is a negative approach to the treatment of this construct. Health, health care, and patient care are critical components in development, as unhealthy people will not be able to offer to the society their maximum, neither will they be able to comparatively contribute the same to productivity and production as their healthy counterparts. Therefore, the conceptualization of health is not merely a concept but a working product that affects all aspects of society.

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6. REFERENCE 1. Lamb, V., and Siegel, J.S. (2005. Health demography. In Siegel, J. S., and Swanson, D. A, (Ed). The Methods and Materials of Demography, 2nd. Elsevier Academic Press, San Diego, pp. 341-363. 2. Spector, P. E. (1992) Summated rating scale construction. An introduction. London: Sage Publication. 3. World Health Organization. (1948) Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, June 19-22, 1946; signed on July 22, 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on April 7, 1948. “Constitution of the World Health Organization, 1948.” In Basic Documents, 15th ed. Geneva, Switzerland 4. Brannon, L., and Feist, J. (2007) Health psychology. An introduction to behavior and health, 6th ed. Wadsworth, Los Angeles. 5. Rowland DT. (2003) Demographic methods and concepts. Oxford University Press, New York. 6. Seigel, J. S., and D. A. Swanson, eds. (2004) The methods and materials of demography, 2nded. Elsevier Academic Press, San Diego. 7. Spiegelman, M. (1980) Introduction to demography, 6th. Harvard University Press, Boston. 8. Shryock, H.S., J. S. Siegel, and Associates. (1976) The methods and materials of demography, (condensed edition by Edward G. Stockwell). Academic Press, San Diego. 9. Smith, J.A. (1983) The idea of health: Implications for the nursing professional. Teachers College, New York. 10. Engel, G. L. (1977) the need for a new medical model: A challenge for biomedicine. Science, 196, 129-136. 11. Engel, G. L. (1980) The clinical application of the biopsychosocial model. American Journal of Psychiatry 137, 535-544. 12. Dubos, R. (1965) Man adopting. Yale University Press, New Haven. 13. Longest, B. B. (2002) Health Policymaking in the United States, 3rd. Foundation of the American College Healthcare, Chicago. 14. Ministry of Health, [MOH]. (2004) National Policy for the Promotion of Health Lifestyle in Jamaica. MOH, Kingston. 15. Stutzer, A., and Frey, B. S. (2003) Reported subjective well-being: A challenge for economic theory and economic policy. http://www.crema-research.ch/papers/2003-07.pdf (accessed August 31, 2006). 16. McConville, C., Simpson, E.E. A., Rae, G., Polito, A., Andriollo-Sanchez, Z., Meunier, N., Stewart-Knox, O’Connor, J.M., Boussel, A.M., Cuzzolaro, M., and Coudray, C. (2005) Positive and negative mood in the elderly: the Zenith study. European Journal of Clinical Nutrition, 59, 22. 17. Erber, J. (2005) Aging and older adulthood. Waldsworth, Thomson Learning, New York. 18. Morrison, E. (2000) Diabetes and hypertension: Twin trouble. Cajanus, 33, 61-63. 19. Callender, J. (2000) Lifestyle management in the hypertensive diabetic. Cajanus, 33, 6770. 20. Steingo, B. (2000). Neurological consequences of diabetes and hypertension. Cajanus,

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59. Watson, D., Clark L.A., and Tellegen, A. (1988) Development and validation of brief measures of positive and negative affect: The PANAS Scale. Journal of Personality and Social Psychology, 54, 1063-1070 60. Watson, D., Clark, L.A., and Tellegen, A. (1988) Positive and negative affectivity and their relation to anxiety and depressive disorders. Journal of Abnormal Psychology, 97, 346-353 61. Acton, G. S. and Zodda, J. J. 2005. Classification of psychopathology: Goals and methods in an empirical approach. Theory of Psychology, 15, 373-399. 62. Whang, K. M. (2006) Wellbeing syndrome in Korea: A view from the perspective of biblical counseling. Evangelical Review of Theology, 30, 152-161. 63. Krause, N. (2006) Religious doubt and psychological well-being: A longitudinal investigation. Review of Religious Research, 47, 287-302. 64. Moody, H. R. (2006). Is religion good for your health? The Gerontologist, 14, 147-149. 65. Jurkovic, D. and Walker, G. A. (2006) Examining masculine gender-role conflict and stress in relation to religious orientation and spiritual well-being in Australian men. The Journal of Men’s Studies, 14, 1:27-46. 66. House, J.S., Robbins, C., and Metzner, J.L. (1982) The Association of Social Relationships and Activities With Mortality: Prospective Evidence From the Tecumseh Community Health Study. American Journal of Epidemiology, 116, 123-140. 67. Kart, C. S. (1990) The Realities of Aging: An introduction to gerontology, 3rd. Allyn and Bacon, Boston. 68. Frazier, C., Mintz, L. B. and Mobley, M. (2005) A Multidimensional Look at Religious Involvement and Psychological Well-Being Among Urban Elderly African Americans. Journal of Counseling Psychology, 52, 583-590. 69. Edmondson, K.A., Lawler, K.A., Jobe, R.L., Younger, J.W., Piferi, R.L. and Jones, W.H. (2005) Spirituality predicts health and cardiovascular responses to stress in young adult women. Journal of Religion and Health, 44, 161-171. 70. Franzini, L., and Fernandez-Esquer, Maria Eugene. (2004) Socioeconomic, cultural, and personal influences on health outcomes in low income Mexican-origin individuals in Texas. Social Sciences and Medicine, 59, 1629-1646. 71. Graham, T. W., B. H. Kaplan, J. C. Cornoni-Huntley, S. A. James, C. Becker, C. G. Hames, and S. Heyden. (1978) Frequency of church attendance and blood pressure elevation. Journal of Behavioral Medicine, 1, 37-43. 72. Gardner, J.W., and Lyon, J.L. (1982) Cancer in Utah Mormon men by lay priesthood level. American Journal of Epidemiology, 116, 243-257. 73. Gardner, J.W., and Lyon, J.L. (1982) Cancer in Utah Mormon women by church activity level. American Journal of Epidemiology, 116, 258-265. 74. Taylor, S. (1999) Health psychology, 4th ed. United States of America: McGraw-Hill. 75. Rice, P. L. (1998) Health psychology. Brooks/Cole Publishing, Los Angeles. 76. Jamaica Social Policy Evaluation [JASPEV]. (2003). Annual Progress Report on National Social Policy Goals 2003. Cabinet Office, Kingston. 77. Grossman, M. (1972) The demand for health- a theoretical and empirical investigation. National Bureau of Economic Research, New York. 78. Smith, J. P., and Kington, R. (1997) Demographic and Economic Correlates of Health in Old Age. Demography, 34, 159-170. 79. Peña, M. (2000) Opening Remarks and Greetings from the Pan American Health

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Organization. Cajanus, 33, 64-70. 80. Jemmott, J.B., and Locke, S.E. (1984) Psychosocial factors, immunologic mediation, and human susceptibility to infectious diseases: How much do we know? Psychological Bulletin, 95:78-108. In Health Psychology, P. L. Rice. 1998. Brooks/Cole, Los Angeles. 81. Lusyne, P., Page, H., and Lievens, J. (2001) Mortality following conjugal bereavement, Belgium 1991-96: The unexpected effect of education. Population studies, 55, 281-28.

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Chapter

4 A conceptual framework of

wellbeing in some Western nations

The aim of this study is to examine and highlight the narrow definition of wellbeing that still exists in some contemporary Western societies. This definition is in keeping with the biomedical model that views the exposure to specific pathogens as the cause of diseases in organisms. Such an approach began during the 130ce to 200ce in Ancient Rome, and despite the efforts of the WHO in 1946 to expand the concept, health in Caribbean societies and in particular Jamaica is still substantially seen as the ‘absence of diseases’ or dysfunctions in the body, which is what is used to indicate wellbeing. Health and wellbeing are multidimensional constructs and so there is a need for academics to begin vociferously working to encapsulate an operational definition of wellbeing that can be used in the images of wellbeing and patient care. This paper presents and examines a conceptual framework on health (or wellbeing) from a biopsychosocial perspective, as well as including an environmental perspective as this is in keeping with an expanded conceptualization of health as forwarded by the WHO in its constitution. Within the discourse, arguments will be presented on both subjective and objective measurements of wellbeing.

Introduction

The traditional view of Western Societies is that health is conceptualized as the ‘absence of diseases’. This approach is both narrow and negative in scope as regards health. According to one school of thought, the aforementioned conceptualization of health emphasizes the absence of some disease-causing pathogens, and not health (Longest, 2002; Brannon, and Feist, 2007; Rice, 1998). Such a perspective is in keeping with the traditional biomedical model that views the exposure to specific pathogens as the cause of diseases in organisms. This began during 130ce to 200ce in Ancient Rome and despite the efforts of the WHO as early as 1946 to expand this construct (WHO, 1948), health in Caribbean societies, in particular Jamaica, is still substantially viewed as the ‘absence of diseases’ or dysfunctions, with wellbeing being the opposite of that state. Humans are multifaceted and so any conceptualization of health that seeks to measure an 77

aspect of their existence cannot be uni-directional or bi-directional, as health, wellbeing and wellness are multidimensional, which would be in keeping with the complexities of people. Lynch (2003) opines that everything that we do, feel, think and experience interfaces with our health; hence, wellbeing cannot be operationally defined solely based on functional limitation because of pathogens, as many events affect the quality of life outside of that space. Thus, this paper recognizes the need for the discourse, as it will allow for a better measurement of the concept. In addition to health measurement, this paper seeks to broaden the scope of the determinants of health, and in the process help policy-makers to understand this concept. In a nationally representative survey of Jamaicans, using observational data on some 2,320 elderly people (ages 65+ years), Bourne (2007) finds 12 factors that determine the wellbeing of elderly Jamaicans. Bourne’s wellbeing model is different to that presented in many other studies, as he uses a combination of physical dysfunctions, income and material possessions to conceptualize wellbeing. Bourne’s overall model explains 40.1% of the variance in wellbeing. Again,

wellbeing is influenced by more than just biological conditions. However, one scholar [Bok, 2004] opined that the WHO’s operationalization of health (or wellbeing) is too broad and by extension difficult to measure. This begs the question, why have we reverted to the ancient conceptualization of wellbeing (or health) and its images to guide patient care? Hence, what are the different discourses on wellbeing? Therefore, the paper presents and examines a conceptual framework on health (or wellbeing) from a biopsychosocial perspective, in addition to including the physical environment in the discourse as well as providing other images within the health discourse, with the aim of aiding health outcome research and patient care.

Result and Discussion
Wellbeing defined
The concept of health according to the WHO is multifaceted. “Health is the state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity” (WHO, 1948). From the WHO’s perspective, health status is an indicator of

wellbeing (Crisp, 2005). Wellbeing for some, therefore, is a state of happiness – positive feeling status and life satisfaction (Easterlin, 2003; Diener et al., 1985; Diener, 1984) satisfaction of preferences or desires, health or prosperity of an individual (Diener, and Suh, 1997a, b; Jones, 2001; Crisp, 2005; Whang, 2006), or what psychologists refer to as positive effects. Simply put,

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wellbeing is subjectively what is ‘good’ for each person (Crisp, 2005).

It is sometimes

connected with good health. Crisp offered an explanation for this, when he said that “When discussing the notion of what makes life good for the individual living that life, it is preferable to use the term ‘wellbeing’ instead of ‘happiness” (Crisp, 2005). Ergo, the term wellbeing is used interchangeably with words such as ‘happiness’, ‘life satisfaction’, and ‘welfare’ by a number of researchers and/or people in intelligentsia (Diener, 1984; Easterlin, 2003; Veenhoven, 1993). While some scholars argue that happiness and life satisfaction are but a fraction of wellbeing, what is embedded in Diener and Easterlin’s usage of those terminologies instead of wellbeing aptly shows that, within the context of a multidisciplinary global market place in which people must operate, the quality of life that people enjoy (or do not enjoy) must be understood before the goals of policy-planning and decision-making on the desire to improve the welfare, quality of life and/or standard of living of a people can materialize. Happiness, according to Easterlin (2003) is associated with wellbeing, and also with illbeing (for example depression, anxiety, dissatisfaction). Easterlin (2003) argued that material resources have the capacity to improve one’s choices, comfort level, state of happiness and leisure, which militates against static wellbeing within the context that developing countries and developed countries had at some point accepted the economic theory that economic wellbeing should be measured by per capita Gross Domestic Product (GDP) – (. total monetary value of goods and services produced within an economy over a stated period per person). Amartya Sen, who is an economist, writes that a plethora of literature exists showing that life expectancy is positively related to Gross National Product (GNP) per capita. (Anand and Ravallion, 1993; Sen, 1989). Such a perspective implies that mortality is lower whenever an economic boom exists within the society and that this is believed to have the potential to increase development, and by extension the standard of living. Sen, however, was quick to offer a rebuttal in that data analyzed have shown that some countries (. Sri Lanka, China and Costa Rica) have had reduced mortality without a corresponding increase in economic growth (Sen, 1989), and that this was attained through other non-income factors such as education, nutrition, immunization, expenditure on public health and poverty removal. The latter factors undoubtedly require income resources, and so it is clear that income is unavoidably a critical component in welfare and wellbeing. Some scholars believe that economic growth and/or development is a measure of

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welfare (Becker et al., 2004). Therefore, those studies on economic wellbeing were able to offer a plethora of answers to national governments on the health status of the people, or the wellbeing and/or illbeing of their citizens. No policy formulation on improving the quality of life of the citizens of a particular space should proceed without firstly unearthing the ‘real’ determinants of wellbeing. From Crisp’s perspective (2005), wellbeing is related to health and the strength of those associations, and secondly planning requires information that is made available by research. Is traditional economists’ operationalization of wellbeing still applicable in contemporary societies, knowing it to be purely objective? If happiness is a state of wellbeing, then if we were to impute depression, anxiety, stress, and illness and/or physical incapacitation, spirituality and environment within the objective measurement of wellbeing, a more holistic valuation would be reached. With the inclusion of subjectivity conditions in the measurement of wellbeing, we come closer to an understanding of people’s state of wellness, health and quality of life, as better nutrition, efficient disposal of sewage and garbage, and a healthy lifestyle also contribute to health status (. wellbeing). It should be noted that the biomedical model that is objective, conceptualizes health as the absence of diseases. This leads to the question, are any of the following diseases – (i) depression, (ii) stress, (iii) fatigue, and (iv) obsession? Hence, an issue arises, does the lack of objectivity mean it should be accepted with scepticism? In order to put forward an understanding of what constitutes wellbeing or illbeing, a system must be instituted that will allow us to coalesce a measure that will unearth peoples’ sense of the overall quality of life from either economic-welfarism (Becker et al. 2004) or psychological theories (Diener et al., 1997; Kashdan, 2004; Diener, 2000). This must be done with the general construct of a complex man. Economists like Smith and Kington, and Stutzer and Frey as well as Engel believe that the state of man’s wellbeing is not only influenced by his/her biologic state, but that it is always dependent on his/her environmental, economical and sociological conditions. Some studies and academics have sought to analyze this phenomenon in a subjective manner by way of general personal happiness, self-rated wellbeing, positive moods and emotions, agony, hopelessness, depression, and other psychosocial indicators (Arthaud-day et al., 2005; Diener et al., 1999; Skevington et al., 1997; Diener, 1984).

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An economist (Easterlin) studying happiness and income, of all social scientists, found an association between the two phenomena (Easterlin, 2001a, b), (Stutzer and Frey, 2003). He began with a statement that “the relationship between happiness and income is puzzling” (Easterlin, 2001a: p. 465), and found that people with higher incomes were happier than those with lower incomes – he referred to it as a correlation between subjective wellbeing and income (Stutzer, and Frey, 2003). He did not cease at this juncture, but sought to justify this reality, when he said that “those with higher incomes will be better able to fulfil their aspirations, and with other things being equal, on an average, feel better off.” (Easterlin, 2001a: p. 472). Wellbeing, therefore, can be explained outside of the welfare theory and/or purely on objectification-objective utility (Kimball, and Willis, 2005; Stutzer, and Frey, 2003). Whereas Easterlin found a bivariate relationship between subjective wellbeing and income, Stutzer and Frey revealed that the association is a non-linear one. They concretized the position by offering an explanation that “In the data set for Germany, for example, the simple correlation is 0.11 based on 12, 979 observations” (Stutzer, and Frey, 2003). Nevertheless, from Stutzer and Frey’s findings, a position association does exist between subjective wellbeing and income despite differences over linearity or non-linearity. The issue of wellbeing is embodied in three theories – (1) Hedonism, (2) Desire, and (3) Objective List. Using ‘evaluative hedonism’, wellbeing constitutes the greatest balance of pleasure over pain (Crisp 2005; Whang 2006: p. 154). With this theorizing, wellbeing is just personal pleasantness, which postulates that the more pleasantries an individual receives, the better off he/she will be. The very construct of this methodology is the primary reason for a criticism of its approach (. ‘experience machine’), which gave rise to other theories. Crisp (2005), using the work of Thomas Carlyle, described the hedonistic structure of utilitarianism as the ‘philosophy of swine’, because this concept assumes that all pleasure is on par. He

summarized this adequately by saying that “… whether they [are] the lowest animal pleasures of sex or the highest of aesthetic appreciation” (Crisp, 2005). The desire approach, on the other hand, is on a continuum of experienced desires. This is popularized by welfare economics, as economists see wellbeing as constituting the satisfaction of preference or desires (Crisp, 2005; Whang 2006: p. 154), which makes for the ranking of preferences and assessment by way of money. People are made better off if their current desires are fulfilled. Despite this theory’s strengths, it has a fundamental shortcoming, the issue of

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addiction. This is exemplified by the possible addictive nature of consuming ‘hard drugs’ because of the summative pleasure it gives to the recipient. Objective list theory: This approach in measuring wellbeing lists items not merely because of pleasurable experiences, nor on ‘desire-satisfaction’, but states that every good thing should be included, such as knowledge and/or friendship. It is a concept influenced by Aristotle, and “developed by Thomas Hurka (1993) as perfectionism” (Crisp, 2005). According to this approach, the constituent of wellbeing is an environment of perfecting human nature. What goes on an ‘objective list’ is based on the reflective judgement or intuition of a person. A criticism of this technique is elitism (Crisp, 2005), since an assumption of this approach is that certain things are good for people. Crisp (2005) provided an excellent rationale for this limitation, when he said that “…even if those people will not enjoy them, and do not even want them.” In the work of Arthaud-Day et al. (2005), applying structural modelling to subjective wellbeing was found to constitute “(1) cognitive evaluations of one's life (., life satisfaction or happiness); (2) positive affect; and (3) negative affect.” Subjective wellbeing, therefore, is the individual’s own viewpoint. If an individual feels his/her life is going well, then we need to accept this as the person’s reality. One of the drawbacks to this measurement is, it is not summative, and it lacks generalizability. Studies have shown that subjective wellbeing can be measured on a community level (Bobbit et al., 2005; Lau, 2005) or on a household level (Lau, 2005; Diener 1984), whereas other experts have sought to use empiricism (biomedical indicators - absence of disease symptoms, life expectancy; and an economic component - Gross Domestic Product per capita; welfarism utility function). Powell (1997) in a paper entitled ‘Measures of quality of life and subjective wellbeing’ argued that psychological wellbeing is a component of quality of life. He believed that this measurement, in particular for older people, must include Life Satisfaction Index, as this approach constitutes a number of items based on “cognitively based attitudes toward life in general and more emotion-based judgment”(Powell, 1997). Powell addressed this in two

dimensions. Where those means are relatively constant over time, and while seeking to unearth changes in the short-run, ‘for example an intervention’, procedures that mirror changed states may be preferable. This can be assessed by way of a twenty-item Positive and Negative Affect Schedule or a ten-item Philadelphia Geriatric Centre Positive Affect and Negative Affect Scale

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(Powell, 1997). In a reading entitled ‘Objective measures of wellbeing and the cooperation production problem’, Gaspart (1998) provided arguments that support the rationale behind the objectification of wellbeing. His premise for objective quality of life is embedded within the difficulty as it relates to consistency of measurement when subjectivity is the construct of operationalization. This approach takes precedence because an objective measurement of

concept is of exactness as non-objectification; therefore, the former receives priority over any subjective preferences. He claimed that for wellbeing to be comparable across individuals, population and communities, there is a need for empiricism. Gaspart discussed a number of economic theorizings (Equal Income Walrasian equilibria, objective egalitarianism, Pareto efficiency; Welfarism), which saw the paper expounding on a number of mathematical theorems in order to quantify quality of life. Such a stance proposes a human predictable, rational form, from which we are able to objectify plans. The very axioms cited by Gaspart emphasized a particular set of assumptions that he used in finalizing a measurement for wellbeing for man who is a complex social animal. The researcher points to a sentence that was written by Gaspart that speaks to the difficulty of objective quality of life; he wrote, “So its objectivism is already contaminated by post-welfarism, opening the door to a mixed approach, in which preferences matter as well as objective wellbeing” (Gaspart, 1998). Another group of scholars emphasized the importance of measuring wellbeing outside of welfarism and/or purely objectification, when they said that “Although GDP per capita is usually used as a proxy for the quality of life in different countries, material gain is obviously only one of many aspects of life that enhances economic wellbeing” (Becker et al., 2004), and that wellbeing depends on both the quality and the quantity of life lived by the individual (Easterlin, 2001). This is affirmed in a study carried out by Lima and Nova (2006), which found that happiness, general life satisfaction, social acceptance and actualizations are all directly related to the GDP per capita for a geographic location (Lima and Nova, 2006). Even though in Europe these were found not to be causal, income provides some predictability of subjective wellbeing, and more so in poor countries than in wealthy nations. (Lima, and Nova, 2006) It should be understood that GDP per capita speaks to the market economic resources, which are produced domestically within a particular geographic space. So increased production in goods and/or services may generate excess, which can then be exported, and vital products

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(such as vaccination, sanitary products, vitamins, iron and other commodities) can be purchased, which are able to improve the standard of living and quality of the life of the same people compared to the previous period. One scholar (Caldwell, 1999) has shown that life expectancies are usually higher in countries with high GDP per capita, which means that income is able to purchase better quality products, which indirectly affects the length of years lived by people. This reality could explain why in economic recession, war and violence, when economic growth is lower (or even non-existent) there is a lower life expectancy. Some of the reasons for these justifications are government’s failure to provide for an extensive population in the form of nutritional care, public health and health-care services. Good health is, therefore, linked to economic growth, which further justifies why economists use GDP per capita as an objective valuation of standard of living; and why income should definitely be a component in the analysis of health status. There is another twist to this discourse as a country’s GDP per capita may be low, but the life expectancy is high because health care is free for the population. Despite this fact, material living standards undoubtedly affect the health status and wellbeing of a people, as well as the level of females’ educational attainment. Ringen (1995) in a paper entitled ‘Wellbeing, measurement, and preferences’ argued that non-welfarist approaches to measuring wellbeing are possible despite its subjectivity. The direct approach for wellbeing computation through the utility function according to Ringen is not a better quantification as against the indirect method (. using social indicators). The stance taken was purely from the vantage point that utility is a function ‘not of goods and preferences’ but of products and ‘taste’. The constitution of wellbeing is based on choices. Choices are a function of individual assets and options. With this premise, Ringen put forward arguments showing that people’s choices are sometimes ‘irrational’, which is the make for the departure from empiricism. Wellbeing can be computed from either the direct (. consumption expenditure) or the indirect (disposable income) approach (Ringen, 1995). The former is calculated using

consumption expenditure, whereas the latter uses disposable income. Rigen noted that in order to use income as a proxy for wellbeing, we must assume that (1) income is the only resource, and (2) all persons operate in identical market places. On the other hand, the direct approach has two key assumptions. These are (1) what we can buy is what we can consume and (2) what we can

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consume is an expression of wellbeing. limitations.

From Rigen’s monograph, the assumptions are

In presenting potent arguments in favour of non-empiricism in the computation of wellbeing, Ringen highlighted a number of drawbacks to welfarism. According to Ringen: Utility is not a particularly good criterion for wellbeing since it is a function not only of circumstances and preferences, but also of expectation. In the measurement of wellbeing, respect for personal preferences is best sought in non-welfarist approaches that have the quality of preference neutrality; …As soon as preferences are brought into the concept of wellbeing, it cannot but be subjective. (Ringen, 1995) The difficulties of using empiricism to quantify wellbeing have not only been put forward by Ringen, as O’Donnell and Tait (2003) were equally forthright in arguing that there were challenges in measuring quality of life quantitatively. O’Donnell and Tait believed that health is a primary indicator of wellbeing. Hence, self-rated health status is a highly reliable proxy of health, which “successfully crosses cultural lines” (O’Donnell, and Tait, 2003). They argued that self-reported health status could be used, as they found that all the respondents of chronic diseases indicated that their health was very poor. To capture the state of the quality of life of humans, we are continuously and increasingly seeking to ascertain more advanced methods that will allow us to encapsulate a quantification of wellbeing that is multidimensional and multifaceted (Pacione, 2003). Therefore, an operational definition of wellbeing that sees the phenomenon in a single dimension such as physical health, medical perspective (Farquhar, 1995), material (Lipsey, 1999) and would have excluded indicators such as crime, education, leisure facilities, housing, social exclusion and the environment (Pacione 2003; Campbell et al., 1976) as well as subjective indicators, cannot be an acceptable holistic measurement of this construct. This suggests that wellbeing is not simply a single space; and so, the traditional biomedical conceptual definitions of wellbeing exclude many individual satisfactions and in the process reduce the tenets of a superior coverage of quality of life. One writer noted that the environment positively influenced quality of life (Pacione, 2003) of people; in order to establish the validity and reliability of wellbeing, empirical data must include issues relating to the environment. The quality of the environment is a utilized condition in explaining the elements of people’s quality of life. Air and water quality through industrial fumes, toxic waste, gases and other pollutants, affect environmental quality. This is

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directly related to the maintenance or lack thereof of societal and personal wellbeing (Pacione, 2003). Studies have conclusively shown that environmental issues such as industrial fumes and gases, poor solid waste management, mosquito infestation and poor housing are likely to result in physiological conditions like respiratory track infections (for example lung infection)and asthma. According to Langlois and Anderson (2002), approximately 30 years ago, a seminal study conducted by Smith (1973) “proposed that wellbeing be used to refer to conditions that apply to a population generally, while quality of life should be limited to individuals’ subjective assessments of their lives …” They argue that a distinction between the two variables has been lost with time. From Langlois and Anderson’s monograph, during the 1960s and 1970s,

wellbeing was approached from a quantitative assessment by the use of GDP or GNP (Becker et al., 2004), and unemployment rates; this they refer to as a “rigid approach to the (enquiry of the subject matter) subject.” According to Langlois and Anderson (2002), the positivism approach to the methodology of wellbeing was objectification, an assessment that was highly favoured by Andrews and Withley (1976) and Campbell et al. (1976). In measuring quality of life, some writers have thought it fitting to use Gross Domestic Product per capita (GDP per capita) to which they referred as standard of living (Lipsey, 1999; Summers, and Heston 1995). According to Summers and Heston (1995), “The index most commonly used until now to compare countries' material wellbeing is their GDP
POP' .”

The

United Nations Development Programme has expanded on the material wellbeing definition put forward primarily by economists, and has included life expectancy and educational attainment (UNDP, 2005: p. 341) as well as other social indicators (Diener, 1984; Diener, and Suh, 1997). This operational definition of wellbeing has become increasingly popular in the last twenty-five years, but given the expanded definition of health as cited by the WHO, wellbeing must be measured in a more comprehensive manner than merely using material wellbeing as seen by economists. Despite the fact that quality of life extends beyond the number of years of schooling and material wellbeing, generally wellbeing is substantially construed as an economic phenomenon. Embedded within this construct of a measure is the emphasis on economic resources, and we have already established that man’s wellbeing is multifaceted. Hence, any definition of the quality of life of people cannot simply analyze spending or the creation of goods and/or services

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that are economically exchangeable, the number of years of schooling and life expectancy, but it must include the psychosocial conditions of the people within their natural environment. GDP is the coalesced sum of all the economic resources of people within certain topography, so this does not capture the psychosocial state of man in attaining the valued GDP. By this approach, we may arrive at a value that is higher than in previous periods, making it seem as though people are doing very well. However, with an increase in GDP, this single component is insufficient to determine wellbeing, as the increase in GDP may be from (1) more working hours, (2) higher rates of pollution and environmental conditions, (3) psychological fatigue, (4) social exclusion, (5) human ‘burn out’, (6) reduction in freedom, (7) unhappiness, (8) chronic and acute diseases and so forth. Summers and Heston (1995) note that “However, GDP POP is an inadequate measure of countries' immediate material wellbeing, even apart from the general practical and conceptual problems of measuring countries' national outputs.” Generally, from that perspective, the measurement of quality of life is therefore highly economic and excludes the psychosocial factors, and whether quality of life extends beyond monetary objectification. In developing countries, Camfield (2003), in looking at wellbeing from a subjective vantage point, notes that Diener (1984) argues that subjective wellbeing constitutes the existence of positive emotions and the absence of negative ones within a space of general satisfaction with life. According to Camfield (2003) and Cummins’ (1997a, b), this perspective subsumed

‘subjective and objective measures of material wellbeing’ along with the absence of illnesses, efficiency, social closeness, security, place in community, and emotional wellbeing, which implies that “life’s satisfaction” comprehensively envelopes subjective wellbeing. Diener (2000) in an article entitled ‘Subjective Wellbeing: The Science of Happiness and a Proposal for a National Index’ theorizes that the objectification of wellbeing is embodied within satisfaction of life. His points to a construct of wellbeing called happiness. He cited that: People's moods and emotions reflect on-line reactions to events happening to them. Each individual also makes broader judgments about his or her life as a whole, as well as about domains such as marriage and work. Thus, there are a number of separable components of SWB [subjective wellbeing]: life satisfaction (global judgments of one's life), satisfaction with important domains (e.g., work satisfaction), positive affect (experiencing many pleasant emotions and moods), and low levels of negative affect (experiencing few unpleasant emotions and moods). In the early research on SWB,

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researchers studying the facets of happiness usually relied on only a single self-reported item to measure each construct (Diener, 2000). Diener’s theorizing on wellbeing encapsulates more than the marginalized stance of other academics and researchers who enlightened the discourse with economic, psychosocial, or subjective indicators. He shows that quality of life is multifaceted, and coalescing economic, social, psychological and subjective indicators is more far-reaching in ultimately measuring wellbeing. This work shows a construct that can be used to operationalize a more multidimensional variable, wellbeing, which widens the tenet of previous operational definition on the subject. From the theorizing of various writers, it is clear that wellbeing is

multidimensional, multidisciplinary and multispatial. Some writers emphasize the environmental components of subject matter (Pacione, 1984; Smith, 1973), from the psychosocial aspect (Clarke et al., 2000) and from a social capital vantage point (Glaeser 2001; Putnam 1995; Woolcock 2001). Smith and Kington (1997), using H t = f (H t-1 , P m G o , Bt , MC t ED, Ā t , to conceptualise a theoretical framework for “stock of health,” noted that health in period t, Ht, is the result of health preceding this period (H t-1) , medical care (MC t) , good personal health (G o) , the price of medical care (P m ), and bad medical care (Bt) , along with a vector of family education (ED), and all sources of household income (Ā t ). Embedded in this function is the wellbeing that an individual enjoys (or does not enjoy) (Smith, and Kington, 1997). In seeking to operationalize wellbeing, the United Nations Development Programme (UNDP) in the Human Development Reports (1997, 2000) conceptualized human development as a “process of widening people’s choice as well as the level of achieved wellbeing”. Embedded within this definition is the emphasis on materialism in interpreting quality of life. From the UNDP’s Human Development (1993), the human development index (HDI) “…is a normative measure of a desirable standard of living or a measure of the level of living”, which speaks to the subjectivity of this valuation irrespective of the inclusion of welfarism (. gross domestic product (GDP) per capita). The HDI constitutes adjusted educational achievement (E= a 1 * literacy + a 2 * years of schooling, where a1, = 2/3 and a2 = 1/3), life expectancy (demographic modelling) and income (W (9y) = 1/ (1 - e) * y
1-e

). The function W(y) denotes

“utility or wellbeing derived from income”. This income component of the HDI is a national average (GDP per capita, which is then adjusted for income distribution (W*(y) = W(y) {1 - G}),

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where G = Gini coefficient). In wanting to disaggregate the HDI within a country, the UNDP (1993) noted that data are not available for many countries, which limits the possibility. An economist writing on ‘objective wellbeing’ summarized the matter simply by stating that “…one can adopt a mixed approach, in which the satisfaction of subjective preferences is taken as valuable too” (Gaspart, 1998; Cummin, 1997), which is the premise to which this paper will adhere in keeping with this multidimensional construct, wellbeing. Wellbeing, therefore, in the context of this paper, will be the overall health status of people, which includes access to and control over material resources, environmental and psychosocial conditions, and per capita consumption.

New Focus: Healthy Life Expectancy One of the drawbacks to the use of life expectancy is the absence of capturing ‘healthy’ years of life. Traditionally, when life expectancy is measured it uses mortality data to

predetermine the number of years of life that are yet to be lived by an individual, assuming that he/she subscribes to the same mortality patterns of the group. The emphasis on this approach is on length of life, not on the quality of those lived years. The rationale why healthy life expectancy is important in ageing comes against the background that age means increased dysfunction and the unavoidable degeneration of the human body. Hence, we must seek to examine more than just the number of years that an individual is likely to survive, and we should be concerned about the quality of those years. Therefore, in attempt to capture ‘quality of lived years’, the WHO in 1999 introduced an approach that will allow us to evaluate this, ‘disability adjusted life expectancy’ (DALE). DALE is not only concerned with length of years to indicate the health and wellbeing status of an individual or a nation, but the number of years without disabilities and the severity of their influence by reducing the quality of lived years.

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DALE is a modification of the traditional ‘life expectancy’ approach in assessing health. It uses the number of years lived as an equivalent to ‘full health’. In calculating DALE, the number of years of ill-health is weighted based on severity. This is then subtracted from the expected overall life expectancy to give what is referred to as years of healthy life. Embedded in this approach is reduction in years because of numbers, and severity of dysfunctions and HIV experienced by the individual or people within a particular socio-political geography. Having arrived at ‘healthy life expectancy’, the WHO has found that poorer countries lost more from their ‘traditional life expectancy’ than developed nations. The reasons put forward by the WHO are the plethora of dysfunctions and the devastating effects of some tropical diseases like malaria that tend to strike children and young adults. The institution found that these account for a 14 percent reduction in life expectancy in poorer countries and 9 percent in more developed nations (WHO, 2000b). This system is in keeping with a more holistic approach to the measure of health and wellbeing, which this study seeks to capture. By using the

biopsychosocial model in the evaluation of the wellbeing of aged Jamaicans, we will begin to understand the factors that are likely to influence the quality of lived years of the elderly, and not be satisfied with the increased length of life of the populace. The rationale behind this study is that it will assist policy-making on health and social services, long term care and pension scheme planning, and will aid in the understanding of future health needs and the evaluation of future health programmes. Conclusion The discourse on health began centuries ago, but today the issues have a changed focus because of new information, and a modification in epistemology about health. In this discourse some scholarships have used the ‘absence of diseases’ or dysfunctions as a conceptual definition of health, and in so doing they work substantially to see health from a mechanistic approach.

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Such an approach treats patient care from a biomedical science standpoint, and the emphasis is on the biology of the organism. The biomedical model as a study of health fails to appreciate that long before any ailments (or dysfunctions) appear within an organism, the socio-physical, cultural and psychological milieu would have had an impact on the quality of that organism. Thus, the use of symptomology as the identification of ill-health, and using the opposite of this to indicate health, is one-dimensional, and fails in its bid to encapsulate all the possible aspects that influence the quality of life, wellbeing, and health of people. Following the clear limitations with the construct of health from the perspective of the biomedical sciences [model], in 1946 the WHO conceptualized a definition of wellbeing that was composite and far reaching, and one scholar (Crisps) refers to this as an elusive dream, which is difficult to operationalize. Although the debate continued for years, George Engel was the first scholar and psychiatrist to map out a conceptual framework for the WHO’s new construct for health as a working definition that guides how he approached patient care. Engel, in the 1950s, began using what he called the biopsychosocial model in treating psychiatric patients. He believed that when a patient goes to a doctor, the individual’s ailment is a complex apparatus of different tenets, and not merely the outward appearance, which is the identified symptomology. Engel proposed that the medical fraternity should commence approaching patient care from the vantage point of mind, body, and social conditions. Although some scholars and practitioners concurred with Engel’s beliefs, and practiced this new model [biopsychosocial], and he (Engel, 1978, 1977a, 1977b, 1960) got Rochester Medical School to institute this approach in the curriculum of medical training, substantially the biomedical approach was widely practiced. Traditionally, people were socialized to use symptomology to identify ill-health and the reverse of this meant ‘health’, so much so that scientists still continue to research in this tradition. Some scholarships argue that Engel’s biopsychosocial model is but an ‘abstraction’ (or a theoretical construct), and so with the objective realities of patient care, the use of morbidity is still the best indicator of the extent of wellbeing. Gradually, the culturalized tradition of the supremacy of the biomedical model began to be seriously challenged in the 20th century. A group of authors claim that the United States, in the 20th century, expanded their operational definition of health from the traditional ‘absence of diseases’ to the biopsychosocial approach argued by Engel (Brannon, and Feist, 2007; Engel, 1960). It was not until the 1970s that a scholar, using empirical data, finally provided an econometric model that encapsulates

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what Engel was arguing some 2 decades before (Grossman). Using data, Grossman (1972) showed that the health status of people in the world is influenced by both biological, and a plethora of other social conditions. He laid the foundation that has shaped the present landscape of social science research on health, wellbeing and quality of life, so much so that a group of scholars have used the advanced quantitative method to model happiness, which was conceptual to measuring wellbeing. Today Grossman’s model, with some modifications, is being used by some Caribbean scholars (Bourne, 2007; Hambleton et al., 2005). Using data from Barbados, Hambleton et al. (2005) showed that health (proxy physical functioning) is a function of biological, cultural and social conditions. Bourne (2007), using data from Jamaica, expanded on the operational definition of health (or wellbeing) from physical functionality used by Grossman and Hambleton et al. (2005) to that of a composite index which captures physical, functional and economic wellbeing (material possessions). Bourne’s work did not only add to the operational definition of health, but he showed that environmental and psychological conditions in addition to social factors do influence health. In sum, only a few studies in the Caribbean have sought to expand the narrow definition of health inspite of the WHO’s efforts as well as others. The narrow definition of health is still dominant in contemporary Jamaica as well as other Caribbean nations, and this primarily accounts for the image of health that is held by many peoples. It is this narrow definition of health that fashions the health care system, patient care, data collected on health and peoples’ image of health, health care and lifestyle practices. This is not only a challenge for public health specialists, but for the general populace as one image of health influences his/her perception of health care, lifestyle and views on preventative health.

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Kimball, M., and Willis, R. (2005). Utility and happiness. www.stanford.edu/group/SITE/papers2005/Kimball.05.doc (Retrieved: 31/08/09). Langlois, A, and Anderson, D.E. (2002). Resolving the quality of life/well-being puzzle: Toward a New Model. Canadian Journal of Regional Studies, 35: 1-10 Lau, A.D. (2005). The International Wellbeing Group and the International Wellbeing Index (Hong Kong and China). Hong Kong: Department of Rehabilitation Sciences, The Hong Kong Polytechnic University. http://www.rs.polyu.edu.hk/rs/people/rsalau_IWG.htm (Retrieved: 27/07/09). Lima, M. L., and R. Nova. (2006). So far so good: Subjective and social wellbeing in Portugal and Europe. Portuguese Journal of Social Science 55-33. Lipsey, R. (1999). Economics, (12th). United States: Addison-Wesley. Longest, B. B. (2002). Health Policymaking in the United States, 3rd. Chicago: Foundation of the American College Healthcare. Lynch, P. M. (2003). Wellness: A National Challenge. Kingston: Grace Kennedy Foundation. Jones, T. G. (2001). Cognitive and psychosocial predictors of subjective wellbeing in older adultshttp://digitalcommons.wayne.edu/dissertations/AAI3010098/ (Retrieved: 30/06/09). Powell, L.M. (1997). Measures of quality of life and subjective well-being. Generation 21, 45. O’Donnell, V, and Tait, H. (2003). Well-being of the non-reserves Aboriginal population. Statistics Canada Catalogue 89-589. Pacione, M. (2003). Urban environmental quality and human wellbeing- a social geographical perspective. Landscape and Urban Planning, 65:19-30. Pacione, M. (1984). The Definition and Measurement of Quality of Life. Quoted in M. Pacione and G. Gordon (eds.). Quality of Life and Human Welfare. Norwick: Geoboks. Putnam, R. (1995). Bowling Alone: America’s Declining Social Capital. Journal of Democracy, 6:65-78. Rice, P.L. (1998). Health psychology. CA, USA: Brooks/Cole Publishing. Ringen, S. (1995). Well-being, measurement, and preferences. Scandinavian Sociological Association 38, no 1:3-15. Sen, A. (1998). Mortality as an indicator of economic success and failure. The Economic Journal 108:1-25. Skevington, S. M., MacArthur, P., & Somerset, M. (1997). Developing items for the WHOQOL: An investigation of contemporary beliefs about quality of life related to health in Britain. British Journal of Health Psychology, 2:55-72. Smith, D. M. (1973). The Geography of social wellbeing in the United States: An introduction to Territorial Social Indicators. New York: McGraw-Hill. Smith, J.P. and R. Kington. (1997). Demographic and Economic Correlates of Health in Old Age. Demography, 34:159-170. Stutzer, A, and Frey, B.S. (2003). Reported subjective well-being: A challenge for economic theory and economic policy. "http://www.crema-research.ch/papers/2003-07.pdf" http://www.crema-research.ch/papers/2003-07.pdf (Retrieved: 31/08/09). Summers, R, and Heston, A. (1995). Standard of Living: SLPOP An Alternative Measure of Nations' Current Material Well-Being. http://pwt.econ.upenn.edu/papers/standard_of_living.pdf (Retrieved: 24/01/09).

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United Nations Development Programmed, UNDP. (2005). Human development report, 2005. New York: UNDP. United Nations Development Programme, UNDP. (2001). Human Development Report, 2000. New York, United States: UNDP. United Nations Development Programme, UNDP. (1998). Human Development Report, 1997. New York, United States: UNDP. United Nations Development Programme, UNDP. (1994). Human Development Report, 1993. New York, United States: UNDP. Veenhoven, R. (1993). Happiness in nations, subjective appreciation of in 56 nations 1946-1992. Rotterdam, Netherlands: Erasmus University. Whang, K. M. (2006). Wellbeing syndrome in Korea: A view from the perspective of biblical counselling. Evangelical Review of Theology 30:152-161. Woolcock, M. (2001). The Place of Social Capital in Understanding Social and Economic Outcomes. ISUMA, 6:11-17. World Health Organization, WHO. (2000b). WHO Issues New Healthy Life Expectancy Rankings: Japan Number One in New ‘Healthy Life’ System. Washington D.C. & Geneva: WHO. World Health Organization, WHO (1948). Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, June 19-22, 1946; signed on July 22, 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on April 7, 1948. “Constitution of the World Health Organization, 1948.” In Basic Documents, 15th ed. Geneva, Switzerland.

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Part III: Health status: Using Health data

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Chapter

5 Paradoxities in self-evaluated health
data in a developing country
Statistics showed that males reported fewer illnesses and greater mortality rates than females, but are outlived by approximately 6 years by their female counterparts, yet their self-rated health status is the same as that of females. This study examines if there (1) Are there paradoxes in health disparity between the sexes in Jamaica; (2) are there an explanation for the disparity outside of education, marital status, and area of residence? Good health status was correlated with self-reported illness (OR =0.23, 95% CI = 0.09-0.59); medical care-seeking behaviour (OR = 0.51, 95% CI = 0.36-0.72); age of respondents (OR = 0.96, 95% CI = 0.96-0.97), and income (OR = 1.00, 95% CI = 1.00-1.00) Self-reported illness of respondents is statistical correlated with sex (OR = 0.25, 95% CI = 0.10-0.62); head of household (OR = 0.33, 95% CI = 0.120.96); age of respondents (OR = 1.04, 95% CI = 1.01-1.07) and current good self-rated health status (OR = 0.32, 95% CI = 0.12-0.84). This paper highlights that caution must be used by researchers in interpreting self-reported health data of males.

Introduction
Jamaica began collecting data on the living standard of its people in 1988, and to date, statistics showed that females continue to report more illnesses, attend medical care more than male [1], and outlive males on average by 6 years [2]. Concurrently, a study by Hutchinson et al. [3], on the wellbeing and life satisfaction of Jamaicans, showed that women had lower psychological wellbeing and life satisfaction than men, which highlights some paradoxities in the health data. However, Bourne [4] found that there was no significant statistical difference between the current good health status of males and females. He however found that there was no statistical correlation between medical care-seeking behaviour and sex of respondents, suggesting that reporting more illnesses does not mean that females are any more willing to address the identified health conditions than males.

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A research on rural Jamaican women in the reproductive ages of 15 to 49 [5] showed 79% were never married; 20% married; 90% had secondary level education; 45% poor (ie 22% below the poverty line); and 15.3% reported an illness while only 5% had health insurance coverage. In Jamaica, poverty is a rural phenomenon (ie in 2007, 15.3% of rural individuals were below the poverty line compared to 4% of semi-urban Jamaicans and 6.2% of urban peoples). Males’ per capita consumption was 1.2 times more than that for females; female-headed household had higher prevalence of poverty compared to male-headed household [1], it follows that socio-demographic and economic challenges faced by females is not discounting from them living longer than men. A study by Bourne [6] showed that elderly men in Jamaica are healthier than their female counterparts, suggesting that longer life does not imply healthy life expectancy. Statistics showed that females are more likely to be unemployed [7]; poorer; live longer; report more illness; visit health care practitioners more than men; and are less healthier than men in later life; on average more educated; yet still their health status is generally equivocal to that of males [8]. Examining mortality data of the sexes for aged Jamaicans, Bourne et al. [9] found that mortality at older ages was between 115 and 120 males to 100 females. A study by Abel et al. [10] found that suicide rate for males was 9 times greater than that of females which indicates that mortality for males is not only greater at older ages but that this is occurring voluntarily throughout their life span. Using secondary data of 8,373 Jamaican children (ages less than 15 years) for 2002 and 2104 for 2007, Bourne [11] found that there was no significance between the sexes health conditions; however, female children are taken to health care practitioners more than male children. A research of 5229 and 1394 adolescents 10 to 19 years in Jamaica, Bourne’s [12] findings showed that mortality for males were greater than that for females; a significant

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statistical correlation existed between health conditions; but none between health conditions and age cohort of the sample. Furthermore, he found that in 2007, 96% of adolescents did not report an illness in the past 4-weeks; 54% sought medical care; and 15% had health insurance coverage. One of the drawbacks of Bourne’s work [12] was the fact that health condition was not disaggregated by sexes; however, invaluable information was provided that showed the low willingness of adolescents to seek medical care. On the contrary, a study on children showed that while there is no significant difference between the health statuses of the sexes, females are socialized to seek more medical care than male children [11] and that this continues over their life course [1]. The literature highlights the fact that the health status disparity does not commence in childhood, which denotes that females longer life and males’ greater health status in later life is a paradox that must be unraveled by researchers. Interestingly to note that while the literature explains Hutchinson et al’s work as to why women have a lower psychological wellbeing and life satisfaction, it does not provide an understanding for the plethora of other studies which showed no significant statistical difference between the general self-rated health of the sexes [4,8] and childhood [11]; the greater health status of elderly men within the context that females reported more illness, live longer and statistics showed that mortality at all ages is greater for males than females [2]. There is a lack of information on the paradox of health disparity between the sexes in Jamaica and this research seeks to fill this gap in the literature. The current research seeks to answer the following questions: (1) Are there paradoxes in health disparity between the sexes in Jamaica; (2) are there an explanation for the disparity outside of education, marital status, and area of residence?

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Materials and methods
Data The current study utilized a dataset collected jointly by the Planning Institute of Jamaica and the Statistical Institute of Jamaica [13]. The survey was conducted between May and August of 2007. The Jamaica Survey of Living Conditions (JSLC) which began in 1988 and it is a modification of the World Bank’s Living Standards Measurement [1, 14]. The sample size was 6,783 respondents, with a non-response rate being 26.2%. The JSLC is a cross-sectional survey which used stratified random sampling techniques to draw the sample. It is a national probability survey, and data were collected across the 14 parishes of the island. The design for the JSLC was a two-stage stratified random sampling design where there was a Primary Sampling Unit (PSU) and a selection of dwellings from the primary units. The PSU is an Enumeration District (ED), which constitutes a minimum of 100 residences in rural areas and 150 in urban areas. An ED is an independent geographic unit that shares a common boundary. This means that the country was grouped into strata of equal size based on dwellings (EDs). Based on the PSUs, a listing of all the dwellings was made, and this became the sampling frame from which a Master Sample of dwelling was compiled, which in turn provided the sampling frame for the labour force. The sample was weighted to reflect the population of the nation. Instrument An administered instrument was used to collect the data from respondents. The questionnaire covers socio-demographic variables such as education, age, consumption; and others variables for example social security; self-rated health status; self-reported health conditions; medical care; inventory of durable goods; living arrangements, immunization of children 0–59 months and

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other issues. Many survey teams were sent to each parish according to the sample size. The teams consisted of trained supervisors and field workers from the Statistical agency of Jamaica. Statistical Analyses The Statistical Packages for the Social Sciences - SPSS-PC for Windows version 16.0 (SPSS Inc; Chicago, IL, USA) – was used to store, retrieve and analyze the data. Descriptive statistics such as median, mean, percentages, and standard deviation were used to provide background information on the sample. Cross tabulations were used to examine non-metric dependent and independent variables. Analysis of variance was used to evaluate a metric and a nondichotomous variable. Ordinal logistic regression was used to determine socio-demographic, economic and biological correlates of health status of Jamaicans, and identify whether the educated have a greater self-rated health status than uneducated respondents. A 95% confidence interval was used to examine whether a variable is statistical significant or not. There was no selection criterion used for the current study. On the other hand, for the model, the selection criteria were based on 1) the literature; 2) low correlations, and 3) nonresponse rate. The correlation matrix was examined in order to ascertain if autocorrelation and/or multicollinearity existed between variables. Based on Cohen & Holliday [15] and Cohen & Cohen [16], low (weak) correlation ranges from 0.0 to 0.39; moderate – 0.4-0.69, and strong – 0.7-1.0. Any correlation that had at least a moderate value was excluded from the model in order to reduce multicollinearity and/or autocorrelation between or among the independent variables [17-21]. Models Health is a multifactorial construct. This indicates that it is best explained with many variables as against a single factor. Health is empirically established as is determined by many factors [22-

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37], and therefore is best established with the use of multivariate regression technique [22-37]. The current study seeks to establish the socio-demographic, economic and biological correlates of self-rated health; and self-reported illness so as to examine the paradoxes in health disparity between the sexes. The aforementioned construct will be tested in two econometric models. Model [1] is good self-rated health statuses and is associated with socio-demographic, economic and biological variables; and Model [2] is self-reported illness and is related to sociodemographic, economic and self-rated health status. H t =f(A i , G i ,HH i , AR i , I t , J i, lnC, lnD i , ED i, MR i , S i , HIi , lnY, CR i , MC t , SA i , Ti , ε i ) (1)

where H t (. self-rated current health status in time t) is a function of age of respondents, A i ; sex of individual i, G i ; household head of individual i, HH i ; area of residence, AR i ; current self-reported illness of individual i, I t ; injuries received in the last 4 weeks by individual i, J i ; logged consumption per person per household member, lnC; logged duration of time that individual i was unable to carry out normal activities, lnD i ; Education level of individual i, ED i ; marital status of person i, MR i ; social class of person i, S i ; health insurance coverage of person i, HIi ; logged income, lnY; crowding of individual i, CRi; medical expenditure of individual i in time period t, MC t ; social assistance of individual i, SA i ; length of time living in current household by individual i, Ti ; and an error term (ie. residual error). It ,=f(A i , G i ,HH i , AR i , J i, lnC, lnD i , ED i, MR i , S i , HIi , lnY, CR i , MC t , SA i , Ti , H t , ε i ) (2) where It (. self-reported illness in last 4-weeks) is a function of age of respondents, A i ; sex of individual i, G i ; household head of individual i, HH i ; area of residence, AR i ; injuries received in the last 4 weeks by individual i, J i ; logged consumption per person per household member, lnC; logged duration of time that individual i was unable to carry out normal activities, lnD i ; Education level of individual i, ED i ; marital status of person i,

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MR i ; social class of person i, S i ; health insurance coverage of person i, HIi ; logged income, lnY; crowding of individual i, CRi; medical expenditure of individual i in time period t, MC t ; social assistance of individual i, SA i ; length of time living in current household by individual i, Ti ; self-rated current good health status, H t ; and an error term (ie. residual error). Models [1] and [2] were modified owing to [3] and [4] owing to collinearity of consumption and income (r ≥ 0.7) and non-response of injury (over 70%). H t =f(A i , G i ,HH i , AR i , I t , lnD i , ED i, MR i , S i , HI i , lnY, CR i , MC t , SA i , Ti , ε i ) It ,=f(A i , G i ,HH i , AR i , lnD i , ED i, MR i , S i , HIi , lnY, CR i , MC t , SA i , Ti , H t , ε i ) Measurement of variables Health in the current study is measured using (1) self-rated health status (self-rated health), and (2) self-reported illness. Self-rated health status was derived from the question “Generally, how is your health?” with the options being very good; good; fair (or moderate); poor or very poor.” The ordinal nature of this variable was kept the literature [38-40]. Self-reported illness was derived from the question, “Have you had any illnesses other than injury? The examples are cold; diarrhoea; asthma attack, hypertension, arthritis; diabetes mellitus or any other illness? (In the past four weeks)? The options were (1) yes and (2) no. This variable was re-coded as a binary value, where 1= yes and 0= otherwise. Self-reported diagnosed recurring illness was derived from “Is this a diagnosed recurring illness? The options were: (1) yes, cold; (2) yes, diarrhoea; (3) yes, asthma; (4) yes, diabetes mellitus; (5) yes, hypertension; (6) yes, arthritis; (7) yes, other; (8) no. Medical care-seeking behaviour was taken from the question ‘Has a health care practitioner, healer, or pharmacist being visited in the last 4 weeks?’ with there being two options Yes or No. (3) (4)

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Medical care-seeking behaviour therefore was coded as a binary measure where 1=Yes and 0= otherwise. Income. Total annual expenditure was used to measure income. Social standing. Income quintile was used to measure social standing. The income quintiles ranged from poorest 20% to wealthiest 20%.

Results
Demographic characteristic of sample The sample was 6,782 respondents: 48.7% males and 51.3 females. The mean age of the sample was 30.0 years (SD = 21.8 years). Almost 15% reported having had an illness in the last 4 weeks: 89.1% reported that the illness was diagnosed by a medical practitioner - cold (14.9%); diarrhoea (2.7%); asthma (9.5%); diabetes mellitus (12.3%); hypertension (20.6%); arthritis (5.6%) and unspecified (23.4%). Bivariate analyses The findings showed that females were more likely to (1) be widowed (7.3% females to 2.3% males); (2) be older (mean age: 30.6 years females to 29.1 years males) – t = -2.8, P = 0.05; (3) report illness (17.5% females to 12.1% males); and (4) spend on medical expenditure (Table 5.1). However, there was no significant statistical difference between the sexes (1) seeking medical care; (2) social standing; and (3) educational levels. Tertiary level graduates were substantially more likely to be in the wealthiest class (54%), and dwelled in urban areas (63.4%). Concomitantly, they reported more illness than secondary level respondents (9.2% tertiary to 5.4% secondary), but less than those with primary or below level education (16.2%) (Table 5.2).

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Table 5.3 showed significant statistical associations between (1) marital status and selfreported illness (P < 0.05); (2) area of residence and self-reported illness (P < 0.05), and (3) medical care expenditure and self-reported illness (P < 0.05). A significant statistical association between health care-seeking behaviour (in %) and social standing of respondents – χ2 =17.12, P = 0.002. The findings revealed that as social standing increases from poorest 20% to wealthiest 20%, health care-seeking behaviour (in %) increases: poorest 20%, 54.7%; poor, 63.2%; middle class, 66.4%; wealthy, 68.4%, and wealthiest 20%, 73.5%. Multivariate analyses Good health status of Jamaicans was correlated with self-reported illness (OR =0.23, 95% CI = 0.09-0.59); medical care-seeking behaviour (OR = 0.51, 95% CI = 0.36-0.72); age of respondents (OR = 0.96, 95% CI = 0.96-0.97), and income (OR = 1.00, 95% CI = 1.00-1.00) (Table 4). The model is a good fit for the data – χ2 = 114.7, P < 0.001, Hosmer and Lemeshow Test P= 0.776. Furthermore, the aforementioned variables accounted 20% of the variability in good health status of Jamaican (R-squared = 0.20) (Table 5.4). Self-reported illness of respondents is statistically correlated with sex (OR = 0.25, 95% CI = 0.10-0.62); head of household (OR = 0.33, 95% CI = 0.12-0.96); age of respondents (OR = 1.04, 95% CI = 1.01-1.07) and current good self-rated health status (OR = 0.32, 95% CI = 0.120.84) (Table 5). The model is a very good fit for the data – χ2 = 33.7, P < 0.001, Hosmer and Lemeshow Test P = 0.766 (Table 5.5).

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Discussion
There are enough empirical studies that agree that there was a positive statistical correlation between income, education, married people, social class and health status of people. The current study concurs with the literature that there is a positive association between income and health status. However, this paper did not find a significant statistical correlation between education, marital status, social class and self-rated health of Jamaicans. The current work highlights a number of disparities between the literature and this paper. Many studies have shown that income is strongly and positively correlated with health status [22, 24]; however, this study disagreed with those findings as it found that income’s contribution was 1% of the explanatory power of 20%. Furthermore, income contributed the least to current good self-rated health status of Jamaicans. Hambleton et al. [23], using elderly Barbadians, found that self-reported illness accounted for the most variability in health status, which is concurred by the current study and therefore emphasizes the secondary role that income plays in influencing health status. Concurrently, in Jamaica, medical care-seeking behaviour is not an indicator of preventative care as those who sought health care were 49% less likely to report good health; and those who did not have an illness spent more on health care compared to those who indicated an ailment. Embedded in this finding is the concept of health that Jamaicans hold and how medical care is still synonymous with illnesses, but that those who are not sick spent more on health care and are healthier indicating that preventative care is being practiced by Jamaicans. Apart from these findings that emerged in the data, a number of health disparities were identified and some could be considered as paradoxical events. The study found that men were 75% less likely to report an illness than females; however, there was no significant statistical difference between the health statuses of the sexes. Males reported greater income than females, yet there was no significance between their health care expenditure and health care-seeking

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behaviour. Is it a paradox that males reported less dysfunctions; attend health care institutions equally as females; and their health status is no better than that of females? The paradox does not cease there as males are outlived by females; experienced greater mortality at all ages than females; and again indicated fewer ailments than females. Is this paradox? Comparatively, using statistics from the Ministry of Health in Jamaica (actual visits to public hospitals), Planning Institute of Jamaica and Statistical Institute of Jamaica (ie. selfreported visits) to measure the validity of self-reported health data, in 1997, it was showed that in 33.1% of Jamaicans attended public hospitals [38] compared to 32.1% who reported having attended public hospitals. Furthermore, in 2004, 52.9% of Jamaicans visited public hospitals [38] compared to 46.8% self-reported as having visited public hospitals. When the data was disaggregated by sex, in 2004, actual visits for females were 69.8% compared to 65.7% selfreported; while for males actual visits were 30.2% compared to self-reported visits of 64.2%. Using curative visits from the Ministry of Health data, 33% of males visited health care facilities to address particular illness; however, 9% of males reported that they had an illness. Embedded in the data are the extent to which males under-report their illnesses, which further emphasizes the paradoxities in the health data. Self-rated health data for females is therefore highly accurate; but this is not the case for males. It was a paradox in the health data to find that males reported fewer illnesses, experience greater mortality at all ages, and had greater income; yet their health status was the same as that of males. There are clearly paradoxities in the health data between the sexes in Jamaica. If males are under-reporting their illnesses by approximately 50%, statistics on health data are therefore fallacious; and that caution must be used in using self-reported health data for males. This paradox can be unraveled in the definition of health and socialization of males in Jamaica.

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Caribbean males in particular Jamaicans are socialized to be strong, brave, and masculinity is tied to strength and so justify the emphasis of physique, and strength. The converse explains why they neglect weakness or the appearance of weakness which include illnesses. Ill-health is conceptualized as weakness and within the context of the socialization; males will not openly speak of illness, avoid medical care-seeking behaviour and visit health care institution on the severity of the illness. Statistics from the Ministry of Health showed that since 2000-to-2004, females outnumber males by 2 to 1 in terms of visits to health care institution [38]. However, using reported data for the same period, the figures were: in 2000 – 57.4% males and 63.2% females; in 2001 -56.3% males and 68.2% females; in 2001 – 62.1% males and 65.3% females and 2004 – 64.2% males and 65.7% females. Clearly the self-reported data are not in keeping with the actual data; and this denotes that males are over-stating their health care visits. On the other hand, using 2004 on actual visits, 69.8% of Jamaican females utilized health care facilities compared to 66% of females who reported health care visit. Within the context of over-statement of health care seeking behaviour and understatement of illness by males in Jamaica, this goes to the crux of the socialization and its influence on health care. A Caribbean anthropologist, Chevannes [39], opined that Caribbean males suppressed responses to pain, which justifies a low, turn out to health care facilities and higher mortality rates. This is not atypical to Caribbean males. Ali & de Muynck [40] in examining street children in Pakistan found a similar gender stereotype. A descriptive cross-sectional study carried out during September and October 2000, of 40 school-aged street children (8-14 years) showed that severity of illnesses and on the onset that ill-health begins to threaten financial opportunities that males sought medical care. Ali & de Muynck’s study therefore provides some understanding for

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the reluctance of males seeking medical care although they have greater income. With 49% of Jamaicans being males, within the context of the socialization, this explains income’s weak correlation with health status. This negative emotional irresponsiveness to medical care-seeking in Jamaica is not limited to males as females are apart of the current study which found no significant statistical difference between them and males seeking health care. Another paradox which is embedded in health data is the fact that people who spent more on medical care reported fewer illnesses; males reported fewer ailments; yet they are not healthier than females. Once again the explanation for this is embodied in the socialization, negative view that Jamaicans have of health, health reporting and males unwillingness to separate health from weakness, weakness from femininity, and how men respond to the interviewers. There is evidence that males are under-reporting their illness in the JSLC’s crosssectional survey, which means that self-reported health data males cannot be trusted. The researcher is proposing that a part of the rationale is under-statement of illnesses by males in Jamaica is owing to the sex of the interviewers. Most interviewers employed by the Statistical Institute of Jamaica to collect data from Jamaicans are females, and within the context of not wanting to exhibit weaknesses based on the definition of health, males are understating their illness in order to create the perception that they are strong which must exclude reporting illness. The issue appears to be extensive as statistics from the Ministry of Health for 2004 showed that for curative visits, females outnumber males by 2 to 1 [38]. Although the researcher was unable to ascertain the Ministry of Health Annual Report for 2007, the 2006 report showed the same ratios as for 2000 to 2004, which implies that gender is creating a noise when collecting data on men’s health in Jamaica.

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Is it a paradox that the educated are wealthier, have greater income and still are not healthier than the poor with less financial resources? This is not a paradox as weak relationship between health status and educational level disappear on the inclusion of income. The current work does show that bivariate relationship existed between education and healthier people; but that when income and education is placed in a single model, education no longer becomes significantly associated with good health status. The current findings concur with the literature which found that when subjective wellbeing, which is a measure of subjective health, was controlled for income and other variables, the statistical correlation between education and health disappears [41-43]. Smith & Kington [4] wrote, “Good health is an outcome that people desire, and higher income enables them to purchase more of it” which implies that (1) health can be bought and (2) those with lower income will have a lower health status. Although the literature as concurred with this study that income is positively associated with health, income’s contribution to health in Jamaica is weak indicating that while more income is correlated with better health status, Smith & Kington perspective must be refined as there was no significant statistical correlation between socio-economic class and health status. In Jamaica, there is no statistical difference between the health statuses of the socio-economic classes and this is equally the case when health is measured using health conditions. On the other hand, there is a clear paradox in the health data of the current study as income is correlated with better health status, yet the wealthy classes do not have greater health status or fewer reported illness than the lower socio-economic classes. The rationales that account for the paradoxes that emerged from the current study are lifestyle practices of the wealthy; the acceptance of the state of the poor, and that income’s

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contribution to health is not its purchase but it better. Marmot [44] opined that poverty is associated with greater infant mortality, more ill-health, material and social deprivation, poor conditions, and greater inequality in occupation, employment and income inequality. Within the inequalities that favour the wealthy, income means that they can afford, purchase and buy good with which they need. Wilkinson [45] found a weak relationship between average income and life expectancy in wealthy nations and Sen [46] found that increased life expectancy in Britain between 1901 and 1960 occurred during slow growth of per capita GDP (Gross Domestic Product). Sen continued that the improvement in life expectancy was owing to support policies such as sharing of health care and limited food supply. Another found a non-linear increase in the probability of dying with increased income [47], suggesting that income fulfills two roles (1) access to better socio-material resources, and (2) retards the positives of access to become a negative. There is a paradox in income as while wealthy Jamaicans has more income and access to more socio-material and political resources; their health status is not greater than the underprivileged, poor and poorest 20%. Concurrently, income’s contribution to health status in Jamaica is minimal and Jamaicans who seek more health care and experiencing more ill-health, it follows that affluent individuals should be encountering more illness; but this was not the case in Jamaica. Having established that health data collected from males indicate a low validity, with 49% of the sample being males, it follows that paradoxities identified in the current study highlights the difficulties in interpreting health data in Jamaica.

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Conclusion
There are some paradoxities in self-reported health data in Jamaica. Although some of these paradoxities are highlighted in this paper, caution now must be used by researchers in interpreting self-reported health data collected from males as they are clearly under-reporting illnesses and over-stating their health care seeking behaviour. Inspite of the paradoxities in the data, self-reported health collected on females in Jamaica is of high quality. This denotes that the paradoxities within the health data have provided critical answers to males’ reluctance in visiting health care facilities, their unwillingness to openly speak about illnesses and the fact that they have concealed information on their health. Therefore a new approach is needed in soliciting information from males about their health status.

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Conflict of interest
There is no conflict of interest to report.

Disclaimer
The researcher would like to note that while this study used secondary data from the Jamaica Survey of Living Conditions, 2007, none of the errors that are within this paper should be ascribed to the Planning Institute of Jamaica or the Statistical Institute of Jamaica as they are not there, but owing to the researcher.

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References
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20. Hamilton JD. Time series analysis. New Jersey: Princeton University Press; 1994. 21. Kleinbaum DG, Kupper LL, Muller KE. Applied regression analysis and other multivariable methods. Boston: PWS-Kent Publishing; 1988. 22. Grossman M. The demand for health – a theoretical and empirical investigation. New York: National Bureau of Economic Research; 1972. 23. Hambleton IR, Clarke K, Broome HL, Fraser HS, Brathwaite F, Hennis AJ. Historical and current predictors of self-reported health status among elderly persons in Barbados. Rev Pan Salud Public 2005; 17: 342-352. 24. Smith JP, Kington R. Demographic and Economic Correlates of Health in Old Age. Demography 1997;34:159-70. 25. Bourne PA. Impact of poverty, not seeking medical care, unemployment, inflation, selfreported illness, health insurance on mortality in Jamaica. North American Journal of Medical Sciences 2009;1:99-109. 26. Bourne PA. An epidemiological transition of health conditions, and health status of the oldold-to-oldest-old in Jamaica: a comparative analysis. North American Journal of Medical Sciences. 2009;1:211-219. 27. Bourne PA. Good Health Status of Older and Oldest Elderly in Jamaica: Are there differences between rural and urban areas? Open Geriatric Medicine Journal. 2009; 2:18-27. 28. Bourne PA. A Comparative Analysis of Health Status of men 60 + years and men 73 + years in Jamaica: a Multivariate Analysis. Asian Journal of Gerontology and Geriatrics. (in print). 29. Bourne PA, McGrowder DA. Rural health in Jamaica: Examining and refining the predictive factors of good health status of rural residents. Journal of Rural and Remote Health 9 (2), 2009:1116 30. Asnani MR, Reid ME, Ali SB, Lipps G, Williams-Green P. 2008. Quality of life in patients with sickle cell disease in Jamaica: rural-urban differences. Journal of Rural and Remote Health 8: 890-899. 31. CSDH. Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health. Geneva, World Health Organization; 2008. 32. Kelly M, Morgan A, Bonnefog J, Beth J, Bergmer V. The Social Determinants of Health: developing Evidence Base for Political Action, WHO Final Report to the Commission; 2007. 33. Wilkinson R, Marmot M. Social Determinants of Health. The Solid Facts.’ Second edition. Geneva: World Health Organization; 2003. 34. Solar O, Irwin A. A Conceptual Framework for Analysis and Action on the Social Determinants of Health. Discussion paper for the Commission on Social Determinants of Health DRAFT April 2007. 35. Graham H. Social Determinants and their Unequal Distribution Clarifying Policy Understanding. The Milbank Quarterly, 2004;82:101-124. 36. Petticrew M. Whitehead M, McIntyre SJ, Graham H, Egan M. Evidence for Public Health Policy on Inequalities: 1: The Reality According To Policymakers. J of Epidemiol and Community Health 2004;5: 811–816. 37. Ross CE, Mirowsky J. Refining the association between education and health: The effects of quantity, credential, and selectivity. Demography 1999;36:445-460. 38. Ministry of Health, Jamaica (MOHJ). Ministry of Health, Jamaica: Annual Report, 2004. Kingston; MOHJ; 2005.

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39. Chevannes B. Learning to be a man: Culture, socialization and gender identity in five Caribbean communities. Kingston: The University of the West Indies Press; 2001. 40. Ali M, de Muynck A. Illness incidence and health seeking behaviour among street children in Pawalpindi and Islamabad, Pakistan – qualitative study. Child: Care, Health and Development 2005;31: 525-32. 41. Clemente F, Sauer WJ. Life satisfaction in the United States. Soci Forces 1976;54:621-631. 42. Spreitzer E, Synder EE. Correlates of life satisfaction among the aged. J of Gerontology 1974;29:454-458. 43. Toseland R, Rasch J. Correlates of life satisfaction: An AID analysis. Int J of Aging and Human Development; 1979-1980;10:203-211. 44. Marmot M. The influence of income on health: views of an epidemiologist: Does money really matter? Or is it a marker for something else? Health Affairs 2002;21:31-46. 45. Wilkinson R. Unhealthy societies: The afflictions of inequality. London: Routledge; 1996. 46. Sen A. Development as Freedom. New York: Alfred A Knopf; 1999. 47. Deaton A. Health inequality and economic development. Working paper, Princeton University Research Program in Development Studies and Center for Health and Wellbeing, 2001.

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Table 5.1. Socio-demographic characteristic of sample by sex of respondents Characteristic Sex Male % Educational level Primary or below Secondary Tertiary Total Social standing Poorest 20% Poor Middle Wealthy Wealthiest 20% Total Marital status Married Never married Divorced Separated Widowed Total Area of residence Urban Semi-urban Rural Total Medical care-seeking behaviour Yes No Total Self-reported illness Yes No Total Age Mean (SD) in years Medical Expenditure1 Mean (SD) in US$ 1 Rate in 2007:1US$= Ja$80.47 87.9 10.5 1.6 3207 20.3 19.4 19.3 20.2 20.9 3303 24.3 71.1 1.6 0.7 2.3 2150 28.5 21.4 50.1 3303 62.3 37.7 406 12.1 87.9 3208 29.1 (21.5) 9.31 (15.48) Female % 86.6 11.0 2.4 3385 19.3 20.5 20.6 19.7 19.9 3479 22.4 67.4 1.8 1.0 7.3 2384 30.4 21.6 47.9 3479 67.6 32.4 599 17.5 82.5 3381 30.6 (21.9) 11.19 (36.51) Total % 87.3 10.8 2.0 6592 > 0.05 19.8 20.0 19.9 19.9 20.4 6782 < 0.05 23.3 69.2 1.7 0.9 4.9 4534 29.5 21.4 49.0 6782 65.6 34.5 1005 < 0.05 14.9 85.1 6589 29.9 (21.8) 10.46 (30.23) > 0.05 P > 0.05

> 0.05

< 0.05 > 0.05

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Table 5.2. Socio-demographic characteristic of sample by educational level Characteristic Educational level
Primary Secondary Tertiary Total P

% Social standing Poorest 20% Poor Middle Wealthy Wealthiest 20% Total Marital status Married Never married Divorced Separated Widowed Total Area of residence Urban Semi-urban Rural Total Medical care-seeking behaviour Yes No Total Self-reported illness Yes No Total Health insurance coverage None Private coverage Public coverage Total Age Mean (SD) in years Medical Expenditure1 Mean (SD) in US$ 1 Rate in 2007:1US$= Ja$80.47 20.3 20.0 19.4 19.9 20.3 5752 25.5 66.1 1.9 1.0 5.5 4048 28.8 22.0 49.2 5752 65.7 34.3 953 16.2 83.8 5736 79.8 12.0 8.2 5682 32.0 (22.6) 10.44 (30.78)

% 19.7 21.7 24.5 20.3 13.7 709 0.0 99.7 0.0 0.3 0.0 344 30.0 19.2 50.8 709 60.0 40.0 40 5.4 94.6 705 83.7 11.7 4.6 689 14.6 (1.7) 12.31 (18.73)

% < 0.05 3.8 7.6 16.0 19.1 53.4 131 16.9 81.5 1.5 0.0 0.0 130 63.4 16.4 20.6 131 66.7 33.3 12 9.2 90.8 130 57.8 35.9 6.3 128 26.4 (10.6) 5.79 (5.51) 19.9 20.0 19.9 19.9 20.2 6592 < 0.05 23.4 69.1 1.7 0.9 5.0 4522 < 0.05 29.6 21.6 48.8 6592 >0.05 65.5 34.5 1005 < 0.05 14.9 85.1 6571 < 0.05 79.8 12.5 7.7 6499 30.0 (21.8 10.46 (30.23)

< 0.05 >0.05

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Table 5.3. Socio-demographic characteristic of sample by self-reported illness
Self-reported illness P

Yes % Social standing Poorest 20% Poor Middle Wealthy Wealthiest 20% Total Marital status Married Never married Divorced Separated Widowed Total Area of residence Urban Semi-urban Rural Total Medical care-seeking behaviour Yes No Total Health insurance coverage None Private coverage Public coverage Total Age Mean (SD) in years Medical Expenditure1 Mean (SD) in US$
1

No % 20.0 20.4 19.8 19.7 20.2 5609 20.9 73.4 1.4 0.8 3.5 3801 30.1 21.9 47.9 5609 77.4 22.6 31

Total % >0.05 19.9 20.0 19.9 19.8 20.3 6589 <0.05 23.3 69.2 1.7 0.9 4.9 4522 <0.05 29.6 21.5 48.9 6589 >0.05 65.4 34.6 1001 <0.05 79.8 12.5 7.7 6503 < 0.05 <0.05

19.7 18.1 20.9 20.4 20.9 980 35.9 46.9 3.1 1.7 12.5 721 26.6 18.7 54.7 980 65.1 34.9 970

75.3 80.6 11.5 12.7 13.3 6.8 978 5525 42.0 28.0 (27.7) (20.0) 9.30 38.80 (18.27) (126.09)

Rate in 2007:US$1.00 = Ja$80.47

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Table 5.4. Stepwise Logistic Regression: Good self-rated health status by sociodemographic, economic and biological variables R-squared Variable Self-reported illness Medical care-seeking Age Income SE 0.48 0.18 0.01 0.00 P 0.002 0.000 0.000 0.007 0.000 Odds ratio 0.23 0.51 0.97 1.00 16.03 95.0% C.I. 0.09-0.59 0.36-0.72 0.96-0.97 1.00-1.00 0.02 0.02 0.15 0.01

Constant 0.54 -2 LL = 857.3 Hosmer and Lemeshow Test P = 0.776 Χ2 = 114.7, P < 0.001 R-squared = 0.20 N=6049 (89.2%)

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Table 5.5. Stepwise Logistic Regression: Self-reported illness by sociodemographic
and biological variables R-square Variable Male Head Household Age SE 0.47 0.54 0.01 P 0.003 0.043 0.010 Odds ratio 0.25 0.33 1.04 0.32 95.0% C.I. 0.10-0.63 0.12-0.96 1.01-1.07 0.12-0.84 0.059 0.024 0.021 0.075

Good Health 0.49 0.020 -2 LL = 177.7 Hosmer and Lemeshow Test P = 0.766 χ2 = 33.7, P < 0.001 R-squared = 0.19 N=6049 (89.2%)

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Chapter

6 Variations

in health, illness and health care-seeking behaviour of those in the upper social hierarchies in a Caribbean society

Little research exists in the Caribbean, and in particular Jamaica, on the upper class, and no study emerged from a search of the literature examining health, illness, and health care-seeking behaviour of this group. To provide pertinent information on the upper class in regards to their general health status, illnesses, typology of illnesses, health care seeking behaviours and factors which determine their (1) moderate-to-very good health status, (2) illness, and (3) health care seeking behaviour in order to make available to policy specialists and public health practitioners information on this group, to be used as a guide in their decision making policies. The majority of the sample stated at least good health status (83.3%), with 0.5% indicating very poor health status, and 15.3% who indicated an illness in the last 4-week period. Four variables emerged as statistically correlated with moderate-to-very good health status of those in the upper class (. second wealthy and wealthiest 20%) - Model fit χ2 = 57.54, P < 0.0001. The model explained 33.2% of the variance in moderate-to-very good health status, and that the model is a good fit for the data. Three variables emerged as statistically correlated with self-reported illness Model fit χ2 = 1087.7, P < 0.0001. The significant variables (. health care-seeking behaviour, good health status, and marital status) accounted for 72.4% of the variability in self-reported illness. Three variables emerged as statistically significant correlates of health care-seekers Model fit χ2 = 995.45, P < 0.0001. The statistically significant correlates (. good health status, self-reported illness, marital status) accounted for 76.4% of the variance in health care-seeking behaviour of the upper class. Rural residents continue to have lower moderate-to-very good health status when compared to the general population, and the second wealthy and the wealthiest 20% in Jamaica. Although only 4 percent of the upper social hierarchy utilize the public health care system, there is still a demand for public health services for this group, and it must be taken into account as a part of the general planning for the health care system of the country.

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Introduction
Studies have long established health disparities between the poor and the wealthy classes, and this is no different in Latin America and the Caribbean [1-17]. According to the World Health Organization [7], 80% of chronic illnesses were in low and middle income countries, which illustrate the dichotomy between illness and material deprivation. The dichotomy between illness and poverty is only limited to low-to-middle income nations, as a study in the Netherlands found that those who were chronically ill were more likely to be poor [15], and this was also found in other European nations [16,17]. The association between insufficient money and health is not limited to illness, but the WHO [7] opined that 60% of global mortality is caused by chronic illness, which raised another issue, the relationship between poverty and premature mortality. Marmot [8] postulated that money makes a difference in health, infant mortality and general morality. The association between income and health expands beyond the direct relationship between income and access to good physical and social milieu, good nutrition and access to high quality health care services, to the indirect association between income and health through access to education, employment, material resources and occupational class. Clearly there are inequalities in health between those in the upper class and those in the lower class [18, 19], but limited studies existed on the wealthy and the wealthiest 20% in nations. In keeping with public health aims, many studies have been carried out on the poor; poverty and illness; poverty and productivity; chronic illness, capabilities and poverty, but what about the second wealthy and the wealthiest 20% in regard to their health, illness, health care-seeking behaviour and factors which influence health, illness and health care-seeking behaviour? Public health is about improvements in the health conditions of all members of a society and not just a particular group. Embedded in the mandate of public health is the access to

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information which will guide policy formulation, intervention and health education programmes, and so information is equally needed on the affluent groups. Limited information, if any, exists in the Caribbean on the health of the second wealthy and wealthiest 20% classes. While general statistics indicate that the upper class has a greater health status and more access to material resources than the poor class, the former group constitutes a percentage of the population and must be studied like the poor class. The current study revealed that the prevalence rate of the upper class utilizing public health care facilities (hospitals and health centres) was 4%, suggesting that this group must be planned for, as they utilize and demand public health care resources like other social classes. Concurringly, this research showed that 3% of those in the wealthy social class had chronic illnesses, and that 1% had diabetes mellitus, which denotes that public health must make available resources for this group. Within the context that the upper social class utilizes public health care resources, it is surprising that no studies exist in Jamaica that have examined health, illness, and the health care seeking-behaviour of this social group. The current study aims to provide pertinent information on the upper class in regards to their general health status, illness, typology of illness, health care seeking behaviours and factors which determine their (1) moderate-to-very good health status, (2) illness, and (3) health care seeking behaviour, in order to make available to policy specialists and public health practitioners information on this group, which will serve as a guide for their decision-making policies.

Methods and materials
Sample A sample of 2,734 respondents from the wealthiest 20% and second wealthy social hierarchy was extracted from a cross-sectional survey of 6,783 respondents: 50.5% in the wealthiest 20% and 49.5% in the second wealthy group. The survey was carried out jointly by the Planning

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Institute of Jamaica and the Statistical Institute of Jamaica [20]. The method of selection of the sample from each survey was based solely on rural residence. The survey (Jamaica Survey of Living Conditions) was begun in 1989, collecting data from Jamaicans in order to assess government policies. Each year since 1989, the JSLC has added a new module in order to examine that phenomenon which is critical within the nation. In 2002, the foci were on 1) social safety net and 2) crime and victimization; while for 2007, there was no focus. The current sample was extracted from the 2007 dataset. The survey was drawn using stratified random sampling. This design was a two-stage stratified random sampling design where there was a Primary Sampling Unit (PSU) and a selection of dwellings from the primary units. The PSU is an Enumeration District (ED), which is composed of a minimum of 100 residences in rural areas and 150 in urban areas. An ED is an independent geographical unit that shares a common boundary. This means that the country was grouped into strata of equal size based on dwellings (EDs). Based on the PSUs, a listing of all the dwellings was made, and this became the sampling frame from which a Master Sample of dwellings was compiled, which in turn provided the sampling frame for the labour force. One third of the Labour Force Survey (LFS) was selected for the JSLC [20]. The sample was weighted to reflect the general population of the nation. The JSLC 2007 [20] was conducted in May and August of that year. An administered questionnaire was used to collect the data, which were stored and analyzed using SPSS for Windows 16.0 (SPSS Inc; Chicago, IL, USA). The questionnaire was modelled on the World Bank’s Living Standards Measurement Study (LSMS) household survey. There are some modifications to the LSMS, as the JSLC is more focused on policy impacts. The questionnaire covered areas such as socio-demographic variables, for example education, daily expenses (for

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the past 7-day period), food and other consumption expenditures, inventory of durable goods, health variables, crime and victimization, social safety net, and anthropometry. The questionnaire contains standardized items such as socio-demographic variables, excluding crime and victimization, which were added in 2002 and later removed from the instrument, with the exception of a few new modules each year. The non-response rate for the survey for 2007 was 27.7%. The non-response includes refusals and cases rejected in data cleaning. Measures Self-rated health status: is measured using people’s self-rating of their overall health status [21], which ranges from excellent to poor. The question that was asked in the survey was “How is your health in general?” And the options were very good; good; fair; poor and very poor. For the purpose of the model in this study, self-rated health was coded as a binary variable (1= good, 0 = Otherwise) [21-28]. The binary good health status was used as the dependent variable. Self-reported illness (or self-reported dysfunction): The question was asked: “Is this a diagnosed recurring illness?” The answering options are: Yes, Influenza; Yes, Diarrhoea; Yes, Respiratory diseases; Yes, Diabetes; Yes, Hypertension; Yes, Arthritis; Yes, Other; and No. A binary variable was later created from this construct (1=no 0=otherwise) in order to be applied in the logistic regression. Age is a continuous variable which is the number of years alive since birth (using last birthday). Age groups were classified as children, young adults, other adults, young-old (or young-elderly), old-old, and oldest-old: children – 0 to 14 years; young adults – 15 to 30 years; other adults – 31 to 59 years; young-old – 60 to 74 years; old-old - 75 – 84 years and oldest-old – 85+ years. Medical care-seeking behaviour was taken from the question ‘Has a health care practitioner or pharmacist been visited in the last 4 weeks?’ with there being two options: Yes or No. Medical

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care-seeking behaviour therefore was coded as a binary measure where 1= Yes and 0 = otherwise.

Crowding is the total number of individuals in the household divided by the number of rooms (excluding kitchen, verandah and bathroom).

Sex: This is a binary variable where 1= male and 0 = otherwise.

Social supports (or networks) denote different social networks with which the individual is involved (1 = membership of and/or visits to civic organizations, or having friends who visit one’s home or with whom one is able to network, 0 = otherwise).

Statistical Analysis Descriptive statistics such as mean, standard deviation (SD), frequency and percentage were used to analyze the socio-demographic characteristics of the sample. Chi-square was used to examine the association between non-metric variables, and t-test and an Analysis of Variance (ANOVA) were used to test the relationships between metric and/or dichotomous and non-dichotomous categorical variables. Box-plots were used to examine what was happening among age, selfreported illness, and social hierarchy as well as age, typology of illness and social hierarchy (. poorest 20% and wealthiest 20%). Multiple logistic regression techniques were conducted to identify parameters and their estimates. Stepwise logistic regression technique was used to determine the contribution of each significant determinant to the model. A p-value less than 0.05 (two-tailed) was selected to indicate statistical significance (. 95% confidence interval).

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Results
Table 6.1 presents information on the socio-demographic characteristics of the sample. One percent of the sample reported an injury. Of those who reported an injury, 67.9% stipulated the injury experienced in the last 4weeks. Domestic accidents and incidents accounted for 47.3% of the injuries experienced. Fifteen percent of the sample indicated an illness in the last 4 weeks. Of those who reported an illness, 89.1% stipulated the typology of the health condition. When the respondents were asked if they had purchased the prescribed medication, 67.7% said yes. Of those who did not purchase the medication, 9.5% claimed they were unable to afford it; 39.7% said they were not ill enough; 27.6% remarked that they used a home remedy; 5.2% indicated that they did not have the time and 18.1% stated other. Seventy-one percent of the sample sought medical care in the last 4weeks, 32.5% had health insurance coverage (23.7% private). The majority of the sample stated at least good health status (83.3%), with 0.5% indicating very poor health status. Of the sample, only 10.6% indicated where the medical visit took place in the last 4weeks. Of those who responded (n=288), 27.4% indicated a public hospital, 61.8% said a private health care centre and 12.5% remarked that it was a public health care centre. Twentynine percent of those who responded to typology of medical facility used in the last 4weeks had chronic conditions and attended a public facility. The prevalence rate of the upper class utilizing public health care facilities (hospitals and health centres) was 4% (3% had a chronic illness; of the 3%, 1% had diabetes mellitus). There was no significant statistical association between marital status and social hierarchy (second wealthy or wealthiest 20%) – χ2 = 8.518, P = 0.744.

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Table 6.2 shows information on particular variables and social hierarchy. A significant statistical relationship existed between area of residence and social hierarchy. Those in the wealthiest 20% were more likely to be urban dwellers (48.6%) than those in the second wealthy social group (36.9%) - χ2 = 57.002, P < 0.0001. Rural dwellers were more likely to be wealthy (59.1%) compared to semi-urban residents (50.1%) and urban respondents (42.1%). Concurringly, urban settlers were more likely to be in the wealthiest 20% (57.9%) compared to semi-urban (49.9%) and rural respondents (40.9%) – P < 0.0001. There was a significant statistical association between educational level and social hierarchy (χ2 = 30.53, P < 0.0001). Those in the wealthiest 20% were more likely to be educated at the tertiary level (5.3%), as compared to those in the second wealthy social group (1.9%). Likewise there was a statistical relationship between health insurance coverage and social hierarchy (χ2 = 113.27, P < 0.0001). Forty-two percent of those in the wealthiest 20% had health insurance coverage compared to 22.6% of those in the second wealthy social group. There were significant statistical differences between those in the wealthy and the wealthiest 20% (1) age ( t = - 4.745, P < 0.001) – mean age of the wealthy 30.14 ± 21.1, and the wealthiest 20% 33.9 ± 20.4; (2) crowding (t = 15.991, P < 0.0001 – mean household crowding for those in the wealthy group was 4.2 ± 2.2 compared to 3.0 ± 1.6 for those in the wealthiest 20%, and (3) total expenditure (t = - 16.219, P < 0.0001) – mean total expenditure for those in the wealthy group was USD 9,713.00 ± USD 5,327.88 and those in the wealthiest 20% was USD 14,915.29 ± USD 10,550.99. Furthermore, there was a significant statistical difference between mean duration of illness of those in the second wealthy social group (23.8 days ± 96) and those in the wealthiest 20% (9.9 days ± 18.7) – t = 1.985, P = 0.048; but none between duration of

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marriage and social hierarchy (wealthy, 16.7 years ± 14.6; wealthiest 20%, 17.3 ± 13.6) – t = 0.593, P = 0.553.

Multivariate analyses Table 6.3 shows information on particular variables that are correlated (or not) with self-reported moderate-to-very good health status of the sample. Four variables emerged as statistically correlated with moderate-to-very good health status of those in the upper class (. second wealthy and wealthiest 20%) - Model fit χ2 = 57.54, P < 0.0001. The model explained 33.2% of the variance in moderate-to-very good health status, and the model is a good fit for the data (Hosmer and Lemeshow goodness of fit χ2 = 2.87, P = 0.94, -2LL = 194.22). Eighty-one percent of the data were correctly classified: 94.9% of those who had indicated moderate-to-very good health status and 33.3% of those that were classified into poor and very poor health status. Table 6.4 presents information on variables that either correlated or did not correlate with self-reported illness of the sample. Three variables emerged as statistically correlated with selfreported illness - Model fit χ2 = 1087.7, P < 0.0001. The significant variables (health careseeking behaviour, good health status, and marital status) accounted for 72.4% of the variability in self-reported illness. The model is a good fit for the data (Hosmer and Lemeshow goodness of fit χ2 = 8.11, P = 0.42, -2LL = 649.69). Ninety-five percent of the data were correctly classified: 72.2% of those who were classified as having an illness and 99.6% of those who did not report an illness. Table 5 displays variables that seek to explain the variability in self-reported health careseeking behaviour of the sample. Three variables emerged as statistically significant correlates of health care-seekers - Model fit χ2 = 995.45, P < 0.0001. The statistically significant correlates (.

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good health status, self-reported illness, marital status) accounted for 76.4% of the variance in health care-seeking behaviour of the upper class. The model was a good fit for the data - Hosmer and Lemeshow goodness of fit χ2 = 3.64, P = 0.90. Ninety-five percent of the data were correctly classified: 96.2% of those who had selected seeking medical care in the last 4 weeks and 95.3% of those who did not seek medical care.

Discussion
The present work revealed that 88 out of every 100 respondents in the upper class in Jamaica indicated that their health status was at least good, with only 5 in every 1,000 experiencing very poor health statuses. One in every 100 had an injury and 15 per 100 had an illness in the last 4week period. The prevalence rate of self-reported diagnosed acute health conditions was 36 per 1,000 and 96 per 1,000 for chronic conditions. Twenty-four per 1,000 had diabetes mellitus; 28 out of every 1,000 had hypertension and 7 per 1,000 reported having been diagnosed with arthritis. Seventy-one percent sought medical care; there was no significant statistical association between (1) self-reported injury and being second wealthy or in the wealthiest 20% as well as (2) between self-reported illness and social hierarchy (second wealthy or wealthiest 20%). The mean length of time experiencing the current illness (in days) was greater for those in the second wealthy class, as compared to those in the wealthiest 20%. Although only 1% of the sample reported an injury in the study, 47.3% of the injuries were owing to domestic accidents and domestic incidents, and 21.1% were due to motor vehicle accidents. Four percent of the sample utilized public health care facilities for their last medical visit, and 11.8% of the sample were elderly (ages 60 years and beyond), 24.6% children (ages less than 15 years); 49.6% of those in the wealthiest 20% dwelled in urban areas compared to 36.9% of those in the second wealthy social group. Those in the wealthiest 20%, according to average total expenditure, were 1.5 times

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more than those in the second wealthy class and they were 2.9 times more educated at the tertiary level. Concurringly, rural upper class respondents had the lowest moderate-to-very good health status; those with good health status were 48% less likely to seek medical care; those with illnesses were 449 times more likely to seek medical care, and married upper class respondents were 45% less likely to seek health care, while married wealthy residents were 2.3 times more likely to report an illness. Marmot [8] asked the question “Does money matter for health? If so, why?” and opined that it does in terms of access to good nutrition, material resources, lower infant mortality, health care choices, and a good physical environment compared to those in the lower socioeconomic group. Clearly there are differences in health outcomes between the social hierarchies [1-17], but does money matter for health between the second wealthy and the wealthiest 20%? The current study found that money does not matter for health between the wealthy and the wealthiest 20%. Money does not matter for the general health status of the wealthy and the wealthiest 20%, but also for self-reported injuries and illnesses (both acute and chronic conditions). Embedded in this finding is the reality that there is a basic amount of money necessary, and any more than that will not improve the health of the individual. This work showed that those in the wealthiest 20% on average spent almost 2 times more than those in the second wealthy class, and are about 3 times more educated at the tertiary level, but this does not produce additional improvements in health for the wealthiest 20%. The present paper found that a large health disparity occurred between upper class respondents and geographic area of residents, which concurs with the findings of Vila et al.’s work. Vila et al.’s research [9] used self-reported health status (. fair-to-poor health status) and found that lower socioeconomic class residents of Milwakee had the greatest fair-to-poor health

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status with those in the upper class indicated the least fair-to-poor health status. Concurringly, they also found that upper socioeconomic group had the greatest health in the city, which was different in this research. In this study, upper socioeconomic group who resided in semi-urban areas were the healthiest, and had lower total annual expenditure than those upper class respondents who lived in urban areas. The huge health disparity was found between the upper class rural and semi-urban dwellers, suggesting that lifestyle practices in semi-urban geographic areas was greatest and was remarkably different from that of upper class rural respondents. However, the health disparity is among those who dwell in particular geographical areas, and those who have health insurance coverage, and not between the wealthy and the wealthiest 20%. Rural upper class Jamaicans had the least moderate-to-very good health status. This health disparity is substantial as upper class semi-urban residents were 4.8 times more likely to report moderate-to-very good health status, and those who dwelled in urban areas were 4.3 times more likely to report moderate-to-very good health status compared to those in the rural areas. Such inequality in health emphasized that the lifestyle of rural residents is such that money does not equate their health status with those of their other wealthy urban and semi-urban peers. This is embedded in the present work as there is no significant statistical correlation between selfreported illness and area of residence, or area of residence and health care seeking behaviour of the upper class. It follows that it is not money and illness that separate the rural from the other affluent respondents, but this must be therefore embedded in the cultural differences between people. Another finding which emerged from the current research is the fact that married upper class respondents reported more illness than those who were never married, yet the former group sought less medical attention than the latter group. Although married upper class respondents reported more illness, there was no statistical correlation between marital status and moderate-to-

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very good health status. A plethora of studies have examined the health status of married and non-married respondents and the verdict is that the former group’s health status is greater [2935], which means that money removes this health disparity. According to Moore et al. [35], people who reside with a spouse have a different base of support which aids in better health choices and justifies greater health status, as against those without social support from a marital union. This was also found in earlier studies by Smith and Waitzman [31] and Lillard and Panis [34]. Cohen and Wills [36] found that perceived support from one’s spouse increased well-being, while Ganster et al. [37] reported that support from supervisors, family members and friends was related to low health complaints. Another study found that being married was a ‘good’ cause for an increase in psychological and subjective well-being in old age [38]. Smith and Waitzman [31] offered the explanation that wives were likely to dissuade their husbands from particular risky behaviours such as the use of alcohol and drugs, and would ensure that they maintained a strict medical regimen coupled with proper eating habits. On the contrary, this paper revealed that married affluent Jamaicans were more likely to report illness, as compared to never-married wealthy respondents, but that this does not translate into better health status for one group over the other. Using the relationship of the absence of illness to health of the wealthy-to-wealthiest 20% of Jamaicans, this should denote that the wealthiest should be healthier than the second wealthy. Clearly, there is a cognitive disparity between the image of health and illness. Illness is well established to be a narrow approach to the conceptualization of health [39-46], and this is what emerged as the case for the upper class. According to the WHO [39], health is social, psychological and physical wellbeing and not merely the absence of illness. Clearly upper class respondents subscribe to this conceptualization as experiencing illness was correlated with low

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moderate-to-very good health status, but illness was not a factor which determines the moderateto-very good health status of those in the upper class. Ferrer and Palmer’s work [14] revealed marginal health variabilities between those people in the second wealthy and the wealthiest 20%, and using self-reported to measure health status, this study found no statistical association between self-reported health and the two social hierarchies. The present work goes further than Ferrer and Palmer’s research that used health status and investigated general illness and particular health conditions and those in the second wealthy and the wealthiest 20%. Ferrer and Palmer’s research did not examine illness or particular typology of illness. Statistics revealed that 15.5% of Jamaicans reported an illness in the last 4weeks in 2007 [47] compared to 15.3% of those in the upper class. Seemingly there is no difference between self-reported illness in the population and those in the upper class, but further examination of the diagnosed health conditions revealed some differences between the population and the subpopulation. For the population, the prevalence rates for people with asthma were 87 per 1,000; diabetes mellitus, 120 per 1,000; hypertension, 224 per 1,000 and arthritis, 88 per 1,000 [47] compared to those in the upper class, being asthma, 12 per 1,000; diabetes mellitus, 24 per 1,000; hypertension, 28 per 1,000 and arthritis, 7 per 1,000. The findings of this study highlight that those in the affluent social hierarchy have a lower prevalence of chronic illness than people in the general population of Jamaica, which concurs with the literature that those in the lower socioeconomic group were more likely to experience more chronic illness than the affluent. Although those in the wealthy-to-wealthiest 20% group in Jamaica had a lower prevalence of chronic health conditions compared to the general population, they had a prevalence rate of 37 per 1,000 for other health conditions. The other conditions constitute ailments such as prostate and breast cancers, ischemic

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heart disease, malignant neoplasm of the trachea, bronchus and other heart diseases. Statistics on the mortality of males 5 years and older revealed that cerebro-vascular diseases, diabetes mellitus, ischemic heart diseases, malignant neoplasm of the prostate, hypertensive disease, chronic lower respiratory infections, other heart diseases and malignant neoplasm of the trachea and HIV were among the 10 leading causes of death [48]. For females 5 years and older it was about the same as the 10 leading causes of death for males, except for malignant neoplasm of the prostate and malignant neoplasm of the trachea, these being replaced by malignant neoplasm of the breast and pneumonia. Although the upper class clearly has lower prevalence rates of particular chronic illnesses, compared to the general population, and more than those in the poorest 20% [47], diabetes mellitus, hypertension and other health conditions are high among them and may explain the levels of mortality among those therein. Chronic illnesses are linked to lifestyle causes, and though they have lower rates of chronic illness than people in the lower socioeconomic group, the reality among the upper class are that their lifestyle explains their particular morbidity and mortality. A study by Wilks et al. [49] found that 64.3% of Jamaicans were currently using alcohol (. liquor, wine, beer or stout, and mixed alcoholic coolers), 13.5% used marijuana, 14.5% smoked cigarettes, and the rates were even greater for males than females. Concurringly, 71% of those in the upper class consumed alcohol (. 84.3% of males and 48.7% of females); 9.8% smoked cigarettes (12.4% of males and 6.7% of females); 10.4% smoked marijuana (16.9% of males and 2.2% of females) and 10.5% used illegal drugs (17.1% of males and 2.7% of females) [49]. Furthermore, the percentage of upper class males who consumed alcohol was more than for those males in the lower (76.1%) and the middle class (79.4%) [49]. Unhealthy lifestyle practices are therefore responsible for the composition of

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illnesses which are experienced by the upper class and account for many of their ailments. Furthermore, it is clear from the findings that among the upper socioeconomic class there are no vulnerable groups, but what is equally evident is that socioeconomic status accounted for a major role in determining the health status of upper class Jamaica as was found for all socioeconomic classess in Blanc et al.’s work [11].

Conclusion
While poverty is associated with illness and illness is more related to poverty and lower health status for the poor than for those in the upper class, the same is not true of the relationship between the wealthy and the wealthiest 20% in Jamaica. It follows that money and wealth, beyond a certain amount, does not add any further improvements to good health status. Income and wealth beyond that which is accessible to the second wealthy in Jamaica do not provide those beyond that with any greater health status. However, what emerged from the current work is that the health disparity between the rural areas’ affluent people and others is vast, suggesting that there are some underlying cultural conditions which exist among the rich of different geographical areas, and which do not disappear because the individual is wealthy. Another pertinent finding is that the wealthy spent more days in illness compared to the wealthiest 20%, but this does not translate into lower moderate-to-very good health status. A part of the justification for this non-health disparity is owing to their conceptualization of health compared to the image of illness. There are affluent Jamaicans who utilize the public health care system, and many of them have diabetes mellitus. Within the context of the utilization of the public health care system by the wealthy, although the percentage is very small, the current finding are important to public

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health policy makers in understanding the service utilization of this group and their health, and illness profile. In summary, money and wealth beyond that which is accessible by the second wealthy in Jamaica will show no further disparity in moderate-to-very good health status. The paper highlighted the fact that health insurance coverage is not a good measure of health care-seeking behaviour and illness is not a good proxy for the health status of the upper class. However, the health disparity which existed for the general society among the different areas of residents is the same for the upper class. Rural residents continue to have lower moderate-to-very good health status than the general population, and the second wealthy and the wealthiest 20% in Jamaica. Although only 4 percent of the upper social hierarchy utilizes the public health care system, there is still a demand for public health services for this group, and it must be taken into account as a part of the general planning for the health care system of the country. Conflict of interest The author has no conflict to interest to report

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Table 6.1. Demographic characteristics of sample Characteristics Social hierarchy Second wealthy Wealthiest 20% Sex Male Female Area of residence Urban Semi-urban Rural Injury Yes No Self-reported typology of injury Motor vehicle accident Domestic accident Industrial accident Domestic incident Other (unspecified events) Self-reported illness Yes No Self-reported diagnosed illness Acute conditions Influenza Diarrhoea Respiratory Chronic condition Diabetes mellitus Hypertension Arthritis Other Educational level Primary or below Secondary Tertiary Length of time married median (inn years) Number of visits to medical practitioners in last 4-weeks mean (SD) Length of illness median (in days)

Frequency 1352 1382 1356 1378 1184 706 844 28 2622 4 7 5 2 1 405 2237

% 49.5 50.5 49.6 50.4 43.3 25.8 30.9 1.1 98.9 21.1 36.8 26.3 10.5 5.3 15.3 84.7

56 8 34 66 76 19 102 2311 241 95

15.5 2.2 9.4 18.3 21.1 5.3 28.3 87.3 9.1 3.6 12 (Range = 1, 71) 1.4 (1.1) 5 (Range = 0,200)

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Table 6.2. Particular variables by social hierarchy Social hierarchy Wealthy Wealthiest 20% n (%) n (%) 499 (36.9) 685 (49.6) 354 (26.2) 352 (25.5) 499 (36.9) 345 (25.0) 667 (49.3) 685 (50.7) 689 (49.9) 693 (50.1) P χ2 = 57.002, P < 0.0001

Area of residence Urban Semi-urban Rural Sex Male Female Self-reported diagnosed health condition Acute conditions Influenza Diarrhoea Asthma Chronic conditions Diabetes mellitus Hypertension Arthritis Other (unspecified) Health care-seeking behaviour Yes No Self-reported illness Yes No Self-reported health status Very good Good Fair Poor Very poor

χ2 = 0.074, P = 0.407 χ2 = 5.190, P = 0.520

32 (17.9) 3 (1.7) 12 (6.7) 33 (18.4) 38 (21.2) 8 (4.5) 53 (29.0) 141 (68.4) 65 (31.6) 200 (15.3) 1105 (84.7) 567 (43.2) 536 (40.8) 157 (12.0) 42 (3.2) 11 (0.8)

24 (13.2) 5 (2.7) 22 (12.2) 33 (18.1) 38 (18.1) 11 (6.0) 49 (26.9) 155 (73.5) 56 (26.5) 205 (15.3) 1132 (84.7) 531 (40.0) 565 (42.5) 185 (13.9) 45 (3.4) 3 (0.2)

χ2 = 1.272, P = 0.154 χ2 = 0.000, P = 0.520 χ2 = 8.815, P = 0.066

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Table 6.3. Logistic regression: Moderate-to-very good health status by particular variables Odds ratio 0.95 0.70 0.00 0.70 0.68 1.00 0.997 0.000 1.474 1.584 0.408 0.000 0.439 0.511 5.976 4.712 11.258 9.622 0.015 0.030 0.001 0.002 2.71 1.00 4.37 4.88 1.00 1.03 1.00 1.22, 6.02 1.00, 1.00 1.85, 10.34 1.79, 13.26

Age Male Self-reported illness Married Divorced, separated or widowed †Never married Health insurance Medical expenditure Urban area Other town †Rural area

Coefficient -0.051 -0.351 -19.926 -0.353 -0.383

Std. Error 0.013 0.387 13414.774 0.433 0.549

Wald 15.260 0.822 0.000 0.666 0.487

P 0.000 0.365 0.999 0.415 0.485

95% CI 0.93, 0.98 0.33, 1.50 0.000, 0.30, 1.64 0.23, 2.00

Head of household 0.031 0.410 0.006 Per capita consumption 0.000 0.000 0.206 2 Model fit χ = 57.54, P < 0.0001 Hosmer and Lemeshow goodness of fit χ2 = 2.87, P = 0.94 -2LL = 194.22 Nagelkerke R2 =0.332 †Reference group

0.940 0.650

0.46, 2.30 1.00, 1.00

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Table 6.4. Logistic regression: Self-reported illness by particular variables Std. Error 0.008 0.233 0.260 0.421 Wald statistic 2.769 3.188 9.960 0.113 Odds ratio 1.01 0.66 2.27 0.87 1.00 0.77 0.71 0.80 1.00 1.50 1.00 0.15 437.11 95.0% C.I. 1.0, 1.03 0.42, 1.04 1.37, 3.79 0.38, 1.98

Variable Age Male Married Divorced, separated or wid †Never married Health insurance Urban area Other town †Rural area Head of household Per capita consumption Good health status Health care-seekers Model fit χ2 = 1087.7, P < 0.0001

Coefficient 0.013 -0.415 0.821 -0.141

P 0.096 0.074 0.002 0.737

-0.259 -0.347 -0.219

0.244 0.257 0.294

1.132 1.832 0.551

0.287 0.176 0.458

0.48, 1.24 0.43, 1.17 0.45, 1.43

0.408 0.000 -1.872 6.080

0.243 0.000 0.248 0.417

2.810 0.595 56.921 212.549

0.094 0.440 0.000 0.000

0.93, 2.42 1.00, 1.00 0.10, 0.25 193.02, 989.89

Hosmer and Lemeshow goodness of fit χ2 = 8.11, P = 0.62 -2LL = 649.69 Nagelkerke R2 =0.724 †Reference group

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Table 6.5. Logistic regression: Self-reported health seeking behaviour by particular variable Std. Error 0.008 0.260 0.295 0.445 Wald statistic 3.080 0.175 4.151 0.429 Odds ratio 1.02 0.90 0.55 0.75 1.00 1.59 1.14 0.97 1.00 0.93 1.00 449.37 0.52 95.0% C.I. 1.00, 1.03 0.54, 1.49 0.31, 0.98 0.31, 1.79

Age Male Married Divorced, separated or wid † Never married Health insurance Urban area Other town †Rural area Head of household Per capita consumption Self-reported illness Good health status Model fit χ2 = 995.45, P < 0.0001

Coefficient 0.014 -0.109 -0.601 -0.291

P 0.079 0.676 0.042 0.513

0.463 0.134 -0.034

0.269 0.287 0.328

2.954 0.218 0.011

0.086 0.640 0.918

0.94, 2.69 0.65, 2.01 0.51, 1.84

-0.069 0.000 6.108 -0.658

0.270 0.000 0.417 0.266

0.066 0.042 214.598 6.147

0.797 0.837 0.000 0.013

0.55, 1.58 1.00, 1.00 198.47, 1017.42 0.31, 0.87

Hosmer and Lemeshow goodness of fit χ2 = 3.64, P = 0.90 -2LL = 446.41 Nagelkerke R2 =0.764 †Reference group

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Chapter

7 Self-reported health and medical care-

seeking behaviour of uninsured Jamaicans

On examination of the literature in Latin America and the Caribbean, and in particular Jamaica, no study could be found that investigated the health and health care-seeking behaviour of uninsured people. This study bridges the gap in the literature, by evaluating uninsured Jamaicans’ medical care-seeking behaviour and good health status. Good health of uninsured Jamaicans is correlated -reported biological condition (OR =0.114, 95% CI = 0.090 -0 .145) followed by age (OR =0.952, 95% CI = 0.946- 0.959); gender (OR = 1.501, 95% CI = 1.221– 1.845); consumption (OR = 1.000, 95% CI = 1.000–1.000); social class (upper class OR = 0.563, 95% CI = 0.357–0.888); education (secondary and above OR = 0.622, 95%CI = 0.402–0.963), and area of residence (other towns OR = 1.351, 95% CI = 1.026–1.778). Medical care-seeking behaviour is associated with age (OR = 1.020, 95% CI = 1.006 – 1.033); poor health status (OR = 2.303, 95% CI = 1.533–3.461), and marital status (married OR = 0.518, 95% CI = 0.325– 0.824). The findings are far reaching and provide an understanding of the uninsured, and the information can be used to aid public health intervention and education programmes.

Introduction
Poverty is among the reasons for some people in developing nations not seeking medical care; and it also explains premature death owing to low health care utilization. The World Health Organization (WHO) [1] opined that 80% of chronic illnesses were in low and middle income countries, suggesting that poverty interfaces with illness and creates other socio-economic challenges. Poverty does not only impact on illness, it causes premature deaths, lower quality of life, lower life and healthy life expectancy, low development and other social ills such as crime, high pregnancy rates, and social degradation of the community. According to Bourne & Beckford [2], there is a positive correlation between poverty and unemployment; poverty and illness; and

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crime and unemployment. Sen [3] encapsulated this well when he put forward the idea that low levels of unemployment in the economy are associated with higher levels of capabilities. The WHO [1] opined that 60% of global mortality is caused by chronic illness, and within the context that four-fifths of chronic dysfunctions are in low-to-middle income countries, health insurance coverage reduces the burden of out-of-pocket medical expenditure for the individual and the family.

Jamaica is among those countries classified as developing nations. Hence, the challenges which were stated earlier also influence the quality of life of some people within the society. In 1988, Jamaica’s unemployment rate was 18.9% and 2 decades later (2007), it fell by 67.2% (to 6.2%) which indicates close to full-employment. [4] This significant reduction in unemployment rates cannot be the only indicator used to evaluate the socio-economic status of Jamaica, or for a hasty conclusion to be drawn that the quality of life of Jamaicans is better in 2007 compared to 1988. In 1988 the inflation rate in Jamaica was 8.8% and this increased by over 90%, suggesting that the economic cost of living for Jamaicans was substantially higher than twenty years earlier. It is important to note that the inflation rate in 2007 (16.8%) increased by 194.7% over 2006. A national representative probability sample cross-sectional survey of 1,338 Jamaicans which was conducted in 2007 revealed that 68.7% of respondents claimed that their current economic situation was at most the same compared to 12 months ago, and of this figure 25% mentioned that it was worse. [5] Furthermore, 62% of the sample indicated that their salaries were not able to satisfactorily cover their basic needs, and 71.9% claimed that they were concerned about the likelihood of being unemployed in the next 12 months. Those realities, then, explain why in 2007, the number of Jamaicans seeking medical care fell to 66% over 70% in the previous year; while the self-reported figures rose to an unprecedented 15.5%.

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In Jamaica, rural poverty is twice (15.3%) that of urban poverty (6.2%). [4] This may create the impression that urban poverty is low and does not demand an examination. Poverty is poverty and whether it occurs in rural, peri-urban and urban areas; its effect is the same. Hence, when poverty is coupled with unemployment, chronic illnesses will require health care for either preventive or curative measures which must lead to a financial commitment that can erode their resources or that of their families. [5] In 2007, statistics on health in Jamaica showed that 50.8% of people in the poorest income quintile (. below the poverty line) indicated that they were unable to afford to seek medical care, compared to 36.7% of those just above the poverty line and 7.1% of those in the wealthiest income quintile. [4] It is private health insurance and social security that facilitate access to medical care for the poor and do assist in reducing the financial commitment of individuals and families for those with chronic or recurring illnesses. Twenty-one of every 100 Jamaican in 2007 has health insurance coverage, suggesting that the majority of people pay for medical care out of their pockets.

Many studies have examined the insured and health care demand of the general populace [6-10] but on reviewing the literature no study was found in Latin America and the Caribbean, in particular Jamaica, that has investigated the uninsured in regards to their medical care-seeking behaviour and health status. According to Call & Ziegenfuss, [7] health insurance is a significant predictor of access to medical care services, and people who do not have access to health insurance have less possibilities of accessing health care services. This was contradicted by Bourne [11] who found that health insurance is not significant when correlated with the medical care-seeking behaviour of Jamaicans or a predictor of the good health of Jamaicans [11] or female Jamaicans. [12] Call & Ziegenfuss [7] added that rural residents are more restricted from access to health insurance coverage than urban citizens, suggesting that medical care-seeking behaviour

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would be lower for rural than urban residents. While Call & Ziegenfuss’ perspectives provide us with basic information about the insured, it is inadequate for this cohort of people based on the findings of Bourne [11], and Bourne & Rhule [12].

For 2007, statistics revealed that 21.2% of Jamaicans had health insurance coverage and 66% sought medical care, indicating that most of the people who utilized medical care services did not use health coverage. Within the context of the global economic downturn, increased job redundancies and prices of commodities, the uninsured will be asked to pay more for medical care. Apart from the increased odds of not utilizing health care services, little is known about the uninsured in Latin American and the Caribbean, and in particular Jamaica. This study will bridge the gap in the literature, by evaluating their health status, medical care-seeking behaviour, and the medical conditions of uninsured Jamaicans in order to establish whether there are differences in the three geographical regions, and to use the information for public health intervention and policy formulation. The researcher used data from the 2007 Jamaica Survey of Living Conditions to evaluate medical care-seeking behaviour, medical conditions, purchased medication, and the health status of uninsured Jamaicans as well as building two models for good health status and health care-seeking behaviour of this uninsured group.

Methods and materials
Data The current study extracted a sample of 5,203 respondents 15 years of age and over from a national probability cross-sectional survey (Jamaica Survey of Living Conditions, JSLC) of 6,782 Jamaicans [13-15]. The cross-sectional survey was conducted between May and August 2007 from the 14 parishes across Jamaica and included 6,782 people of all ages [16]. The JSLC used

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stratified random probability sampling technique to draw the original sample of respondents, with a non-response rate of 26.2%. The sample was weighted to reflect the population. [13-15] Study instrument The JSLC used an administered questionnaire where respondents were asked to recall detailed information on particular activities. The questionnaire was modelled on the World Bank’s Living Standards Measurement Study (LSMS) household survey. There are some modifications to the LSMS, as the JSLC is more focused on policy impacts. The questionnaire covers demographic variables, health, and other issues. Interviewers were trained to collect the data from household members. Data on 5, 203 individuals who indicated not having health insurance coverage was used in data analysis. Statistical methods Descriptive statistics such as mean, standard deviation, frequency and percentage were used to analyze the socio-demographic characteristics of the sample. Chi-square analyses were used to examine the association between non-metric variables for area of residence, and gender of respondents. Logistic regression analyses examined 1) the relationship between good health status and some socio-demographic, economic and biological variables; as well as 2) a correlation between medical care-seeking behaviour and some socio-demographic, economic and biological variables. The statistical package SPSS for Windows version 16.0 (SPSS Inc; Chicago, IL, USA) was used to analyze the data. A p-value less than 5% was used to indicate statistical significance. The correlation matrix was examined in order to ascertain if autocorrelation and/or multicollinearity existed between variables. Based on Cohen and Holliday [17] correlation can be low (weak) - from 0 to 0.39; moderate – 0.4-0.69, and strong – 0.7-1.0. The approach in addressing collinearity (r > 0.6) was to independently enter variables in the model to determine

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which one should be retained during the final model construction. The method of retaining or excluding a variable from the model was based on the variables’ contribution to the predictive power of the model and its goodness of fit. [18-24] Wald statistics were used to determine the magnitude (or contribution) of each statistically significant variable in comparison with the others, and the Odds Ratio (OR) for the interpreting of each significant variable. Models The current study will employ multivariate analyses in the study of the health status (Equation [1]) and medical care seeking behaviour of Jamaicans (Equation [2]). The use of this approach is better than bivariate analyses as many variables can be tested simultaneously for their impact (if any) on a dependent variable. H t =f(A i , G i , HH i , AR i , lnC, ED i, MR i , S i , ∑MC t , SRIi , ε i ) 1

Where H t (. self-rated good current health status in time t) is a function of age of respondents A i ; sex of individual i, G i ; household head of individual i, HH i ; area of residence, AR i ; logged consumption per person per household member, lnC; Education level of individual i, ED i ; marital status of person i, MR i ; social class of person i, S i ; summation of medical expenditure of individual i in time period t, MC t ; self-reported illness, SRIi , and an error term (. residual error). MCSBi =f(PH t ,A i , G i , HH i , AR i , lnC, ED i, MR i , S i , CR i , ε i ) 2

Where MCSBi is medical care-seeking behaviour of individual i is a function of PH t (ie self-rated poor current health status in time t of individual i); age of respondents A i ; sex of individual i, G i ; household head of individual i, HH i ; area of residence, AR i ; logged consumption per person per household member, lnC; education level of individual i, ED i ; marital status of person i, MR i ; social class of person i, S i ; logged consumption per person

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per household member i, lnC; crowding of person i, CR i; and an error term (. residual error). From Equation (1) was derived Equation (3) and Equation (4): H t =f(A i , lnC, SRIi , S i , ED i, AR i , G i , ε i ) MCSB i =f(PH t ,A i , MR i , ε i ) Measures 3 4

An explanation of some of the variables in the model is provided here. Self-reported illness status is a dummy variable, where 1 = reporting an ailment or dysfunction or illness in the last 4 weeks, which was the survey period; 0 if there were no self-reported ailments, injuries or illnesses. [11, 12, 25] While self-reported ill-health is not an ideal indicator of actual health conditions because people may under-report, it is still an accurate proxy of ill-health and mortality. [26, 27] Health status is a binary measure where 1=good to excellent health; 0= otherwise which is determined from “Generally, how do you feel about your health”? Answers for this question were on a Likert scale matter ranging from excellent to poor. Age group was classified as children (ages less than 15 years); young adults (ages 15 through 30 years); other aged adults (ages 30 through 59 years); young-old (ages 60 through 74 years); old-old (ages 75 through 84 years) and oldest-old (ages 85+ years). Medical care-seeking behaviour was taken from the question ‘Has a health care practitioner, healer , or pharmacist been visited in the last 4 weeks?’ with there being two options Yes or No. Medical care-seeking behaviour therefore was coded as a binary measure where 1=Yes and 0= otherwise.

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Results
Socio-demographic characteristics of sample The sample was 5,203 uninsured respondents (49.2% males and 50.8% females). Of the sample, 32.9% were children; 26.9% young adults; 30.0% other aged adults; 10.8% elderly. The majority of those sampled had good health status (82.9%); 73% were never married; 62.0% visited medical care-seeking behaviour; 60.3% had at most no formal education; 52.2% lived in rural areas; 21.0% in semi-urban areas and 26.8% in urban areas. Fifty-nine percent of the sample purchased the prescribed medication, and 14.2% reported an illness. Of those who reported ailments, 89.5% revealed that they were diagnosed by health care practitioners. Approximately 17% indicated cold; 3.5% diarrhoea; 9.8% asthma; 19.7% hypertension; 5.5% arthritis; 25.3% and unspecified dysfunctions. Forty-five percent of the sample was poor (23.1% below the poverty line), 20.9% in the middle class, and 34.1% were classified as wealthy (14.8% in the wealthiest group). A significant statistical correlation was found between medical care-seeking behaviour and health status (χ2 (df = 2) =36.199, P < 0.001, n=752). Seventy-six percent (N= 160) of those who reported poor health status sought medical care compared to 68.0% (n = 174) of those who reported fair health status and 50.6% (n= 170) of those who indicated good health status. Table 7.1 revealed that significantly more rural residents were poor (58.7%) compared to 34.9% of semi-urban and 26.5% of urban dwellers. Only 21.2% of rural respondents were in the upper class which was significantly lower than those in semi-urban areas (42.6%) and the percentage is even greater in urban zones (52.5%). A cross-tabulation between health status and area of residence revealed a statistical correlation (P<0.001). Further examination showed that substantially more rural respondents indicated poor health status (6.3%) than semi-urban (3.3%) and urban (3.9%) (see Table 7.1).

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Significantly more rural dwellers reported being diagnosed with a recurring illness (15.9%) than semi-urban (11.8%) and urban respondents (12.7%). No significant statistical correlation was found between medical care-seeing behaviour and area of residence (P= 0.375). Seventeen percent of females reported a recurring illness which was significantly more than the 12% for males (Table 7.2). Of the diagnosed recurring illness, approximately twice as many females reported diabetes mellitus (11.3%) and hypertension (24.6%) than males (6.1%) and 12.6% respectively. While more males indicated cold (18.1%); diarrhoea (3.6%); asthma (11.3%); arthritis (6.5%); and unspecified (27.5%) compared to females – cold (15.6%); diarrhoea (3.4%); asthma (8.8%); arthritis (4.7%), and 23.7% unspecified ailments. A cross-tabulation between health status and self-reported illness found that there was a significant statistical correlation (χ2 (df = 2) = 989.552, P < 0.001). The association was a moderately strong one (contingency coefficient = 0.401). Further examination of the results revealed that 89.4% (n=3,964) of those who reported no illness had good health status, and only 43.7% of respondents with an ailment indicated poor health status. Approximately 22% of individuals with at least one dysfunction had poor health status compared to 2.3% of those who did not have an illness (Table 7.3). A significant statistical correlation existed between self-reported illness and age cohort (χ2 (df = 5) = 407.365, P < 0.001, n = 5,189). The findings revealed that 12.4% children reported at least one illness compared to 5.5% of young adults and following this age cohort self-reported illness increased to 14.7% for other aged adults; 33.3% of young old; 49.7% of old-old and 51.2% of oldest-old.

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Multivariate Analysis Table 7.4 examines variables that seek to explain the good health status of insured Jamaicans. Good health statuses of uninsured Jamaicans are correlated with socio-demographic, economic and biological factors. The correlates of good health status of uninsured Jamaicans are statistically significant (χ2 (df = 15) =993.114, P < 0.001; -2 Log likelihood = 2554.359; Nagelkerke R2 =0.390; Hosmer and Lemeshow goodness of fit χ2=11.159), and 84.6% of the data were correctly classified: 94.9% of cases in good health status were correctly classified and 46.6% were cases with poor health status. Table 7.5 presents information on variables that determine (or not) the medical careseeking behaviour of uninsured Jamaicans. The correlates that explain medical care-seeking behaviour of uninsured respondents are statistically significant χ2 (df = 14) = 47.79, P < 0.001; -2 Log likelihood = 648.32; Nagelkerke R2 =0.117; Hosmer and Lemeshow goodness of fit χ2=4.480), and 67.5% of the data were correctly classified: 88.1% of data correctly classified medical care-seeking behaviour and 30.0% of data otherwise.

Discussion
Caribbean societies, in particular Jamaica, have seen an increase in illnesses such as HIV/AIDS, malignant neoplasm, diabetes mellitus, hypertension, ischaemic heart disease, and arthritis [2833] which require continued treatment. Although this is a reality, only 21.2% of Jamaicans had health insurance coverage in 2007, indicating that the majority of people are without health insurance coverage and many people will not be able to afford medical care. The current study found that approximately one-half of Jamaicans who do not have health insurance were poor compared to 34.1% of the wealthy and 20.9% of those in the middle class. Substantially more Jamaicans below the poverty line (23.1%) did not have health insurance

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compared to 14.8% of those in the wealthiest 20%. In addition, 33% were children compared to 11% who were older than 60 years. Although there is a preponderance of Jamaicans who are poor and uninsured, this research found that there was no statistical difference between medical careseeking behaviour and social class; medical care-seeking behaviour and sex; and health careseeking behaviour and area of residence. Embedded in this finding is the dominance of a nonmedical care-seeking behaviour culture in Jamaica, and it is so fundamental that education, social class and income are not able to retard the practice. This is captured in an analysis of the study that had 44 out of every 100 respondents indicating that they were ill enough to seek medical care compared to 34 out of every 100 in the population; and 18 out of every 100 stated they preferred home remedies compared to 30 in 100 in the populace. Sixty-six out of every 100 Jamaicans sought medical care, comprising the poorest 20%to-wealthiest 20% in 2007. The current study revealed that 45 out of every 100 poor people were not covered by health insurance compared to 17 out of 50 for the wealthy and 21 out of 100 for the middle class. Concomitantly, 33 out of every 100 children (less than 15 years) and 60 out of every 100 Jamaicans who had no formal education were not covered by health insurance. The rationale which accounts for the fact that there is no significant difference in medical care-seeking behaviour among the social classes is embedded in the removal of user fees in the health care system; and how this has narrowed the health care-seeking behaviour gap between the poor and the wealthy. In 2007, the government of Jamaica introduced national health insurance coverage for those who suffer from particular illnesses, as well as for those who are older than 60 years. This social security coverage commissioned by the Jamaican government eliminates health insurance for ‘unwell’ patients, suggesting that health is conceptualized as diseases, which is not in keeping

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with an operationalization of health offered by the WHO. [34] According to the WHO, health does not only mean the absence of disease, but it must include social, psychological and physical wellbeing. The health insurance coverage offered by the government explains the low uninsured group among the Jamaican elderly. Hence, this means that most of those who possess health insurance would have private coverage; the high ‘unwell’ Jamaicans therefore justify the high non-insured group in the nation. This paper examines the uninsured or the ‘unwell’. This analysis has found that good health status can be determined by age, consumption, self-reported illness, social class, education, area of residence and gender of respondents, which concurs with other studies. [35-39] While this study is the first of its type in Jamaica, its findings are similar to other multivariate studies that have examined the health status of people. Using data for elderly Barbadians, Hambleton et al.’s work [35] found that dysfunction accounted for the most explanatory power in health status, which is confirmed by this analysis. The model that was developed for the good health status of uninsured Jamaicans was based on the 7 aforementioned variables with a coefficient of determination of the current study being 39.0% (Nagelkerke R2 =0.390). This predictive model seems weak; but Hambleton et al’s work on elderly Barbadians had a coefficient of determination of 38.2%, indicating that the analysis of this paper is relatively good in keeping with a non-Jamaican study of a similar nature. In spite of the similarities, there are some notable differences with other studies. Eightthree out of every 100 uninsured Jamaicans reported at least good health status; 20 out of every 100 were hypertensive; 9 out of 100 diabetic and 6 out of 100 arthritic compared to the percentage of respondents in the population with particular health conditions: hypertension, 22 out of every 100; diabetes mellitus, 12 out of every 100; and, arthritis, 9 out of every 100. It is interesting to note that Jamaicans have a preference for private health care utilization [15] but this is not the

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case for the uninsured. In 2007, 52 out of every 100 Jamaican visited private health care services compared to 6 out of every 100 of the uninsured. The percentage of uninsured who visited public health care facilities (34 out of every 100) was also lower than in the general populace (41 out of every 100). The analysis of this study went further than that of other identified studies as it found that uninsured Jamaicans who resided in rural areas reported a greater percentage of illnesses, followed by urban, than other town residents. Marmot [35] opined that income influences health as it provides access to more resources, medical services, and lower infant mortality. The analysis of this work concurs with Marmot [35] and PAHO et al. [9] as consumption (which can proxy income) is positively correlated with good health status. With this reality, there seems to be a paradox, as those in the wealthy classes had lower good health status than those in the poor classes. Income undoubtedly provides access to more resources, better physical conditions and opens the way to better quality of water and food; it also offers individuals, societies or nations the highest quality medical services which cannot be accessed by the poor. [35] There is another side to this discourse in that the lifestyle practices of the wealthy help to erode the advantages of income. According to Bourne, McGrowder & Holder-Nevins, [41] health behaviour which is a function of one’s culture suggests that the wealthy will continue their involvement in parties and other social arrangements which will involve the use of alcoholic beverages, smoking and other risky lifestyle practices that reduce the advantage of income. While income can buy access to better medical services, this paper highlights that it cannot buy good health. It is clear from the current study that wealthy uninsured Jamaicans are using their income the wrong way in regards to its negative impact on health. Insufficient money is associated with more illness; however, this

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study has revealed that there is no statistical difference between the wealthy and the poor seeking medical care. Although the wealthy substantially used private health care facilities and the poor utilized public health facilities, [15] embedded in this analysis therefore is the fact that the quality of primary level care in Jamaica is of a high standard. While there is no difference between the wealthy uninsured and the poor uninsured seeking medical care, the study revealed that those with poor health status were 2.3 times more likely to seek health care services than those in good health. The analysis of this work showed that 22 out of every 100 uninsured Jamaicans who indicated at least one health condition reported poor health status. Hence this study highlights the fact that there is a disparity between respondents’ conceptualization of health status and that of illness, as 44% of uninsured ill respondents indicated that they had good health status. The JSLC report revealed that the prevalence of recurrent (chronic) diseases is highest among individuals 65 years and over. [41] According to PIOJ & STATIN [42] individuals 60-64 years were 1.5 times more likely to report an injury than children less than five years old, and the figure was even higher for those 64 years and older (2.5 times more). It should be noted here that this increase in self-reported cases of injuries/ailments does not represent an increase in the incidence of cases as the JSLC for 2004 said that the proportion of recurring/chronic cases fell from 49.2% in 2002 to 38.2% in 2004 [43]. Eldemire [44] found that 34.8% of new cases of diabetes and 39.6% of hypertension were associated with senior citizens (. ages 60 and over). Bourne, McGrowder, & Crawford [39] found that the poor health status of people 60 to 64 years was 33.2% and this increased to 36.1% for elderly 65 to 69 years, 49.4% for elderly 70 to 74 years and 51.7% for those 75 years and older, emphasizing the positive correlation between increased ailments and ageing of the Jamaican elderly.

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An analysis of the current study revealed that there is no significant difference among the populations across the 3 geographical areas in Jamaica in regards to health care-seeking behaviour, suggesting that the uninsured medical care-seeking behaviour is the same in the 3 geographical areas. This research concurs with the finding of a study by Call & Ziegenfuss [7] meaning that the uninsured in Jamaica are not atypical as they are in keeping with those in Minnesota, United States. Further, no significant correlation was found among urban, semi-urban, rural and educational levels of uninsured Jamaicans which were similar to that of Call & Ziegenfuss. Many studies have shown that married people (or those in unions) had greater health status than those who were never married. [45-51]. The current work disagreed with those findings as it found that there was no significant statistical correlation between good health status of married uninsured people, and those who were never married, or separated, divorced or widowed. Analysis of this research revealed that those who were married were 48.2% less likely to seek medical care than those who were never married. The answer to this lies in the lifestyle practices of these people. Smith & Waitzman [49] offered the explanation that wives were able to dissuade their husband from particular risky behaviours such as the use of alcohol and drugs, and would ensure that they maintain a strict medical regimen coupled with proper eating habits. [50,51] Koo, Rie & Park’s findings [48] revealed that being married was a ‘good’ cause for an increase in psychological and subjective wellbeing in old age. This study is the first of its kind in the Caribbean, in particular Jamaica, which models the health care-seeking behaviour of uninsured respondents, and so there is nothing to compare it with. The coefficient of determination for this model was 11.9%, which means that although it is low its validation will need further research.

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Limitation of study
A single cross-sectional study cannot be used to examine causality, as well as a snap shot survey cannot effectively capture the continuous matter of the variables. The severity of illness was excluded from the medical care-seeking behaviour model because of missing cases and this could have been critical to the study.

Conclusion
The findings of this research are far reaching and provide an understanding of the uninsured, and the information can be used to aid public health intervention and education programmes.

Conflict of interest
There is no conflict of interest to report.

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intervention model for Jamaicans: Charting the Way forward in Public Health. Asian J of Medical Sciences (in print). 42. PIOJ, STATIN. Jamaica Survey of Living Conditions, 2000. Kingston: PIOJ & STATIN; 2001. 43. PIOJ, STATIN. Jamaica Survey of Living Conditions, 2004. Kingston: PIOJ & STATIN;2005. 44. Eldemire D. A situational analysis of the Jamaican elderly, 1992. Kingston: Planning Institute of Jamaica;1995. 45. Bourne PA, McGrowder DA. Rural health in Jamaica: examining and refining the predictive correlates of good health status of rural residents. J of Rural and Remote Health 2009;9 : 1116. 46. Bourne PA. Medical Sociology: Modelling Well-being for elderly People in Jamaica. West Indian Med J 2008;57: 596-04. 47. Bourne PA. Health Correlates: Using Secondary Data to Model Correlates of Wellbeing of Jamaicans. West Indian Med J 2008;57: 476-81. 48. Koo J, Rie J, Park K. Age and gender differences in affect and subjective wellbeing. Geriatrics and Gerontology Int 2004;4:S268-S270. 49. Smith KR, Waitzman NJ. Double jeopardy: Interaction effects of martial and poverty status on the risk of mortality. Demography 1994;31,487-507. 50. Ross CE, Mirowsky J, Goldsteen K. The impact of the family on health. J of Marriage and the Family 1990;52: 1059-1078. 51. Gore WR. Sex, marital status, and mortality. Am J of Sociology 1973;79:45-67.

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Table 7.1: Socio-demographic characteristics of sample Area of residence Variable Urban Semi-urban n (%) n (%) Sex Male 662 (47.4) 544 (49.9) Female 735 (52.6) 547 (50.1) Social class Poor 370 (26.5) 381 (34.9) Middle 294 (21.0) 245 (22.5) Upper 733 (52.5) 465 (42.6) Age group Children 418 (29.9) 334 (30.6) Young adults 411 (29.4) 306 928.0) Other aged adults 416 (29.8) 344 (31.5) Young old 93 (6.7) 72 (6.6) Old-old 48 (3.4) 27 (2.5) Oldest-old 11 (0.8) 8 (0.7) Health status Good 1137 (81.7) 956 (87.6) Fair 201 (14.4) 99 (9.1) Poor 54 (3.9) 36 (3.3) Education No formal 841 (60.4) 687 (63.1) Basic 174 (12.5) 118 (10.8) Primary/preparatory 168 (12.1) 158 (14.5) Secondary/High 166 (11.9) 111 (10.2) Tertiary 43 (3.1) 14 (1.3) Marital status Married 177 (18.3) 132 (17.5) Never married 721 (74.5) 562 (74.6) Divorced 18 (1.9) 17 (2.3) Separated 5 (0.5) 8 (1.1) Widowed 47 (4.9) 34 (4.5) Self-reported illness Yes 176 (12.7) 128 (11.8) No 1215 (87.30 958 (88.2) Medical care-seeking behaviour Yes 120 (66.3) 78 (59.5) No 61 (33.7) 53 (40.5) 1.4 days (SD 1.4 days Number of visits to medical = 0.7) (SD= 1.3) facilities

P Rural n (%) 0.284 1354 (49.9) 1361 (50.1) < 0.001 1594 (58.7) 546 (20.1) 575 (21.2) 0.002 961 (35.4) 646 (23.8) 803 (29.6) 199 (7.3) 82 (3.0) 24 (0.9) < 0.001 2202 (81.6) 329 (12.2) 169 (6.3) < 0.001 1599 (59.1) 362 (13.4) 429 (15.8) 300 (11.1) 17 (0.6) 0.012 382 (21.9) 1245 (71.4) 15 (0.9) 20 (1.1) 82 (4.7) 0.001 432 (15.9) 2280 (84.1) 0.375 270 (60.9) 173 (39.1) 1.4 days (SD = 1.0)

0.846

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Table 7.2: Sociodemographic characteristic by Sex Variable Male Self-reported illness Yes No Diagnosed Self-reported illness Cold Diarrhoea Asthma Diabetes mellitus Hypertension Arthritis Other (unspecified) No Medical care-seeking behaviour Yes No Purchase medication Prescribed medicine Partial prescription Prescribed/over the counter Over counter Prescribed/did not buy None prescribed required Number of visits to medical facilities Mean (SD)

Sex Female

P < 0.001

298 (11.7) 2256 (88.3) 56 (18.1) 11 (3.6) 35 (11.3) 19 (6.1) 39 (12.6) 20 (6.5) 85 (27.5) 44 (14.2) 182 (58.5) 129 (41.5) 170 (56.9) 3 (1.0) 9 (3.0) 20 (6.7) 9 (3.0) 88 (29.4) 1.3 days (0.7)

438 (16.6) 2197 (83.4) < 0.001 69 (15.6) 15 (3.4) 39 (8.8) 50 (11.3) 109 (24.6) 21 (4.7) 105 (23.7) 35 (7.9) 0.101 286 (64.4) 158 (35.6) 0.251 259 (60.1) 13 (3.0) 15 (3.5) 25 (5.8) 17 (3.9) 102 (23.7) 1.4 days (1.1)

0.252

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Table 7.3. Health status by Self-reported dysfunction Self-reported Dysfunction At least one ailment n (%) 320 (43.7)

Health Status

No ailment n (%) 3964 (89.4)

Total n (%) 4284 (82.9)

Good

Fair

372 (8.4)

255 (34.8)

627 (12.1)

Poor Total
χ2 (df = 2) =989.552, P < 0.001

100 (2.3) 4436

158 (21.6) 733

258 (5.0) 5169

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Table 7.4. Jamaicans

Ordinary Logistic Regression: Correlates of Good Health Status of Uninsured
Wald statistic 191.667 11.692 323.527 0.314 6.107 Odds ratio 0.95 1.00 0.11 1.09 0.56 1.00 1.15 0.81 1.00

Variable Age Logged consumption per capita Self reported illness Middle class Upper class †Lower class Married Divorced/separated/widowed †Never married Primary schooling Secondary and above †No formal education Urban area Other town †Rural area Man Household head Cost of public medical care Cost of private medical care

Coefficient -0.049 0.000 -2.168 0.086 -0.575

Std Error 0.004 0.000 0.121 0.154 0.233

95.0% C.I. 0.95 -0.96*** 1.00 - 1.00** 0.09 -0.15*** 0.81 - 1.47 0.36 - 0.89*

0.138 -0.217

0.129 0.192

1.154 1.277

0.89 -1.48 0.55 - 1.17

19.089 -0.475

40192.970 0.223

0.000 4.525

0.62 1.00 0.89 1.35 1.00 1.50 1.10 1.00 1.00

0.00 -0.00 0.40 - 0.96*

-0.115 0.301

0.124 0.140

0.870 4.593

0.70 -1.14 1.03 -1.78*

0.406 0.097 0.000 0.000

0.105 0.113 0.000 0.000

14.872 0.741 0.040 3.003

1.22 -1.85*** 0.88 -1.37 1.00 - 1.00 1.00 -1.00

χ2 (df = 15) =993.114, P < 0.001 -2 Log likelihood = 2554.359 Nagelkerke R2 =0.390 Hosmer and Lemeshow goodness of fit χ2=11.159, P = 0.693 Overall correct classification = 84.6% Correct classification of cases of good health status = 94.9% Correct classification of cases of poor health status = 46.6% †Reference group *P < 0.05, **P < 0.01, ***P < 0.001

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Table 7.5. Ordinary Logistic Regression: Correlates of Medical Care-Seeking Behaviour of Uninsured Jamaicans
Variable Man Age Middle class Upper class †Lower Poor health Urban area Other town †Rural Crowding Per capita consumption Secondary and above †No formal education Married Divorced, separated/widowed †Never married Head household Coefficient -0.282 0.019 0.544 0.683 Std. Error 0.205 0.007 0.284 0.427 Wald statistic 1.894 8.213 3.675 2.558 Odds ratio 0.76 1.02 1.72 1.98 1.00 2.30 1.07 0.78 1.00 1.12 1.00 1.54 1.00 0.52 0.62 1.00 0.81 95% C.I. 0.51 - 1.13 1.01 - 1.03** 0.99 - 3.00 0.86 - 4.57

0.834 0.070 -0.243

0.208 0.248 0.260

16.139 0.079 0.877

1.53 - 3.46*** 0.66 - 1.75 0.47 - 1.31

0.111 0.000 0.431 -0.659 -0.453

0.067 0.000 0.571 0.237 0.332

2.749 0.017 0.569 7.720 1.864

0.98 - 1.27 1.00 - 1.00 0.50 - 4.71 0.33 -0 .82** 0.33 - 1.22

χ2 (df = 14) = 47.79, P < 0.001 -2 Log likelihood = 648.32 Nagelkerke R2 =0.117 Hosmer and Lemeshow goodness of fit χ2=4.480, P = 0.811 Overall correct classification = 67.5% Correct classification of cases of medical care-seeking behaviour = 88.1% Correct classification of cases of no medical care-seeking behaviour = 30.0% †Reference group *P < 0.05, **P < 0.01, ***P < 0.001

-0.210

0.218

0.933

0.53 - 1.24

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Chapter

8 Social determinants of self-reported
health across the Life Course
The socio-psychological and economic factors produced inequalities in health and need to be considered in health development. In spite of this, extensive review of health Caribbean revealed that no study has examined health status over the life course of Jamaicans. With the value of research to public health, this study is timely and will add value to understanding the elderly, middle age and young adults in Jamaica. The aim of this study is to develop models that can be used to examine (or evaluate) social determinants of health of Jamaicans across the life course, elderly, middle age and young adults. Eleven variables emerged as statistically significant predictors of current good health Status of Jamaicans (p<0.05). The factors are retirement income (95%CI=0.49-0.96), logged medical expenditure (95% CI =0.91-0.99), marital status (Separated or widowed or divorced: 95%CI=0.31-0.46; married: 95%CI=0.50-0.67; Never married), health insurance (95%CI=0.029-0.046), area of residence (other towns:, 95%CI=1.051.46; rural area:), education (secondary: 95%CI=1.17-1.58; tertiary: 95%CI=1.47-2.82; primary or below: OR=1.00), social support (95%CI=0.75-0.96), gender (95%CI=1.281-1.706), psychological affective conditions (negative affective: 95%CI=0.939-0.98; positive affective: 95%CI:1.05-1.11), number of males in household (95%CI:1.07-1.24), number of children in household (95%CI=1.12-1.27) and previous health status. There are disparities in the social determinants of health across the life course, which emerged from the current findings. The findings are far reaching and can be used to aid policy formulation and how social determinants of health are viewed in the future.

I NTRODUCTION Health is a multidimensional construct which goes beyond dysfunctions (illnesses, ailment or injuries) [1-14]. Although World Health Organization (WHO) began this broaden conceptual framework in the late 1940s [1], Engel [3] was the first to develop the biopsychosocial model that can be used to examine and treat health of mentally ill patient. Engel’s biopsychosocial model was both in keeping with WHO’s perspective of health and again a conceptual model of health. Both WHO and Engel’s works were considered by some scholar as too broad and as such difficult

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to measure [15]; although this perspective has some merit, scholars have ventured into using different proxy to evaluate the ideal conceptual definition forwarded by WHO for some time now. Psychologists have argued that the use of diseases to proxy health is unidirectional (or negative) [2], and that the inclusion of social, economic and psychological conditions in health is broader and more in keeping with the WHO’s definition of health than diseases. Diener was the first psychologist to forward the use of happiness to proxy health (or wellbeing) of an individual [16, 17]. Instead of debating along the traditional cosmology health, Diener took the discussion into subjective wellbeing. He opined that happiness is a good proxy for subjective wellbeing of a person, and embedded therein is wider scope for health than diseases. Unlike classical economists who developed Gross Domestic Product per capita (GDP) to examine standard of living (or objective wellbeing) of people as well this being an indicator of health status along with other indicators such as life expectancy, Diener and others believe that people are the best judges of their state. This is no longer a debate, as some economists have used happiness as a proxy of health and wellbeing [18-20]; and they argued that it is a good measurement tool of the concept. Theoretical Framework Whether the proxy of health (or wellbeing) is happiness, self-reported health status, selfrated health conditions, life satisfaction or ill-being, it was not until in the 1970s that econometric analyses were employed to the study of health. Grossman [9] used econometric to capture factors that simultaneously determine health stock of a population. Grossman’s work transformed the conceptual framework outlined by WHO and Engel to a theoretical framework for the study of health. Using data for the world, Grossman established an econometric model that captures determinants of health. The model read (Model 1): H t = ƒ (H t-1 , G o , B t , MC t , ED) ……………………………………………….. Model (1)

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where H t – current health in time period t , stock of health (H t-1 ) in previous period , B t – smoking and excessive drinking, and good personal health behaviours (including exercise – G o ), MC t ,- use of medical care, education of each family member (ED), and all sources of household income (including current income). Grossman’s model was good at the time; however, one of the drawbacks to this model was the fact that some crucible factors were omitted by the aforementioned model. Based on that limitation, using literature, Smith and Kington [10] refined, expanded and modified Grossman’s work as it omitted important variables such as price of other inputs and family background or genetic endowment which are crucible to health status. They refined Grossman’s work to include socioeconomic variables as well as some other factors [Model (2)]. H t = H* (H t-1 , P mc , P o , ED, Et , R t , A t , G o ) ………………………..…………… Model (2) Model (2) expresses current health status H t as a function of stock of health (H t-1 ), price of medical care P mc , the price of other inputs P o , education of each family member (ED), all sources of household income (Et ), family background or genetic endowments (G o ), retirement related income (R t ), asset income (A t ). It is Grossman’s work that accounts for economists like Veenhoven’s [20] and Easterlin’s [19] works that used econometric analysis to model factors that determine subjective wellbeing. Like Veenhoven [20], Easterlin [19] and Smith and Kington [10], Hambleton et al. [6] used the same theoretical framework developed by Grossman to examine determinants of health of elderly (ages 65+ years) in Barbados. Hambleton et al.’s work refined the work of Grossman and added some different factors such as geriatric depression index; past and current nutrition; crowding; number of children living outside of household; and living alone. Unlike Grossman’s study, he found that current disease conditions accounted for 67.2% of the explained variation in health

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status of elderly Barbadians, with life style risks factors accounting for 14.2%, and social factors 18.6%. One of the additions to Grossman’s work based on Hambleton et al.’s study was actual proportion of each factor on health status and life style risk factors. A study published in 2004, using life satisfaction and psychological wellbeing to proxy wellbeing of 2,580 Jamaicans, Hutchinson et al. [21] employed the principles in econometric analysis to examine social and health factors of Jamaicans. Other studies conducted by Bourne on different groups and sub-groups of the Jamaican population have equally used the principles of econometric analysis to determine factors that explain health, quality of life or wellbeing [5, 8, 22, 23]. Despite the contribution of Hutchinson et al’s and Bourne’s works to the understanding of wellbeing, there is a gap in the literature on a theoretical framework explains good health status of the life course of Jamaicans. The current study will model predictors of good health status of Jamaicans as well as good health status of young adults, middle age adults and elderly in order to provide a better understanding of the factors that influence each cohort. METHODS Participants and questionnaire The current research used a nationally cross-sectional survey of 25,018 respondents from the 14 parishes in Jamaica. The survey used stratified random probability sampling technique to draw the 25,018 respondents. The non-response rate for the survey was 29.7% with 20.5% who did not respond to particular questions, 9.0% did not participated in the survey and another 0.2% was rejected due to data cleaning. The study used secondary cross-sectional data from the Jamaica Survey of Living Conditions (JSLC). The JSLC was commissioned by the Planning Institute of Jamaica (PIOJ) and the Statistical Institute of Jamaica (STATIN). These two organizations are responsible for planning, data collection and policy guideline for Jamaica.

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The JSLC is a self-administered questionnaire where respondents are asked to recall detailed information on particular activities. The questionnaire covers demographic variables, health, immunization of children 0 to 59 months, education, daily expenses, non-food consumption expenditure, housing conditions, inventory of durable goods, and social assistance. Interviewers are trained to collect the data from household members. The survey is conducted between April and July annually. Model The multivariate model used in this study is a modification of those of Grossman and Smith & Kington which captures the multi-dimensional concept of health, and health status. The present study further refine the two aforementioned works and in the process adds some new factors such as psychological conditions, crowding, house tenure, number of people per household and a deconstruction of the numbers by particular characteristics . males, females and children (ages ≤ 14 years). Another fundamental difference of the current research and those of Grossman, and Smith and Kington is that it is area specific as it is focused on Jamaican residents. The proposed model that this research seeks to evaluate is displayed below [Model (3)]:
H t = f(H t-1 ,P mc , ED i , R t , At , Q t , HH t , C i , En i , MS i , HI i , HT i , SS i , LL i ,X i , CR i , D i , O i , Σ(NP i ,PP i ), M i ,N i , FS i , Ai , Wi , ε i )….. Model (3)

The current health status of a Jamaica, H t , is a function of 23 explanation variables, where H t is current health status of person i, if good or above (. no reported health conditions four week leading up to the survey period), 0 if poor (. reported at least one health condition); H t-1 is stock of health for previous period; lnPmc is logged cost of medical care of person i; ED i is educational level of person i, 1 if secondary, 1 if tertiary and the reference group is primary and below; Rt is retirement income of person i, 1 if receiving private and/or government pension, 0 if otherwise; HI i is health insurance coverage of person i, 1 if have a health insurance policy, 0 if otherwise; HT i is house tenure of person i, 1 if rent, 0 if squatted; Xi is gender of person i, 1 if female, 0 if 176

male; CRi is crowding in the household of person i; Σ(NPi,PPi) NPi is the summation of all negative affective psychological conditions and PPi is the summation of all positive affective psychological conditions; M i is number of male in household of person i and Fi is number of female in household of person i; Ai is the age of the person i and N i is number of children in household of person i; LLi is living arrangement where 1= living with family members or relative, and 0=otherwise and social standing (or social class), W i . Statistical analysis Statistical analyses were performed using Statistical Packages for the Social Sciences (SPSS) for Windows, Version 16.0 (SPSS Inc; Chicago, IL, USA). A single hypothesis was tested, which was ‘health status of rural resident is a function of demographic, social, psychological and economic variables.’ The enter method in logistic regression was used to test the hypothesis in order to determine those factors that influence health status of rural residents if the dependent variable is a binary one; and linear multiple regression in the event the dependent variable was a normally distributed metric variable . The final model was established based on those variables that are statistically significant (ie. p < 0.05) – ie 95% confidence interval (CI), and all other variables were removed from the final model (p>0.05). Continuing, categorical variables were coded using the ‘dummy coding’ scheme. The predictive power of the model was tested using Omnibus Test of Model and Hosmer and Lemeshow [24] was used to examine goodness of fit of the model. The correlation matrix was examined in order to ascertain whether autocorrelation (or multi-collinearity) existed between variables. Cohen and Holliday [25] stated that correlation can be low/weak (0 to 0.39); moderate (0.4-0.69), or strong (0.7-1.0). This was used in this study to exclude (or allow) a variable in the model. Where collinearity existed (r > 0.7), variables were entered independently into the model

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to determine those that should be retained during the final construction of the model. To derive accurate tests of statistical significance, we used SUDDAN statistical software (Research Triangle Institute, Research Triangle Park, NC), and this was adjusted for the survey’s complex sampling design. Finally, Wald statistics was used to determine the magnitude (or contribution) of each statistically significant variables in comparison with the others, and the odds ratio (OR) for the interpreting each significant variables. Results: Modelling Current Good Health Status of Jamaicans, Elderly, Middle Age and Young adults Predictors of current Good Health Status of Jamaicans. Using logistic regression analyses, eleven variables emerged as statistically significant predictors of current good health status of Jamaicans (p<0.05, see Model 4). The factors are retirement income, logged medical expenditure, marital status, health insurance, area of residence, education, social support, gender, psychological affective conditions, number of males in household, number of children in household and previous health status (Table 8.1). H t = f(H t-1 , Rt , Pmc , ED i , MS i , HI i , SS i ,ARi , Xi , Σ(NPi ,PPi ), M i ,N i , ε i )...……..... Model (4) The model [ie Model (4)] had statistically significant predictive power (χ2 (27) =1860.639, p < 0.001; Hosmer and Lemeshow goodness of fit χ2=4.703, p = 0.789) and overall correctly classified 85.7% of the sample (correct classified 98.3% of cases of good health status and correctly classified 33.9% of cases of dysfunctions). There was a moderately strong statistical correlation between age, marital status, education, retirement income, per capita income quintiles, property ownership, and so these were omitted from the initial model (ie model 3). Based on that fact, three age groups were classified (young adults – ages 15 to 29 years; middle age adults – ages 30 to 59 years; and elderly – ages

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60+ years) and the initial model was once again tested. There were some modifications of the initial model in keeping with the age group. For young adults the initial model was amended by excluding retirement income, property ownership, divorced, separated or widowed, number of children in household, and house tenure. The exclusion was based on the fact that more than 15% of cases missing in some categories and a high correlation between variables. Predictors of current Good Health Status of elderly Jamaicans. From the logistic regression analyses that were used on the data, eight variables were found to be statistically significant in predicting good health Status of elderly Jamaicans (P < 0.5) (see Model 5). These factors were education, marital status, health insurance, area of residence, gender, psychological conditions, number of males in household, number of children in household and previous health status (see Table 8.2). H t = f(H t-1 , ED i , MS i , HI i , ,ARi , Xi , Σ(PPi ), M i ,N i , ε i )...……………………... Model (5) The model had statistically significant predictive power (model χ2 (27) =595.026, P < 0.001; Hosmer and Lemeshow goodness of fit χ2=5.736, p = 0.677) and overall correctly classified 75.5% of the sample (correctly classified 94.6% of cases of good or beyond health status and correct classified 44.7% of cases of dysfunctions).

Predictors of current Good Health Status of middle age Jamaicans. Using logistic regression, six variables emerged as statistical significant predictors of current good health status of middle age Jamaican (p < 0.05) (Model 6). These factors are logged medical expenditure, physical environment, health insurance, gender of respondents, psychological condition, number of children in household and previous health status (see Table 8.3)
H t = f(H t-1 , P mc , En i , HI i , X i , Σ(NP i ),N i , ε i ).......................……………………………..... Model (6)

179

Based on Table 8.3, the model had statistically significant predictive power (model χ2 (27) =547.543, p < 0.001; Hosmer and Lemeshow goodness of fit χ2=4.318, p = 0.827) and overall correctly classified 87.2% of the sample (correctly classified 98.3% of cases of good or beyond health status and correct classified 28.2% of cases of dysfunctions).

Predictors of current Good Health Status of young adult in Jamaica. Using logistic regression, two variables emerged as statistically significant predictors of current good health status of young adults in Jamaica (p<0.05) (Model 7). These are health insurance coverage, psychological condition, social class and previous health status (Table 4).
H t = f(H t-1 , W i , HI i , Σ(NP i ), ε i )...............................................…………………………….....Model (7)

From Table 8.3, the model had statistically significant predictive power (model χ2 (19) =453.733, p < 0.001;8. Hosmer and Lemeshow goodness of fit χ2=5.185, p = 0.738) and overall correctly classified 92.6% of the sample (correctly classified 99.0% of cases of good or beyond health status and correct classified 28.2% of cases of dysfunctions). Limitations to the Models Good Health Status of Jamaicans [Model (4)], elderly [ie Model (5)], middle age adults [Model (6)], and young adults [Model (7) are derivatives of Model (3). Good Health Status [Model (4) – Model (7)] cannot be distinguished and tested over different time periods, person differential, and these are important components of good health.
H t = f(H t-1 , R t , P mc , ED i , MS i , HI i , SS i ,AR i , X i , Σ(NP i ,PP i ), M i ,N i , ε i )...………………………..... Model (4) H t = f(H t-1 , ED i , MS i , HI i , ,AR i , X i , Σ(PP i ), M i ,N i , ε i )...………………………………………..... Model (5) H t = f(H t-1 , P mc , En i , HI i , X i , Σ(NP i ),N i , ε i )....................................……………………………..... Model (6) H t = f(H t-1 , Wi , HI i , Σ(NP i ), ε i ).......................................................……………………….…….......Model (7)

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H t = f(H t-1 ,P mc , ED i , R t , A t , Q t , HH t , C i , En i , MS i , HI i , HT i , SS i , LL i ,X i , CR i , D i , O i , Wi ,ε i )……………………………………………………………………….. Σ(NP i ,PP i ), M i ,N i , FS i , A i , Model (3)

The current work is a major departure from Grossman’s theoretical model as he assumed that factors affecting good health Status over the life course are the same, this study disagreed with this fundamental assumption. This study revealed that predictors of good health status are not necessarily the same across the life course, and differently from that of the general populace. Despite those critical findings, healthy time gained can increase good health status directly and indirectly but this cannot be examined by using a single cross-sectional study. Health does not remain constant over any specified period, and to assume that this is captured in age is to assume that good or bad health change over year (s). Health stock changes over short time intervals, and so must be incorporated within any health model. People are different even across the same ethnicity, nationality, next of kin and socialization. This was not accounted for in the Grossman’s or the current work, as this is one of the assumptions. Neither Grossman’s study nor the current research recognized the importance of differences in individuals owing to culture, socialization and genetic composition. Each individual’s is different even if that person’s valuation for good health Status is the same as someone else who share similar characteristics. Hence, a variable P representing the individual should be introduced to this model in a parameter α (p). Secondly, the individual’s good (or bad) health is different throughout the course of the year and so time is an important factor. Thus, the researcher is proposing the inclusion of a time dependent parameter in the model. Therefore, the general proposition for further studies is that the function should incorporate α (p, t) a parameter depending on the individual and time.

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An unresolved assumption of this work which continues from Grossman’s model is that people choose health stock so that desired health is equal to actual health. The current data cannot test this difference in the aforementioned health status and so the researcher recommends that future study to account for this disparity so we can identify factors of actual health and difference between the two models. Discussions This study has modelled current good status of Jamaicans. Defining health into two categories (good – not reported an acute or illness; or poor – reported illness or ailment), this study has found that using logistic regression health status can be modeled for Jamaicans. The findings revealed that the probability of predicting good health status of Jamaicans was 0.789, using eleven factors; and that approximately 86% of the data was correctly classified in this study. Continuing, in Model (4) approximately 98% of those who had reported good health status were correctly classified, suggesting that using logistic regression to examine good health status of the Jamaican population with the eleven factors that emerged is both a good predictive model and a good evaluate or current good health status of the Jamaican population. This is not the first study to examine current good health status or quality of life in the Caribbean or even Jamaica [6, 2123, 26], but that none of those works have established a general and sub-models of good health over the life course. In Hambleton et al’s work, the scholars identified the factors (historical, current, life style, diseases) and how much of health they explain (R2=38.2%). However, they did not examine the goodness of fit of the model or the correctness of fit of the data. Bourne’s works [12,13] were similar to that of Hambleton et al’s study, as his study identified more factors (psychological conditions; physical environment, number of children or males or females in household and social support) and had a greater explanatory power (adjusted r square = 0.459) but again the goodness

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of fit and correctness of fit of the data were omitted. Again this was the case in Hutchinson et al.’s research. Like previous studies in the Caribbean that have examined health status [6, 21-23, 26], those conducted by the WHO and other scholars [27-32] did not explore whether social determinants of health vary across the life course. Because this was not done, we have assumed that the social determinants are the same across the life. However, a study by Bourne and Eldemire-Shearer [33] introduced into the health literature that social determinants differ across social strata for men. Such a work brought into focus that there are disparities in the social determinants of health across particular social characteristic and so researchers should not arbitrarily assume that they are the same across the life course. While Bourne and EldemireShearer’s work [33] was only among men across different social strata in Jamaica (poor and wealthy), the current study shows that there are also differences in social and psychological determinants of health across the life course. The current study has concluded that the factors identified to determine good health status for elderly, had the lowest goodness of fit (approximately 68%) while having the greatest explanatory power (R2= 35%). The findings also revealed low explanatory powers for young adults (R2=22.6%) and middle age adults (R2=23%), with latter having a greater goodness of fit for the data as this is owing to having more variables to determine good health. Such a finding highlights that we know more about the social determinants for the elderly than across other age cohorts (middle-aged and young adults). And that using survey data for a population to ascertain the social determinants of health is more about those for the elderly than across the life course of a population.

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Another important finding is of the eleven factors that emerge to explain good health status of Jamaicans, when age cohorts were examine it was found that young adults had the least number of predictors (ie health insurance, social class and negative affective psychological conditions). This suggests that young adult’s social background and health insurance are important factors that determine their good health status and less of other determinants that affect the elderly and middle age adults. It should be noted that young adult is the only age cohort with which social standing is a determinant of good health. Even though the good health status model that emerged from this study is good, the low explanatory power indicates that young adults are unique and further study is needed on this group in order to better understand those factors that account for their good health. Furthermore, this work revealed that as people age, the social determinants of health of the population are more in keeping with those of the elderly than at younger ages. Hence, the social determinants identified by Grossman [9], Smith and Kington [10] and purported by Abel-Smith [11] as well as the WHO [27] and affiliated researchers [28-32] are more for the elderly population than the population across the life course. Conclusions There are disparities in the social determinants of health across the life course, which emerged from the current findings. The findings are far reaching and can be used to aid policy formulation and how we examine social determinants of health. Another issue which must be researched is whether there are disparities in social determinants of health based on the conceptualization and measurement of health status (using self-reported health, and health conditions). Disclosures The author reports no conflict of interest with this work.

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Disclaimer
The researcher would like to note that while this study used secondary data from the Jamaica Survey of Living Conditions (JSLC), none of the errors in this paper should be ascribed to the Planning Institute of Jamaica (PIOJ) and/or the Statistical Institute of Jamaica (STATIN), but to the researcher.

Acknowledgement
The author thanks the Data Bank in Sir Arthur Lewis Institute of Social and Economic Studies, the University of the West Indies, Mona, Jamaica for making the dataset (2002 JSLC) available for use in this study, and the National Family Planning Board for commissioning the survey.

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15. Bok S. Rethinking the WHO definition of health. Working Paper Series, 14; 2004. Retrieved from http://www.golbalhealth.harvard.edu/hcpds/wpweb/Bokwp14073.pdf (accessed May 26, 2007). 16. Diener E. Subjective wellbeing. Psychological Bulletin. 1984; 95:542-575. 17. Diener E. Subjective wellbeing. The science of happiness and proposal for a national index. Am Psychol Ass. 2000; 55:34-43. 18. Crisp R. Wellbeing. The Stanford Encyclopedia of Philosophy (winter edition) E N Zalta ed; 2005. Retrieved from http://plato.stanford.edu/archives/win2005/entries/wellbeing (accessed August 22, 2006). 19. Easterlin RA. Building a better theory of well-being. Prepared for presentation at the conference Paradoxes of Happiness in Economics, University of Milano-Biococca, March 21-23, 2003. Retrieved from http://www-rcf.use.edu/ easterl/papers/BetterTheory.pdf (accessed August 26, 2006). 20. Veenhoven R. Happiness in nations, subjective appreciation of in 56 nations 1946-1992. Rotterdam, Netherlands: Erasmus University; 1993. 21. Hutchinson G, Simeon DT, Bain BC, Wyatt GE, Tucker MB, LeFranc E. Social and health determinants of wellbeing and life satisfaction in Jamaica. International J of Social Psychiatry. 2004; 50:43-53. 22. Bourne PA. Modelling social determinants of self-evaluated health of poor old people in a middle-income developing nation. J Biomedical Sci and Engineering, 2010;3: 700-710.

23. Bourne PA. Social and environmental correlates of self-evaluated health of poor aged Jamaicans. HealthMed journal 2010;4(2):284-296. 24. Homer D, Lemeshow S. Applied Logistic Regression, 2nd edn. John Wiley & Sons Inc., New York, 2000. 25. Cohen L, Holliday M. Statistics for Social Sciences. London, England: Harper and Row, 1982. 26. Asnani MR, Reid ME, Ali SB, Lipps G, Williams-Green P. Quality of life in patients with sickle cell disease in Jamaica: rural-urban differences. Rural and Remote Health. 2008; 8: 1-9. 27. WHO. The Social Determinants of Health; 2008. Available at http://www.who.int/social_determinants/en/ (accessed April 28, 2009). 28. Kelly M, Morgan A, Bonnefog J, Beth J, Bergmer V. The Social Determinants of Health: developing Evidence Base for Political Action, WHO Final Report to the Commission; 2007. 29. Wilkinson RG, Marmot M. Social Determinants of Health. The Solid Facts, 2nd ed. Copenhagen: World Health Organization; 2003.

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30. Solar O, Irwin A. A Conceptual Framework for Analysis and Action on the Social Determinants of Health. Discussion paper for the Commission on Social Determinants of Health DRAFT April 2007. Available from http://www.who.int/social_determinants/resources/csdh_framework_action_05_07.pdf (Accessed April 29, 2009). 31. Graham H. Social Determinants and their Unequal Distribution Clarifying Policy Understanding The MilBank Quarterly 2004;82 (1), 101-124. 32. Pettigrew M, Whitehead M, McIntyre SJ, Graham H, Egan M. Evidence for Public Health Policy on Inequalities: 1: The Reality According To Policymakers. Journal of Epidemiology and Community Health 2004;5, 811 – 816. 33. Bourne PA, Eldemire-Shearer D. Differences in social determinants of health between men in the poor and the wealthy social strata in a Caribbean nation. North Am J of Med Sci 2010;2(6):267-275.

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Table 8.1: Good Health Status of Jamaicans by Some Explanatory Variables
Wald statistic Variable Middle Quintile Two Wealthiest Quintiles Poorest-to-poor Quintiles* Retirement Income Household Head Logged Medical Expenditure Average Income Average Consumption Environment Separated or Divorced or Widowed Married Never married* Health Insurance Other Towns Urban Area Rural Area* House Tenure - Rent House Tenure - Owned House Tenure- Squatted* Secondary Education Tertiary Education Primary and below* Social Support Living Arrangement Crowding Land ownership Gender Negative Affective Positive Affective Number of males in household Number of females in household Number of children in household Constant Coefficient -0.03 -0.11 -0.38 0.17 -0.05 0.00 0.00 0.01 -0.97 -0.55 Std Error. 0.10 0.10 0.17 0.29 0.02 0.00 0.00 0.07 0.10 0.08 0.09 1.26 4.88 0.37 5.10 1.56 0.16 0.02 87.36 53.05 P 0.764 0.261 0.027 0.543 0.024 0.212 0.689 0.891 0.000 0.000 CI (95%) Odds Ratio 0.97 0.90 0.68 1.19 0.95 1.00 1.00 1.01 0.38 0.58 Lower 0.81 0.74 0.49 0.68 0.91 1.00 1.00 0.88 0.31 0.50 Upper 1.17 1.09 0.96 2.08 0.99 1.00 1.00 1.16 0.46 0.67

-3.31 0.21 -0.01

0.12 0.08 0.13

776.64 6.64 0.00

0.000 0.010 0.952

0.04 1.24 0.99

0.03 1.05 0.78

0.05 1.46 1.27

-1.08 -0.42

0.88 0.55

1.48 0.58

0.224 0.447

0.34 0.66

0.06 0.23

1.93 1.93

0.31 0.71

0.08 0.17

15.81 18.09

0.000 0.000

1.36 2.03

1.17 1.45

1.58 2.82

-0.17 -0.06 -0.01 -0.07 0.39 -0.04 0.07 0.14 0.06 0.17 1.89

0.07 0.13 0.04 0.07 0.07 0.01 0.01 0.04 0.04 0.03 0.65

6.33 0.20 0.08 0.90 28.67 14.96 26.26 13.36 2.36 29.16 8.31

0.012 0.659 0.772 0.342 0.000 0.000 0.000 0.000 0.124 0.000 0.004

0.85 0.95 0.99 0.93 1.48 0.96 1.08 1.15 1.06 1.19 6.59

0.75 0.73 0.91 0.81 1.28 0.94 1.05 1.07 0.98 1.12

0.96 1.22 1.07 1.08 1.71 0.98 1.11 1.24 1.14 1.27

χ2 (27) =1860.639, p < 0.001; n = 8,274 -2 Log likelihood = 6331.085 Hosmer and Lemeshow goodness of fit χ2=4.703, p = 0.789. Nagelkerke R2 =0.320 Overall correct classification = 85.7% (N=7,089) Correct classification of cases of good or beyond health status =98.3% (N=6,539) Correct classification of cases of dysfunctions =33.9% (N=550); *Reference group

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Table 8.2: Good Health Status of Elderly Jamaicans by Some Explanatory Variables
Coefficient Middle Quintile Two Wealthiest Quintiles Poorest-to-poor quintiles Retirement Income Household Head Logged Medical Expenditure Average Income Environment Separated or Divorced or Widowed Married Never married* Health Insurance Other Towns Urban Rural areas* House tenure - rented House tenure - owned House tenure – squatted* Secondary Education Tertiary Education Primary or below* Social support Living arrangement Crowding Landownership Gender Negative Affective Positive Affective Number of male Number of females Number of children Constant -20.37 1.22 40192.9 1.24 0.00 0.96 1.000 0.327 0.00 3.38 0.00 0.30 -0.10 0.12 -0.22 0.89 -0.06 0.00 -0.16 -0.49 -0.33 -3.35 0.33 0.40 Std Error 0.15 0.17 0.22 0.65 0.04 0.00 0.12 0.15 0.15 0.22 0.14 0.21 Wald statistic 0.47 0.47 1.00 1.86 2.16 0.93 1.80 11.00 4.82 241.88 5.32 3.48 P 0.495 0.491 0.317 0.172 0.142 0.335 0.180 0.001 0.028 0.000 0.021 0.062 Odds Ratio 0.90 1.12 0.81 2.44 0.95 1.00 0.86 0.61 0.72 0.04 1.39 1.49 CI (95%) Lower 0.67 0.81 0.53 0.68 0.88 1.00 0.68 0.46 0.54 0.02 1.05 0.98 Upper 1.22 1.56 1.23 8.76 1.02 1.00 1.08 0.82 0.97 0.05 1.83 2.27

38.60

-0.46 0.81

0.11 0.35

16.06 5.45

0.000 0.020

0.63 2.26

0.51 1.14

0.79 4.47

-0.08 0.26 -0.05 0.17 0.47 -0.03 0.07 0.18 0.05 0.22 -1.32

0.11 0.18 0.09 0.13 0.12 0.02 0.02 0.07 0.07 0.06 1.44

0.47 2.11 0.29 1.72 14.67 1.97 9.26 6.75 0.49 12.09 0.83

0.495 0.146 0.593 0.190 0.000 0.160 0.002 0.009 0.485 0.001 0.362

0.93 1.30 0.95 1.19 1.60 0.97 1.07 1.19 1.05 1.24 0.27

0.75 0.91 0.80 0.92 1.26 0.94 1.03 1.04 0.91 1.10

1.15 1.84 1.14 1.54 2.04 1.01 1.12 1.36 1.21 1.40

χ2 (27) =595.026, p < 0.001; n = 2,002 -2 Log likelihood = 2,104.66 Hosmer and Lemeshow goodness of fit χ2=5.736, p = 0.677. Nagelkerke R2 =0.347 Overall correct classification = 75.5% (N=1.492) Correct classification of cases of good or beyond health status =94.6% (N=1,131) Correct classification of cases of dysfunctions =44.7% (N=361); *Reference group

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Table 8.3: Good Health Status of Middle Age Jamaicans by Some Explanatory Variables
Coefficient Middle Quintile Two Wealthiest Quintiles Poorest-to-poor Quintiles* Retirement Income Household Head Logged Medical Expenditure Average Income Environment Separated or Divorced or Widowed Married Never married* Health Insurance Other Towns Urban Rural areas* House tenure - rented House tenure - owned House tenure – squatted* Secondary education Tertiary education Primary or below* Social support Living Arrangement Crowding Landownership Gender Negative Affective Positive Affective Number of males in house Number of female in house Number of children in house Constant
2

Std Error 0.15 0.15 0.36 0.45 0.04 0.00 0.12

Wald statistic 0.04 3.67 2.44 1.24 6.44 0.53 7.41

P 0.834 0.055 0.119 0.265 0.011 0.465 0.006

Odds Ratio 1.03 0.75 0.57 1.66 0.91 1.00 1.37

CI (95%) Lower 0.76 0.56 0.28 0.68 0.85 1.00 1.09 Upper 1.40 1.01 1.16 4.01 0.98 1.00 1.71

0.03 -0.29 -0.57 0.50 -0.09 0.00 0.31

-0.20 -0.18 -3.04 0.11 -0.01 17.94 -1.33 0.19 0.34 -0.08 -0.19 -0.05 -0.13 0.51 -0.08 0.05 0.03 0.08 0.10 3.29

0.23 0.11 0.17 0.12 0.19 20029.78 1.12 0.13 0.23 0.10 0.21 0.06 0.11 0.11 0.02 0.02 0.06 0.06 0.04 1.25

0.77 2.68 320.76 0.75 0.00 0.00 1.43 2.11 2.23 0.57 0.87 0.65 1.47 21.41 24.66 4.51 0.23 2.09 5.47 6.89

0.380 0.102 0.000 0.387 0.963 0.999 0.232 0.146 0.135 0.450 0.351 0.419 0.226 0.000 0.000 0.034 0.630 0.149 0.019 0.009

0.82 0.84 0.05 1.11 0.99

0.53 0.68 0.03 0.87 0.68 0.00 0.03 0.94 0.90 0.76 0.55 0.85 0.71 1.34 0.90 1.00 0.92 0.97 1.02

1.28 1.04 0.07 1.42 1.44

0.26 1.20 1.41 0.93 0.83 0.95 0.88 1.66 0.92 1.05 1.03 1.08 1.11 26.77

2.35 1.55 2.21 1.13 1.24 1.07 1.08 2.06 0.95 1.10 1.14 1.21 1.21

χ (27) =547.543, p < 0.001; n = 3,799 -2 Log likelihood = 2,776.972 Hosmer and Lemeshow goodness of fit χ2=4.318, p = 0.827. Nagelkerke R2 =0.230 Overall correct classification = 87.2% (N=3,313) Correct classification of cases of good or beyond health status =98.3% (N=3,143) Correct classification of cases of dysfunctions =28.2% (N=170); *Reference group

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Table 8.4: Good Health Status of Young Adults Jamaicans by Some Explanatory Variables
Coefficient Middle Quintile Two Wealthiest Quintiles Poorest-to-poor quintiles* Household Head Logged Medical Expenditure Average Income Environment Health Insurance Other Towns Urban Rural area* Secondary education Tertiary education Primary and below* Social support Crowding Gender Negative Affective Positive Affective Number of males in house Number of females in house Married Never married* Constant -0.06 -0.59 -0.25 0.01 0.00 -0.03 -3.73 0.23 -0.05 Std Error 0.19 0.18 0.39 0.04 0.00 0.13 0.21 0.15 0.18 Wald statistic 0.10 11.10 0.41 0.09 3.29 0.04 321.51 2.42 0.07 P 0.747 0.001 0.520 0.760 0.070 0.840 0.000 0.120 0.788 Odds Ratio 0.94 0.55 0.78 1.01 1.00 0.97 0.02 1.26 0.95 CI (95%) Lower Upper 0.65 0.39 0.36 0.93 1.00 0.75 0.02 0.94 0.68 1.37 0.78 1.68 1.10 1.00 1.26 0.04 1.69 1.34

-0.06 -0.39 -0.14 0.04 0.19 -0.04 0.07 0.13 0.06 0.08 2.75

0.41 0.47 0.13 0.06 0.15 0.02 0.03 0.07 0.06 0.22 0.67

0.02 0.70 1.22 0.65 1.60 4.22 6.81 3.67 0.87 0.13 16.62

0.886 0.405 0.269 0.420 0.206 0.040 0.009 0.055 0.351 0.717 0.000

0.94 0.68 0.87 1.05 1.20 0.96 1.07 1.13 1.06 1.09 15.57

0.43 0.27 0.68 0.94 0.90 0.93 1.02 1.00 0.94 0.70

2.09 1.69 1.12 1.16 1.60 1.00 1.13 1.29 1.20 1.68

χ2 (19) =453.733, p < 0.001; n = 4,174 -2 Log likelihood = 2,091.88 Hosmer and Lemeshow goodness of fit χ2=5.185, p = 0.738. Nagelkerke R2 =0.226 Overall correct classification = 92.6% (N=3,864) Correct classification of cases of good or beyond health status =99.0% (N=3,757) Correct classification of cases of dysfunctions =28.2% (N=107); *Reference group

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Chapter

9 Social Determinants of Health in a

developing Caribbean nation: Are there differences based on municipalities and other demographic characteristics?

This study examined socioeconomic determinants of self-reported health status of Jamaicans and whether self-reported illness is a good measure of health status. In addition, the study went further to identify the predictors of the sexes and different area of residences as those cohorts have different economic characteristics. Age, self-reported illness and consumption were determinants across the sexes, and area of residences. Education and social class were correlate of women and not men and social assistance a predictor of health status for men and not women. Although dwellers in urban areas have less determinants, it had the greatest explanatory power (45.7%) compared to rural areas (44.5%) and urban residence (30.5%). Length of time in household and education were social determinants synonymous with only urban areas; social class and gender were social predictors of only rural areas while age, self-reported ill and consumption were correlates of all area of residences. A critical finding that emerged from this study is the fact that self-reported health status is a good predictor of health status and so can be used if self-rated health status is not available. Generally, the social determinants of health status of Jamaicans are mostly the same across the sexes, and the difference area of residences.

Introduction
Traditionally, in Western Societies, health is the ‘absence of diseases’. This approach is both narrow and negative in scope. According to some scholars, the aforementioned conceptualization emphasizes the absence of some disease causing pathogens, and not really health [1, 2]. Such a perspective is in keeping with traditional biomedical model that views the exposure to specific pathogen as the cause of diseases in organisms. This began during 130ce to 200ce in Ancient Rome and despite the efforts of the WHO as early as in 1946 to expand this construct [3]; health

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in Caribbean societies in particular Jamaica is still substantially viewed as the ‘absence of diseases’ or dysfunctions, with wellbeing being the opposite of that state. Lynch [4] opines that everything that we do, feel, think and experience interface with our health. Hence, health status cannot be operationally defined solely based on functional limitation because of pathogens as many events affect ones quality of life outside of that space. The concept of health according to the WHO is multifaceted. The WHO [3] wrote in its preamble to its Constitution that “Health is state of complete physical, mental and social wellbeing, and not merely being the absence of disease or infirmity”. From the WHO’s perspective, health status is an indicator of wellbeing [5] and that there are social determinants of health status. One scholar [6] opined that the WHO operationalization of health (or wellbeing) is too broad and by extension difficult to measure. While there are some merits to this perspective, some researchers have used happiness [7-11], life satisfaction [5, 12-16], and self-reported health status to proxy health. The argument is that those constructs are broad and cover wellbeing (or health) and so partially dismisses the propositions of Bok. This in part is owing to the fact that researchers continue to investigate in order to ascertain a better measure of health (or wellbeing). A part from the discourse on operational definition of health, the WHO conceptualization of health identifies social determinants and not merely biological factors. Engel [17-20] believed that the state of man’s wellbeing is not only influenced by his/her biologic state but that is always dependent on his/her environment, economic and sociologic conditions. Using econometric analyses, Grossman [21] was the first to develop a model that identified some of the social determinants of health status. He found that smoking and excessive drinking, and good personal health behaviours (including exercise), use of medical care, education of each family member, and all sources of household income (including current income); to be determinants of

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health status. Smith & Kington [22] expanded on the social determinants developed by Grossman, by including and refining some of the factors. They found that the price of medical care, the price of other inputs, family background or genetic endowments, retirement related income, and asset income can be perceived as social predictors of wellbeing. There is a thrust by the WHO to examine social determinants of health for the individual and the population [23]. A part of the rationale for this drive is the role poverty plays in producing health inequalities and the need to examine health development. Many researchers who are affiliated with the WHO [24-26] and others [27, 28] have been reviewing and examining social determinants of health. Caribbean scholars [29–33] have been using econometric analyses to establish social determinants of health (or wellbeing); ergo such is the rationale for its usage in this research. Hambleton et al. [33] went further to include self-reported illness along with some social determinants of health in a study of elderly Barbadians. Their work used data on the elderly population and this has never been applied to data for the population. No such study in the Caribbean, in particular Jamaica, has been identified in the literature which has examined whether self-reported illness is highly correlated with self-rated health status as well as social determinants of self-evaluated health status, using national probability data. It is within this framework that this study examined factors that determined self-reported health status of Jamaicans including whether self-reported health conditions are highly correlated with selfevaluated health status; and to decompose this for sex and area of residence using a model derived by econometric analysis. This will be done by testing a general hypothesis which reads socio-economic variables and self-reported illness are determinants of self-evaluated health status (Equation [1]).

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Method
The current study used a sample of 6,783 respondents. The sample was drawn from a large nationally representative cross-sectional survey of 6,783 Jamaicans [34]. The survey was drawn using stratified random sampling. This design was a two-stage stratified random sampling design where there was a Primary Sampling Unit (PSU) and a selection of dwellings from the primary units. The PSU is an Enumeration District (ED), which constitutes of a minimum of 100 dwellings in rural areas and 150 in urban areas. An ED is an independent geographic unit that shares a common boundary. This means that the country was grouped into a strata of equal size based on dwellings (EDs). Pursuant to the PSUs, a listing of all the dwellings was made, and this became the sampling frame from which a Master Sample of dwellings was compiled, which in turn provided the sampling frame for the labour force. One third of the 2007 Labour Force Survey (LFS) was selected for the survey. This study used JSLC 2007 which was conducted by the Statistical Institute of Jamaica (STATIN) and the Planning Institute of Jamaica (PIOJ) between May and August 2007. The researchers chose this survey based on the fact that it is the latest survey on the national population and that it has data on self-rated health status of Jamaicans. An administered questionnaire was used to collect the data, which were stored and analyzed using SPSS for Windows 16.0 (SPSS Inc; Chicago, IL, USA). The questionnaire was modelled from the World Bank’s Living Standards Measurement Study (LSMS) household survey. There are some

modifications to the LSMS, as JSLC is more focused on policy impacts. The questionnaire covered areas such as socio-demographic, economic and health variables. The non-response rate for the survey was 26.2%.

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Descriptive statistics such as mean, standard deviation (SD), frequency and percentage were used to analyze the socio-demographic characteristics of the sample. Chi-square was used to examine the association between non-metric variables, and an Analysis of Variance (ANOVA) was used to test the relationships between metric and non-dichotomous categorical variables. Logistic regression examined the relationship between the dependent variable and some predisposed independent (explanatory) variables, because the dependent variable was a binary one (self-reported health status: 1 if reported good health status and 0 if poor health). The results were presented using unstandardized B-coefficients, Wald statistics, Odds ratio and confidence interval (95% CI). The predictive power of the model was tested using the Omnibus Test of Model and Hosmer & Lemeshow [35] were used to examine the goodness of fit of the model. The correlation matrix was examined in order to ascertain whether autocorrelation (or multicollinearity) existed between variables. Based on Cohen & Holliday [36] correlation can be low (weak) - from 0 to 0.39; moderate – 0.4-0.69, and strong – 0.7-1.0. This was used to exclude (or allow) a variable in the model. Wald statistics were used to determine the magnitude (or contribution) of each statistically significant variable in comparison with the others, and the Odds Ratio (OR) for the interpreting of each significant variable. Multivariate regression framework [29,30] was utilized to assess the relative importance of various demographic, socio-economic characteristics, physical environment and psychological characteristics, in determining the health status of Jamaicans; and this has also been employed outside of Jamaica [21,22,33]. This approach allowed for the analysis of a number of variables simultaneously. Secondly, the dependent variable is a binary dichotomous one and this

statistical technique has been utilized in the past to do similar studies. Having identified the determinants of health status from previous studies, using logistic regression techniques; final

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models were built for Jamaicans as well as for each of the geographical sub-regions (rural, periurban and urban areas) and sex of respondents using only those predictors that independently predict the outcome. A p-value of 0.05 was used for all tests of significance. Model The use of multivariate analysis in the study of health and subjective wellbeing (. self-reported health or happiness) is well established [21, 22, 37, 38] and this is equally the case in Jamaica and Barbados [14, 30-32]. The current study will employ multivariate analyses in the study of health and medical care seeking behaviour of Jamaicans. The use of this approach is better than bivariate analyses as many variables can be tested simultaneously for their impact (if any) on a dependent variable. Scholars like Grossman [21], Smith & Kingston [22], Hambleton et al. [33], Kashdan [39], Yi & Vaupel [40], the World Health Organization pilot work a 100-question quality of life survey (WHOQOL) [41] and Diener [8, 42] have used and argued that self-reported health status can be effectively applied to evaluate health status instead of objective health status

measurement. Other scholars, on the other hand, employed self-reported health conditions to operationalize the health of an individual [30]. Embedded in the works of those researchers is the similarity of self-reported health status and self-reported dysfunction in assessing health. The current study will examine the social determinants of self-rated health status of Jamaicans and whether self-reported dysfunction is correlated with self-reported illness (Equation (1)). Equation (1) was again tested but this time it was decomposed by (i) sex of respondents and (ii) area of residents in order to ascertain those social predictors of each subgroup.

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H t =f(A i , G i ,HH i , AR i , I t , J i, lnC, lnD i , ED i, MR i , S i , HIi , lnY, CR i , MC t , SA i , Ti , ε i )

(1)

where H t (. self-rated current health status in time t) is a function of age of respondents, A i ; sex of individual i, G i ; household head of individual i, HH i ; area of residence, AR i ; current self-reported illness of individual i, I t ; injuries received in the last 4 weeks by individual i, J i ; logged consumption per person per household member, lnC; logged duration of time that individual i was unable to carry out normal activities, lnD i ; Education level of individual i, ED i ; marital status of person i, MR i ; social class of person i, S i ; health insurance coverage of person i, HIi ; logged income, lnY; crowding of individual i, CRi; medical expenditure of individual i in time period t, MC t ; social assistance of individual i, SA i ; length of time living in current household by individual i, Ti ; and an error term (ie. residual error).

The final models derived from the general Equation (1) that can be used to predict health status of Jamaicans are (Equation (2); men (Equation (3); women (Equation (4); urban area (Equation [5]); other towns (Equation (6); and rural areas (Equation (7). H t (Jamaicans) = f(A i , G i , AR i , It , lnC, S i , ED, ε i ) H t (men) = f(A i , AR i , It , lnC, SA i , ε i ) H t (women) = f(A i , AR i , It , lnC, ED i, S i , ε i ) H t (urban area) = f(Ti , A i , I t , lnC, ED i, ε i ) H t (other town) = f(A i , I t , J i, lnC, ε i ) H t (rural area = f(A i , S i , G i , It , lnC, ε i ) Measure Age is a continuous variable which is the number of years alive since birth (using last birthday) Age group is a non-binary measure: children (ages less than 15 years); young adults (ages 15 to 30 years); other-aged adults (ages 31 to 59 years); young elderly (ages 60 to 74 years); old elderly (ages 75 to 84 years) and oldest elderly (ages 85 years and older). 199 (2) (3) (4) (5) (6) (7)

Self-reported illness (or self-reported dysfunction): The question was asked: “Is this a diagnosed recurring illness?” The answering options are: Yes, Cold; Yes, Diarrhoea; Yes, Asthma; Yes, Diabetes; Yes, Hypertension; Yes, Arthritis; Yes, Other; and No. A binary variable was later created from this construct (1=yes, 0=otherwise) in order to be applied in the logistic regression. Self-rated health status: “How is your health in general?” And the options were very good; good; fair; poor and very poor. For this study the construct was categorized into 3 groups – (i) good; (ii) fair, and (iii) poor. A binary variable was later created from this variable (1=good and fair 0=otherwise). Social hierarchy: This variable was measured based on income quintile: The upper classes were those in the wealthy quintiles (quintiles 4 and 5); middle class was quintile 3 and poor those in lower quintiles (quintiles 1 and 2).

Results
Demographic characteristics of sample The study had a sample of 6,782 respondents (48.7% were men and 51.3% were women). Forty nine percent of the sample lived in rural areas; 69.2% were never married; 61.8% had no formal education; 29.6% were head of households; 40.3% were wealthy (. upper class), and the mean age was 29.9 years (± 21.8 years). Majority of the sample indicated good self-rated health status (82.2%) compared to 85.1% that claimed no illness. Of the sample, 14.8% responded to the question of having had visited a health practitioner or healer in the past 4 weeks. Of those who answered the aforementioned question, 65.5% reported having sought medical care (Table 9.1).

Further examination of the self-rated health status of the sample by sex revealed a statistical correlation between the two variables (χ2 (2) =44.666, p < 0.001, n=6,565). Table 9.2 showed that more men reported good health status (85.4%) compared to women (79.2%); 200

suggesting that more women reported fair to poor health than men. The statistical association between the two aforementioned variables was a very weak one (c=0.082 or 8.2%).

A cross tabulation between self-reported illness and sex respondents revealed a statistical association (χ2 (2) =38.121, p < 0.001, n=6,589). Eighty-eight percent of men reported having not had an illness in the past 4weeks compared to 83% of women (Table 9.3). This means that more women (18%) than men (12%) reported a dysfunction.

On examining self-reported illness by sex of the respondents a statistical correlation was revealed (χ2 (7) =40.916, n=999). The association was a very weak one (c=0.198 or 19.8%). Thirteen percent of the sample claimed that their illness was diagnosed as recurring (. chronic) ailment compared to 2% who said no. Hypertension and diabetes mellitus were reported to be experienced by mostly women, and cold, asthma as well as unspecified ailments was reported in a larger number by men than women (Table 9.4). Examination of diagnosed self-reported illness and the age group of respondents revealed a statistical correlation (χ2 (7) =457.834, p < 0.001) (Table 5). Children are mostly likely to have cold (37.5%), diarrhoea (5.0%) and asthma (19.7%) compared to the other age cohorts (Table 9.5). However as an individual gets older he/she is more likely to report as having been diagnosed with hypertension, arthritis and diabetes mellitus. The most reported cases of hypertension were experienced by the oldest elderly (33.1%) compared to the old elderly (31.6%) and young elderly (25.3%) and this was similarly for arthritic cases: 12.6%, 11.4% and 5.7% respectively (Table 9.5). A cross tabulation of self-rated health status and age group revealed a statistical relationship (χ2 (7) =1,266.065, p < 0.001) (Table 9.6). Based on Table 9.6, the oldest elderly

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reported the worst health status (32.3% indicated poor health status); 29.0% for the old elderly; 16.3% for the young elderly, 4.1% of other-aged adults; 1.7% of young adults and 2.0% for children. Using F statistic test, it was revealed that a statistical difference existed between social classes and consumption expenditure (F statistic [2, 6779] = 2,659.28; p < 0.001). The mean consumption expenditure for the poor was JA $70, 448.55 (US $1= JA. $80.47) which was 58.9% of consumption expenditure of those in the middle class (JA. $119,562.00) and 27.4% of the expenditure of those in the upper class (JA. $256,984.80). This signifies that the poor’s consumption expenditure was 45% of the mean consumption expenditure of Jamaicans (JA. $155,429.80). An investigation between cost of private medical care and social class revealed a statistical correlation (F statistic [2,580] =5.211, p = 0.006). The mean cost for medical care of Jamaicans was US $14.11 ± US $27.21. The mean amount spent by the poor on health care expenditure was US $9.88 ± US $30.15 which was not statistical different (ie p= 0.642) from the mean amount spent by the middle class (US $12.66 ± US $17.98); as well as no statistical difference (. p=0.171) between the mean amount spent by the middle class and the upper class (US $17.94 ± US $28.10), while a difference was found between the mean spent by the poor and the wealthy. Multivariate Analyses Predictors of self-rated health status of Jamaicans Of the 15 socio-economic variables and 2 biological variables identified in Equation [1], seven socio-economic factors and one biological variable was found to be predictors of self-rated health status of Jamaicans (Table 9.7). Age (OR=0.951, 95% CI=0.946, 0.956); social class

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(upper class - OR=0.629, 95% CI=0.462, 0.857); education (secondary or tertiary – OR=0.587, 95% CI=0.403, 0.855); area of residence (other town - OR= 1.318, 95%CI=1.055, 1.646); sex of respondents (men – OR=1.471, 95% CI=1.231, 1.757) and consumption (OR=1.759, 95% CI=1.452, 2.133) were the socio-economic predictors and self-reported illness (OR=0.122, 95% CI=0.100, 0.150) was also found to be correlated with health status of Jamaicans (Table 9.7). Using logistic regression analysis, the study tested equation [1] and found that the 7 factors were statistically significant predictors of self-rated health status (χ2 (7) =1,332.149, p < 0.001; Hosmer & Lemeshow goodness of fit χ2=23.831, P = 0.882) (Table 9.7). The model explains 40.1% of the variability in self-rated health status of Jamaicans. The most significant predictor of self-rated health status of Jamaicans is self-reported illness followed by age, consumption, sex of respondents, social standing, education and area of residents. Predictors of self-rated health status of men Five factors determined the self-rated health status of men in Jamaica. These are social assistance (OR=0.023, 95%CI=0.255, 0.902); age of respondents (OR=0.951, 95%CI=0.943, 0.958); selfreported illness (OR=0.103, 95%CI=0.078, 0.153); consumption (OR=1.370, 95%CI=1.107, 1.696) and area of residence (urban area – OR=0.595, 95%CI=0.436, 0.813). The socio-

economic and biological determinants accounted for 39.7% of the explained variability in selfrated health status of men (Table 9.8). Further examination revealed that the aforementioned predictors have a statistically significant predictive power (χ2 (5) =573.649, p < 0.001, Hosmer & Lemeshow goodness of fit χ2=19.746) and 87.5% of the data were correctly classified (Table 9.8).

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Predictors of self-rated health status of women There are six factors that were found to be predictors of self-rated health status of women in Jamaica (Table 9.9). They are age of respondents (OR=0.953, 95%CI=0.947, 0.959); social class (upper class – OR=0.571, 95%CI=0.380, 0.857); illness (OR=0.131, 95%CI=0.101, 0.168); education (OR=0.366, 95%CI=0.366, 0.908); consumption (OR=1.981, 95%CI=1.537, 2.554) and area of residence (other towns – OR=1.347, 95%CI=1.009, 1.799). The aforementioned variables accounted for 39.7% of the variability in self-rated health status of women in Jamaica. The factors are statistically significant predictive ones (χ2 (6) =729.618, p < 0.001; Hosmer & Lemeshow goodness of fit χ2=9.579, P = 0.870). Eight-two percent of the data were correctly classified: 92.5% of cases with good self-rated health status 51.6% of cases that were otherwise (Table 9.9). Predictors of Self-rated health status of different area of residences The deconstruction of self-rated health status by area of residence revealed some similarities and differences on the predictors. Age, illness and consumption were the three predictors over the different area of residence. On the other hand, length of time dwelling in household and education affected only urban residents while social standing and gender influenced only rural dwellers. In all 3 residences, the factors were statistically significant predictors ones (Tables 9.10, 9.11, 9.12). The factors determining self-rated health status for other town dwellers accounted for the highest explanatory variability (45.7%) compared to rural areas (44.5%) and 30.5% for urban areas.

Discussion
When WHO in the preamble to its Constitution in 1946 wrote that health was more than dysfunctions, this was an acceptance of the socio-economic determinants. This perspective was

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equally agreed on by a psychiatrist [17-20] in the treatment of mentally ill patients. Engel called this multifactorial approach of health, the biopsychosocial model. It was a conceptual expansion of the traditional biomedical model in the treatment and perspective of health. Using data for the world, Grossman [21] was able to develop a health function with the use of econometric analysis. Grossman’s model identified different socio-economic determinants (such as medical care; the adoption of good personal health behaviour and the avoidance of bad ones; education of the family, and family background) of self-rated health status for people in the world. This was later expanded upon by Smith & Kington [22] who added price of medical care, other inputs and financial resources (ie retirement-related income; government transfer; asset income). Despite the WHO forwarding the perspective about the social determinants of health as early as in the 1940s, it was not until recently (in 2000s) that the institution began writing on those factors. After an extensive review of health literature in the Caribbean, it was ascertained that Hambleton et al. [33] were the only group of scholars whose health function incorporated socioeconomic determinants of illness. No study in Jamaica identified by the literature search has ever linked the self-rated health status, self-reported illness and socioeconomic variables. Although Jamaica is located in the Caribbean, like Barbados, it has different literacy rates, economic system, customs and practices and this means that what applies in Barbados does not necessarily apply to Jamaica. Secondly, the study of Hambleton et al. [33] used data for elderly people (ages 65 years and older) and therefore this group is different from the general populace. The current study, which used data for the populace of Jamaicans, found that selfreported illness was a significant predictor of health status and concurred with Hambleton et al.’s work. This finding revealed that an individual who reported an illness was 88% less likely to report good health, suggesting that self-reported health condition is a good measurement for the

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health status of Jamaicans. It follows from the current findings that those who do not report an illness is a good measurement for good health status. Hence, when Bourne & McGrowder [30] used no health conditions to evaluate good health for rural residents, this approach is similar and therefore acceptable. This research found that men who reported an illness were 89% less likely to rate their health as good and this finding was 87% for women, indicating that former group’s no illness was a better measure for health status than the latter group. When self-reported illness and self-rated health was broken down based on area of residence, rural dwellers who reported an illness were 99% less likely to rate their health status as good compared to 90% for other town residents and 85% for urban dwellers. This means that self-reported dysfunctions data for rural dwellers is highly reliable for use to measure health status and the urban dataset is the least reliable. The general health status model for Jamaicans had socio-economic variables such as age, social class, consumption, area of residence and sex of respondents as well as self-rated illness. This study found that people with secondary or tertiary level education in Jamaica had lower health status than those with no formal education. Such a finding is contrary to other studies [21, 22, 31, 43-45]. Sen [46] provided us with a succinct description of the interconnectivity between income, education and health status. He argued that income buys health; education begets income, and higher quality education and health afford a larger income. The current work disagrees with Sen and other scholars who found that those with higher education had a greater health status. A group of demographers [44] refined the association between health and education, when they found that the number of years of school (ie. The Quantity Theory) was a crucial predictor of health status of an individual. The current work revealed that education was a

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predictor of health status of men, other town and rural dwellers but was for women and urban residents. According to Koo et al. 43], age was a significant predictor of subjective wellbeing, which is concretized by this study. Some studies also revealed that there was a negative association between age and subjective wellbeing [43, 47-49], which is also the case in the current work. The current research went further than the aforementioned studies and found that age was the strongest predictor of health status for other town residents and men; and second to illness for urban and rural dwellers, and women. Most importantly, the oldest old reported the most poor health status of all the age cohorts and that hypertension was increasing with ageing. Diabetes and arthritis were higher for the elderly than other age cohorts. One Caribbean scholar [50] found that 34.8% of new cases of diabetes and 39.6% of hypertension were associated to senior citizens (ages 60 years and older). The World Health Organization [51] forwarded a position that there was a disparity between contracting many diseases and the gender constitution of an individual. One health psychologist, Rice [52] argued that differences in death and illnesses are the result of differential risks acquired from functions, stress, life styles and ‘preventative health practices’. Lifestyle practices may justify the advantages that women enjoy compared with men concerning health status. However, a survey done by Rudkin found that women have lower levels of wellbeing (. economic) than men [53]. This finding is further sanctioned by Haveman et al [54] whose study revealed that retired men’s wellbeing was higher than that of their female counterparts, because men usually receive more material resources in their working life than women, and so their retired benefits are greater when compared to women. Other research have shown [55] that men in general tend to be more stressed and less

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healthy than females, and further argued that men can use denial, distraction, alcoholism and other social strategies to conceal their illness or disabilities [56-59]. On the other hand, Herzog [60] in Physical and Mental Health in Older Women, using studies from a number of experts wrote that females had higher rates of depression than their male counterparts. In the current study for every 150 women who reported an illness there were 100 men; and there are some dysfunctions that were are gender biased. There was twice the number of women with diabetes mellitus compared to men, 172 women per 100 men with hypertension, and no difference between the sexes with regards to diarrhoea. While there were 128 men for every 100 women with the cold; 146 men per 100 women with asthma, 111 men for every 100 women with arthritis, and 115 men per 100 women who did not specify their ailment. Another important finding of the current work is the fact that there were 100 women for every 182 men whose dysfunction was not diagnosed by a medical practitioner. A part from the aforementioned disparities in dysfunctions between the sexes, social assistance, education, social class and area of residences were different. Social assistance was a weak social predictor of health status of men but not for men; while social class and education were weak predictors of health status of women and not for men. Another difference between the sexes was with area of residence. The current work found that there is a statistical difference between the health status of men who dwelled in urban area with reference to rural areas, and women who resided in other towns with reference to rural women. A key finding was that consumption was positively correlated with health status and the sexes. The findings revealed that women who consumed more health status were 1.9 times greater than women who consumed less and this was 1.4 times more for men. This study included another variable (. length of time in household) in the examination of

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health status. Length of time in household was positively correlated with health status of urban residents. The findings revealed that the odds of reporting good health status was 1.2 times more for those who stay longer in the household; but this was not true for other and rural dwellers. It should be noted at this juncture, that this variable is a weak predictor and that it is not a predictor for health status for Jamaicans. There is a seeming paradox in this research as consumption positively correlates to health status but that the upper class had lower health status than the poor. The study showed that the wealthy Jamaicans consumed 3.7 times more than the poor yet the poor had a greater health status. Consumption is highly correlated with absolute-or-relative income or wealth [61-64], and that lack of income accounts for the poor’s inability to purchase particular good and services and equally justify their poor environment. Poverty does not only mean low income; but it speaks to the lowered access to material resources and choices such as education, nutrition, water, conditions of the community, social participation and medical care compared to the wealthy. Despite those inadequacies which arise owing to maldistribution of money and income inequality in the society, the poor still were reporting greater health status than the wealthy and this is partially owing to the spending pattern of the latter group. Wealthy Jamaicans are clearly spending on the wrong things. Embedded in this study is the erosion of the good health based on the lifestyle practices of wealthy individuals. Sen [46] opined that improved life expectancy in rich nations happened outside of income; and that the improvements were owing to policy support such as means of survival, sharing of health care and food supply. This means that the composition of an individual spending behaviour, which is an expression of his/her lifestyle, can either increase or reduce his/her health status; as the wealthy’s access to more resources and income are not transformed into healthy lifestyle practitioners. The wealthy spent on an average

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1.8 times more than the poor, yet their health status is lower. Although poverty is correlated with poor health, material deprivation and restriction in social participation, more income is not improving the health status of the wealthy over the poor.

Conclusion
The social indicators of health status of Jamaicans are age, education, social class, area of residence and sex of respondents with consumption being an economic indicator and selfreported illness being a biological predictor. Self-reported illness was found to be a significant predictor of self-rated health status for Jamaicans, and this was the same for both sexes and the different area of residences. The current study has shown that not all the social determinants of health status of a population are determinants of sexes or area of residence; and that the consumption (an economic factor) is consistent across the sexes or place of residences. Interestingly there are differences and similarities between the social determinants of health status of men and women in Jamaica. Although there are more social determinants of health status for women than men, the explanatory power in each is the same. Other similarities are age, illness, are consumption socio-economic indicators of health status in each sex; and that there is a dissimilarity in area of residence both men and women. The current work identified that there is a statistical difference between women who dwelled in other towns and rural residence and not urban and rural area while for men the difference is between urban and rural areas and not other area of residence. In summing, a critical finding that emerged from this study is the fact that self-reported health status is a good predictor of health status and so can be used if self-rated health status is not available. Generally, the social determinants of health status of Jamaicans are mostly the 210

same across the sexes and area of residences. Crucially, public health practitioners in Jamaica need to design healthy lifestyle campaign for the wealthy as the rich’s lifestyle is accounting for lower self-rated health status than the poor.

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Di Tella R, MacCulloch R, Oswald AJ. The Macroeconomics of Happiness, mimeo, Harvard Business School; 1998. Blanchflower DG, Oswald AJ. Well-Being Over Time In Britain And The USA. Journal of Public Economics, 2004;88(7-8, Jul), 1359-1386. Kashdan TB. The assessment of subjective well-being (issues raised by the Oxford Happiness Questionnaire). Personality and Individual Differences 2004;36:1225–1232. Yi J, Vaupel JW. Functional Capacity and Self-Evaluation of Health and Life of Oldest Old in China. Journal of Social Issues 2002;58(4): 733-748. Orley J. The WHOQOL Measure: Production of the WHOQOL-100 Field Trial form. Quality of Life News Letter 1995;12(3). Diener E. Subjective well-being: the science of happiness and a proposal for a national index. Am Psychologist 2000;55: 34–43. Koo J, Rie J, Park K. Age and gender differences in affect and subjective well-being. Geriatrics and Gerontology International 2004;4:S268-S270. Ross CE, Mirowsky J. Refining the association between education and health: The effects of quantity, credential, and selectivity. Demography 1999;36:445-460. Preston SH, Elo IT. Are Educational Differential in Adult Mortality Increasing in the United States? Journal of Aging and Health 1995; 7: 476-496. Sen A. Development as freedom. Oxford: Oxford University Press; 1999. Netuveli G, Wiggins RD, Hildon Z, Montgomery SM, Blane D. Quality of life at older ages: evidence form the English longitudinal stud y on aging (wave 1). Journal of Epidemiology and Community Health 2006; 60:357-371. Prause W, Saletu B, Tribl GG, Rieder A, Rosengerger A, Bolitschek J, Holzinger B, Kaplhammer G, Datschning H, Kunze M, Popovic R, Graetzhofer E, Zeitlhofer J. Effects of socio-demographic variables on health-related quality of life determined by the quality of life index—German version. Human psychopharmacology Clinical and Expremental 2005; 20:359-365. Dunn JR, Dyck I. Social determinants of health in Canada’s immigrant population: results from the Nation Population Health survey. Social Science and Medicine 2002;51:1553-1593. Eldemire D. 1995. A situational analysis of the Jamaican elderly, 1992. Kingston: Planning Institute of Jamaica; 1995. WHO. Healthy Ageing: Practical pointers on keeping well. Regional Office for the Western Pacific, Manila, Philippines: WHO; 2005. Rice PL. Health psychology. CA, USA: Brooks/Cole Publishing; 1998. Rudkin L. Gender differences in economic well-being among the elderly of Java. Demography, 1993; 30:209-226. Havenman R, Holden K, Wilson K, Wolfe B. Social security, age of retirement, and economic well-being: Inter-temporal and demographic patterns among retired-worker beneficiaries. Demography 2003; 40:369-394. Schoen C, Davis K, DesRoches C, Shekhdar A. The health of adolescent boys: Commonwealth Fund survey findings. New York: Commonwealth Fund; 1998. Friedman HS, Ed. Hostility, coping, and health. Washington, DC: American Psychological Association; 1991. Kopp MS, Skrabski A, Szedmak S. Why do women suffer more and live longer? Psychosomatic Medicine, 1998; 60:92-135. 214

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Weidner G, Collins RL. Gender, coping, and health. In H.W. Krohne (Ed.), Attention and avoidance. Seattle, WA: Hogrefe and Huber; 1993: pp. 241-265. Sutkin L, Good G. Therapy with men in health-care settings. In: Scher M, Stevens M, Good G, Eichenfield GA, eds. Handbook of counseling and psychotherapy with men. Thousand Oaks, CA: Sage Publications; 1987: pp. 372-387. Herzog AR. Physical and Mental Health in Older Women: Selected Research Issues and Data Sources. In: Hendricks JA, ed. Health and Economic Status of Older Women: Research Issues and Data Sources. New York, USA: Baywood Publishing Company; 1989. Keynes JM. The General Theory of Employment, Interst, and Money. New York: Harcourt Brace; 1936. Duesenberry JS. Income, Savings, and the Theory of Consumer Behavior. Cambridge: Harvard University Press; 1952. Ando A, Modigliani F. The Life Cycle Hypothesis of Saving: Aggregate Implications and Test. American Economic Review 1963;33:55-84. Friedman M. A Theory of the Consumption Function. Princeton: Princeton University Press; 1957.

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Table 9.1: Demographic characteristic of sample, n = 6,782 Variable Frequency Percent Social Assistance: Yes 637 9.7 No 5936 90.7 Medical Care seeking behaviour: Yes 659 65.5 No 347 34.5 Social class: Poor 2697 39.8 Middle 1351 19.9 Upper 2734 40.3 Self-reported Illness: Yes 980 14.9 No 5609 85.1 Self-rated Health Status: Good 5397 82.2 Other (Poor- to –fair) 1178 17.8 Education: No formal education 4071 61.8 Nursery 782 11.9 Primary or preparatory 898 13.6 Secondary 709 10.8 Tertiary 131 2.0 Household head Yes 2007 29.6 No 4775 70.4 Area of residence Urban areas 2002 29.5 Other towns 1458 21.5 Rural areas 3322 49.0 Marital status: Married 1056 23.3 Never married 3136 69.2 Divorced 77 1.7 Separated 41 0.9 Widowed 224 4.9 Sex Male 3303 48.7 Female 3479 51.3 Age Mean ± SD 29.9 years ± 21.8 years Length of illness - Median 7 days †Medical Expenditure Mean ± SD US $18.36 ± US $58.55 Median = 5 persons Persons per household
†US$ 1.00 = Ja. $ 80.47

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Table 9.2: Self-rated health status By Sex Self-rated health status: Sex Men n (%) 2,729 (85.4) 331 (10.4) 135 (4.2) 3,195 Women n (%) 2,688 (79.2) 517 (15.3) 185 (5.5) 3,370

Good Fair Poor Total χ2 (2) =44.666, p < 0.001, cc=0.082, n=6,565

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Table 9.3: Diagnosed Self-reported illness By Sex Sex Self-reported illness: Men n (%) 2,820 (87.9) 388 (12.1) 3,208 Women n(%) 2,789 (82.5) 592(17.5) 3,381

No illness Illness Total χ2 (2) =38.121, p < 0.001, cc=0.076, n=6,589

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Table 9.4: Typology of Self-reported Diagnosed Illness By Sex Diagnosed Illness (recurring) Men n (%) Cold 69 (17.2) Diarrhoea 11 (2.7) Asthma 47 (11.7) Diabetes mellitus 31 (7.7) Hypertension 58 (14.4) Arthritis 24 (6.0) Other 102 (25.4) No 60 (14.9) Total 402 χ2 (7) =40.916, p < 0.001, cc=0.198, n=999 80 (13.4) 16 (2.7) 48 (8.0) 92 (15.4) 148 (24.8) 32 (5.4) 132 (22.1) 49 (8.2) 597 Sex Women n (%)

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Table 9.5: Diagnosed Self-reported illness By Age group Age Group Otheraged adults n (%) 22 (7.3) 6 (2.0) 18 (6.0) 44 (14.7) 76 (25.3) 17 (5.7)

Diagnosed Self-reported illness
Cold

Children n (%) 97 (37.5) 13 (5.0)

Young adults n (%) 14(13.3) 2 (1.9)

Young adults n (%) 8 (4.1) 2 (1.0) 7 (3.6) 49 (25.4) 61 (31.6) 22 (11.4) 32 (16.6) 12 (6.2) 193

Old Elderly n (%) 8 (7.2) 3 (2.7) 2 (1.8) 19 (17.1) 49 (44.1) 14 (12.6) 13 (11.7) 3 (2.7) 111

Oldest Elderly n (%) 0 (0.0) 1 (3.2) 1 (3.2) 5 (16.1) 14 (45.2) 2 (6.5) 7 (22.6) 1 (3.2) 31

Diarrhoea Asthma Diabetes mellitus Hypertension Arthritis Other (unspecified) NO

51 (19.7) 16 (15.2) 3 (1.2) 0 (0.0) 0 (0.0) 3 (2.9) 6 (5.7) 1 (1.0)

54 (20.8) 43 (41.0) 85 (28.3) 41 (15.8) 20 (19.0) 32 (10.7) 300

Total 259 105 2 χ (7) =457.834, p < 0.001, cc=0.561, n=999

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Table 9.6: Self-rated Health Status by Age group Age group Self-rated Health status Good Fair Poor Young Children adults n (%) n (%) 1851 (91.3) 1544 (91.4) 136 (6.7) 41 (2.0) 116 (6.9) 29 (1.7) Other-aged adults n (%) 1678 (81.5) 296 (14.4) 84 (4.1) 2058 Young adults n (%) 241 (46.8) 190 (36.9) 84 (16.3) 515 Old Elderly n (%) 63 (30.0) 86 (41.0) 61 (29.0) 210 Oldest Elderly n (%) 20 (30.8) 24 (36.9) 21 (32.3) 65

Total 2028 1689 χ2 (7) =1,266.065, p < 0.001, cc=0.402, n=6,565

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Table 9.7: Predictors of Self-rated Health Status of Jamaicans Predictors Age Upper class †Poor Illness Secondary or tertiary †No formal education lnConsumption Other town †Rural areas Sex (1=Man) Constant
χ2 (7) =1,332.149, p < 0.001; -2 Log likelihood = 3,304.144 Nagelkerke R2 =0.401
Coefficient Std. Error Odds ratio 95.0% C.I.

-0.050 -0.463

0.003 0.158

0.951 0.629

0.946 - 0.956*** 0.462 - 0.857**

-2.102 -0.532

0.103 0.192

0.122 0.587

0.100 - 0.150*** 0.403 - 0.855**

0.565 0.276

0.098 0.114

1.759 1.318

1.452 - 2.133*** 1.055 - 1.646*

0.386 -2.731

0.091 1.123

1.471 0.065

1.231 - 1.757*** -

Hosmer and Lemeshow goodness of fit χ2=23.831, P = 0.882

Overall correct classification = 84.5% Correct classification of cases of self-rated good health status =94.8% Correct classification of cases of poor self-rated health status =38.6% †Reference group *P < 0.05, **P < 0.01, ***P < 0.001

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Table 9.8: Predictors of Self-rated Health status of men in Jamaica Predictors Social Assistance Age Illness lnConsumption Urban areas †Rural area Constant
χ2 (5) =573.649, p < 0.001; -2 Log likelihood = 1,372.047 Nagelkerke R2 =0.397
Coefficient Std. Error Odds ratio 95.0% C.I.

-0.734 -0.051 -2.214 0.315 -0.519

0.322 0.004 0.173 0.109 0.159

0.480 0.951 0.109 1.370 0.595

0.255 - 0.902* 0.943 - 0.958*** 0.078 - 0.153*** 1.107 - 1.696** 0.436 - 0.813** -

0.763

1.288

2.145

Hosmer and Lemeshow goodness of fit χ2=19.746, P = 0.956

Overall correct classification = 87.5% Correct classification of cases of self-rated good health status =97.0% Correct classification of cases of poor self-rated health status =43.1% †Reference group *P < 0.05, **P < 0.01, ***P < 0.001

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Table 9.9: Predictors of Self-rated Health status of women in Jamaica Predictors Age Upper class †Poor Illness Secondary or Tertiary †No formal education lnConsumption Other town †Rural areas Constant
χ2 (6) =729.618, p < 0.001; -2 Log likelihood = 1,918.149 Nagelkerke R2 =0.397
Coefficient Std. Error Odds ratio 95.0% C.I.

-0.048 -0.560

0.003 0.207

0.953 0.571

0.947 - 0.959*** 0.380 - 0.857**

-2.035 -0.551

0.129 0.232

0.131 0.576

0.101 - 0.168*** 0.366 - 0.908*

0.684 0.298

0.130 0.148

1.981 1.347

1.537 - 2.554*** 1.009 - 1.799* -

-4.224

1.478

0.015

Hosmer and Lemeshow goodness of fit χ2=9.579, P = 0.870

Overall correct classification = 82.0% Correct classification of cases of self-rated good health status =92.5% Correct classification of cases of poor self-rated health status =51.6% †Reference group *P < 0.05, **P < 0.01, ***P < 0.001

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Table 9.10: Predictors of Self-rated Health Status of Jamaicans in Urban Areas Predictors Length of time in household Age Illness Secondary or tertiary †No formal education lnConsumption Constant
χ2 (5) =296.347, p < 0.001; -2 Log likelihood = 1,109.989 Nagelkerke R2 =0.305
Std. Error Odds ratio

Coefficient

95.0% C.I.

0.153 -0.045 -1.897 -0.943

0.065 0.005 0.184 0.259

1.166 0.956 0.150 0.389

1.027 - 1.324* 0.948 - 0.965*** 0.105 - 0.215*** 0.235 - 0.646***

0.290 -1.574

0.113 1.567

1.336 .207

1.071 - 1.666* -

Hosmer and Lemeshow goodness of fit χ2=9.235, P = 0.888

Overall correct classification = 82.0% Correct classification of cases of self-rated good health status =95.0% Correct classification of cases of poor self-rated health status =37.1% †Reference group *P < 0.05, **P < 0.01, ***P < 0.001

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Table 9.11: Predictors of Self-rated Health Status of Jamaicans in Other towns Predictors Age Illness lnConsumption Constant
χ2 (3) =316, p < 0.001; -2 Log likelihood = 593.189 Nagelkerke R2 =0.457
Coefficient Std. Error Odds ratio 95.0% C.I.

-.063 -2.311 .505 -1.008

.006 .244 .181 2.142

.939 .099 1.657 .365

.927 - .950*** .061 - .160*** 1.162 - 2.362** -

Hosmer and Lemeshow goodness of fit χ2=4.543, P = 0.805

Overall correct classification = 88.4% Correct classification of cases of self-rated good health status =96.4% Correct classification of cases of poor self-rated health status =51.2% †Reference group *P < 0.05, **P < 0.01, ***P < 0.001

Table 9.12: Predictors of Self-rated Health Status of Jamaicans in Rural Areas Predictors Age Upper class †Poor Illness lnConsumption Sex (1=Man) Constant
χ2 (5) =733.802, p < 0.001; -2 Log likelihood = 1568.072 Nagelkerke R2 =0.445

Coefficient

Std. Error

Odds ratio

95.0% C.I.

-0.051 -0.726

0.004 0.257

0.951 0.484

0.944 - 0.957*** 0.292 - 0.801**

-2.219 0.693 0.608 -4.200

0.147 0.137 0.132 1.551

0.109 2.000 1.837 0.015

0.081 - 0.145*** 1.528 - 2.617*** 1.418 - 2.379*** -

Hosmer and Lemeshow goodness of fit χ2=3.895, P = 0.866

Overall correct classification = 84.7% Correct classification of cases of self-rated good health status =94.3% Correct classification of cases of poor self-rated health status =54.9% †Reference group *P < 0.05, **P < 0.01, ***P < 0.001

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Chapter

10
Introduction

Health Inequality in Jamaica, 1988-2007

Globally, in 1950-1955, life expectancy for women was 47.9 years compared to 45.2 years for men. One-half of a century later, the disparity has increased to 4.2 years (68.1 years for women and 63.9 years for men). In the Caribbean, in the same aforementioned period, life expectancy for women was 53.5 years and 50.8 years for men and 50 years later the disparity has increased to 5.5 years (70.9 years for women and 65.4 years for men). Life expectancy which is an indicator of mortality and to some extent morbidity is also proxy for health status of people. Although there is some morbidity that is not life threatening, it is established that healthy life is not equivalent to longer life. Hence, the World Health Organization developed DALE (disability adjusted life expectancy) to discount life expectancy by lost time due to illness. This showed that developing countries lost 9 years of life expectancy owing to unhealthy years. There has always been a health differential between the sexes in Jamaica[1] Dating back as far as 1880, which was the first time that life expectancy data was recorded for men and women in the island, women were outliving men. The Demographic Statistics for Jamaica showed that for 1880 and 1882 women lived approximately 3 years more than men and 122 years later (2002-2004), they outlived them by 6 years, which is an additional 3 years. Globally, women live longer than men by 8 years which is 2 years more than that of the life expectancy gender differential in Jamaica. They are not only living longer, but enjoying greater quality of life [2] A study of 3,009 older people done in 2007 in Jamaica [3] revealed that elderly women had 227

a higher quality of life (3.3 ± 2.2) than men (2.8 ± 1.8; p value = 0.001), which concurred with the earlier work done by the WHO in 1998. But, studies that have examined well-being have shown that men experienced a greater economic wellbeing than women[4], despite not having a higher subjective wellbeing. What is explaining this health differential between the sexes? Life expectancy which is calculated using mortality data indicate that men are experiencing particular pathogen causing diseases which are accounting for the greater increase in mortality and lower life expectancy than women. An epidemiological profile of selected health conditions and services in Jamaica for 1990-2002 was conducted by the Health Promotion and Protection Division, Ministry of Health in 2005 which revealed that malignant neoplasm was the leading cause of death in Jamaica. It was 39% greater for men than women. The second leading cause of death, cerebrovascular disease, was 14% higher for men than women; heart diseases rate was 71.2 per 100,000 for men and 66.1 per 100,000 for women, and diabetes mellitus was greater for women than men. The statistics revealed that mortality caused by diabetes mellitus was 64% higher for women than men. Jamaica is not unique in regard to i) women outliving men, ii) particular morality is greater for men than women, and ii) some of the leading causes and death are gender specific[2] The issue of higher mortality differential between the sexes at older ages begins with boys suffering more illnesses and injuries than girls [5] The World Health Organization (WHO) offered a potent finding that age-and sex differential in mortality dates back to 1955[2] This indicates that higher mortality in the world’s population tend to favour men, and justifies the longer life that they live compared to men. In demography, life expectancy is used to measure health. But this approach fails to capture health as one can be alive but enjoy optimum health – living with varying levels of

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morbidity. There is an argument that morbidity is accounted for in mortality, and this so. However, some dysfunctions are not death causing, and so quality of life (health) will be lower with these health conditions. It is owing to this reality that the World Health Organization (WHO) introduced what is known as healthy life expectancy which discounts life expectancy by morbidity. Healthy Life Expectancy One of the drawbacks to the use of life expectancy is its absence to capture ‘hale’ years of life. Traditionally when life expectancy is measured, it uses mortality data to predetermine the number of years of life yet to be lived by an individual, assuming that he/she subscribes to the same mortality patterns of the group. The emphasis of this approach is on length of life and not on the quality of those years lived. Hence changes in life expectancy are primary due to mortality movements, and imply changes in external conditions of the socio-biological environment. These changes include the components of public health, the physical milieu, and technological/medical advancement. With all the aforementioned conditions that have improved over the last century, increased life expectancy in the world is not surprising to scholars. One way of evaluating population ageing in the world or in any geopolitical space is ‘life expectancy’. Today, it should come as no surprise to people that many developing nations have been experiencing increased gains in additional years of life for members with its population in comparison to 20th century. Associated with ageing are high probability of increased dysfunctions and the unavoidable degeneration of the body. This explains why it is germane to analyze healthy life expectancy and not merely life expectancy. Healthy life expectancy is defined as the number of years that an individual is expected to live in ‘good’ health. Technological advancement is

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able to prolong life, but it is not able to remove morbidity and its deterioration in quality of lived years of the individual. Thus, while life expectancy in the Caribbean is increasing and that this is in keeping with the rest of the world, there is a simultaneous increase in chronic diseases and resurgence of infectious disease. This reality highlights the disparity between quantity of years lived and the quality of those lived years because of sociopsychological conditions- such as loneliness, bereavement, social support (or the lack of), low self-esteem, and low selfactualization and so on. In evaluating health or wellbeing, we must seek to examine more than just the number of years that an individual is likely to survive as we should be concerned about the quality of those years. Even though, life expectancy is an indicator of health, the new focus is on healthy life expectancy. Based on the Healthy People 2010, the new thrust is on increasing quality of years of life. In attempting to capture ‘quality of years lived’, in 1999, the WHO introduced an approach that allows us to evaluate this, by the ‘disability adjusted life expectancy’ (DALE)[6] DALE does not only use length of years to indicate health and wellbeing status of an individual or a nation, but incorporate the number of years lived without disabilities. DALE is a modification of the traditional ‘life expectancy’ approach in assessing health. It uses the number of years lived as its principal component. This is referred to as ‘full health’. In addition, the number of years of ill-health is weighted based on severity as another component in the equation. This is then subtracted from the expected overall life expectancy to give what is referred to as years of hale life. Embedded in this approach is the adjustment of years lived in ‘ill-health’. Having arrived at ‘healthy life expectancy’, the WHO has found that poorer countries lost more from their ‘traditional life expectancy’ than developed nations. The reasons forwarded by

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the WHO are the plethora of dysfunctions and the devastating effects of some tropical diseases like malaria that tend to strike children and young adults. The institution found that these accounted for a 14 percent reduction in life expectancy for poorer countries and 9 percent for more developed nations[6] This is in keeping with a more holistic approach to the measure of health and wellbeing with which this study seeks to capture. By using the biopsychosocial model in the evaluation of wellbeing of aged Jamaicans, we will begin to understand factors that are likely to influence the quality of lived years of the elderly, and not be satisfied with the increased length of life of the populace. Looking at the life expectancy data for Jamaica, the figure is 74.1 years for both sexes[6] but by using healthy life expectancy it is 65.1 years[6] Here life expectancy has been increasing at a faster rate than ‘healthy life expectancy’. Therefore, Jamaicans are expected to spend some 9 years of their life in ‘poor health’. In summary, the use of life expectancy to measure health is inadequate and so morbidity must be taken into consideration. When life expectancy is discounted by morbidity, it provides an account of the healthy life expectancy of an individual. Hence, the use of life expectancy to indicate health for men and women is equally insufficient in health analysis. It is evident from statistics on life expectancy and particular diseases causing mortality that men are experiencing a lower health status, and what accounts for this reality? Within the context of the aforementioned issues, and the fact that medical health care seeking has increased from 54.6% in 1989 to 66.0% in 2007 and that there is a decline of 5.7% over 2006 (Table 10.1), is this offering some explanation the gender differential in health status? Although less Jamaicans are seeking medical care of those who reported illnesses, 27.1% more Jamaicans reported dysfunctions (Table 10.1), suggesting that there is greater health differential between the sexes. Hence, for this study, medical seeking behaviour, self-reported ill-health, and gender differential in medical seeking

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health care and self-reported ill-health will be examine to provide a better understanding of the healthy life expectancy of the sexes in Jamaica. Materials and Method The current research used secondary data. The data constitute statistics from the Planning Institute of Jamaica and the Statistical Institute of Jamaica (in Jamaica Survey of Living Conditions, JSLC) and Ministry of Health Jamaica (MOH). The data were extracted from the JSLC on medical care seeking behaviour, self-reported illness (or ill-health) and the gender composition of those who reported ill-health. The Ministry of Health’s Annual Report provided data on actual percentage of Jamaicans who visited public hospitals, which was contrasted by the JSLC’s self-reported visits to public hospitals in order to further examine the gender differentials on subjective ill-health. This study used 19 years of published data extracted from the JSLC (1988-2007). The JSLC was born out of the World Bank’s Living Standard Survey. The JSLC began in 1988 when the Planning Institute of Jamaica (PIOJ) in collaboration with the Statistical Institute of Jamaica (STATIN) adopted with some modifications of the World Bank's Living Standards Measurement Study (LSMS) household surveys. The JSLC has its focus on policy implications of government programmes, and so each year a different module is included, evaluating a particular programme. The JSLC is a self-administered questionnaire where respondents are asked to recall detailed information on particular activities. The questionnaire covers demographic variables, health, immunization of children 0 to 59 months, education, daily expenses, non-food consumption expenditure, housing conditions, inventory of durable goods, and social assistance. Interviewers are trained to collect the data, which is in preparation of the household members. The survey is usually conducted between April and July annually. Furthermore, the instrument is posted on the

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World Bank’s site to provide information on the typologies of question and the (http://www.worldbank.org/html/prdph/lsms/country/jm/docs/JAM04.pdf). Ministry of Health is the body which is constituted by statutes to regulate all health institutions in the country. The Ministry of Health (MOH) collects statistics on health, health services, health utilization, health related matters, and carry out health mandate of the government. MOH has decentralized its operations. The island is sub-divided in four regions (South-East; North-East; Western, and Southern), which emerged owing to the passage of the National Health Service Act of 1997. Each region operates as a semi-autonomous regional body under the general directs of the central Ministry of Health, which is subject to the directions of the Minister of Health. The central Ministry of Health collates all the data sent it by the four health authorities in country. Therefore, data revealed in the Annual Reported of the Ministry of Health, Jamaica, reflect actual accounts of the health matters in the country. Scatter diagrams and best fitted lines were used to examine correlations between different variables, and percentages were also utilized to evaluate events over two decade (1988-2007).

Measure Gender is being male or female. Gender differential is the disparity between self-reported ill-health of male or female. Medical Care Seeking Behaviour denotes the proportion of self-reported cases of visits for seeking medical care of those who indicated ill-health. Self-reported Illness is the percentage of people who have reported cases of dysfunctions (illhealth or health conditions) as indicated by a respondent in a 4-week reference period.

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Poverty is measured using the poverty line. The poverty line estimate is particular attainable consumption expenditure in excess of a minimum necessary level of expenditure on a representative bundle of necessary goods and services valued at germane prices. (JSLC 2008) Results Some scholars may want to believe that the use of subjective data on health (self-reported illhealth) cannot be used to proxy health as it is not a good estimate of actual health status. In order to remove this myth, the researcher will examine the actual figures provided by the Ministry of Health on visits to public health care facilities and those garnered by the Jamaica Survey of Living Conditions (JSLC). The JSLC is an annual probability sampled survey which collects data from Jamaicans based on their recollection of events (self-reported). Based on Table 4, self-reported health as indicated by the JSLC is a good proxy of visits. The data revealed that in 1997, the difference between Jamaicans recall of events and those actually happened as recorded by the Ministry of Health was marginally different (1%). Some 7 years later (2004), the difference between same phenomena was 6.1% suggesting that subjective assessment of health is a good proxy for actual health. It is within this context, that the researcher will examine self-reported health data from JSLC to understanding health differential between the sexes in Jamaica. During the periods of the greatest double digits inflation in history of Jamaica (early 1990s) (Table 10.2) in particular inflationary rates that were in excess of 25% (1990-1995), Jamaicans reported the lowest percentages in ill-health (health conditions). Moreover, in 1991 when inflation was at it peaks, the prevalence of poverty stood at its highest (44.6%), and the data showed that self-reported illnesses were 13.7%. This figure was the fifth highest selfreported ill-health in an 18 year period (1989-2007). In the unprecedented inflation of 1991 234

(80.2%), less men sought medical care (12.0%) over 1990 (16.35) compared to 15.0% in 1991 and 20.3% in 1990. In 1990, it was the first time in the history the of nation that inflation rose to in excess of 20% and self-reported illness reached its maximum of 18.3%, and medical care seeking behaviour was at its lowest (38.6%). In addition, in 1990, both sexes sought the most medical care (Table 10.3). Two years later (1992), inflation rate fell by 49.9% (to 40.2%) over 1991 which explains the rationale for the 24.0% decrease in prevalence of poverty; self-reported ill-health declined by 22.6%, ownership of health insurance increased so to were people seeking medical care and the private health care utilization. The irony here is that 17.5% less men reported accessing medical care for their ill-health and 24.7% less women. This indicates that more of those people who did not report ill-health visited private health care facilities for medical care. In 1993, inflation declined further by 25.1%; poverty saw a reduction of 28.0%; self-reported health conditions increased by 13.2%; health insurance coverage increased by 12.2%; number of people seeking medical care increased by 1.8%. In that same period, the number of women who sought care was 3.8 times more (19.5%) than men (5.1%). Hence, high inflation was reducing visits for medical care and another matter which emerged from the data during that period, that those who attending public hospitals began reducing their visits while private hospital users, increased utilization (Table 10.2). There is a paradox post-2005 as inflation increased by an unprecedented 194.7% in 2007 over 2006 and this explains a corresponding decline in the number of persons who sought medical care (by 5.7%). Nevertheless, the number of men who visited health care facilities increased in the period by 21.2% and the number of women was 1.24 times more than men. The data show that in the last 17 years, women place more emphasis on their health than men. Between 1988 and 2007, it was only on one occasion that men have indicated having

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sought more medical care than women (in 1997) (Table 10.3). The difference between men seeking medical care and that of women was 0.7%. If health seeking behaviour is a proxy for preventative care, then it would appear that they were more health conscious. This is the not the case as in the same period, then spent more days receiving care (mean of 11 days) compared to 10 for women. Hence, this increased in health seeking behaviour was owing to curative and preventative care. Nevertheless, over the studied period, severity of care for both sexes has been reality the same. Using mean number of days men received care for illness/injury, the difference is minute, suggesting that severity of illness between the sexes in Jamaica is the same. Another interesting finding that emerged from the data is the narrowing of the gap between public health care utilization and private health care utilization in the nations, suggesting that costing of living is accounting for more visits to public care facilities. Embedded in those findings is the affordability in people’s decision to seek medical care. This indicates that there are some other conditions that are interfacing with men’s and women’s decision to visit health care facilities for care outside of prices (inflation). Results: Bivariate Analyses Percentage of People Seeking Medical Care by Percentage of People reporting Illness On examination of Figure 10.1, it was revealed that a negative correlation exists between number of people who sought medical care and percentage of people who reported ill-health. This indicates that as more people report health conditions, less of them are likely to seek medical care. Furthermore, 16.3% of the variability in people seeking medical care can be explained by illness, suggesting that ill-health is not a good reason for Jamaicans visiting health care practitioners. On further investigation of people seeking medical care and self-reported illness/injury, data (Tables 10.2, 10.3) revealed that on the occasion when the highest percentage

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of illnesses were reported, the least number of person sought care for those conditions. This irony was equally the case for men (16.3%) as well as women (20.3%) (Table 10.3). Percentage of People Seeking Medical Care by Prevalence of Poverty On examination of a scatter diagram; it was observed that there is a negative correlation between the percentage of people seeking medical care and prevalence of poverty. The best fit line revealed that 57.6% of why people seek health care in Jamaica is determined by poverty (Figure 10.2). Hence, people are highly likely to visit health care facilities in periods of low poverty and vice versa. This indicates that medical care is not simply about ill-health, it is equally determined by affordability, suggesting that people will switch to home care in periods of increased poverty. Irrespective of this knowledge, is there is sex disparity in regard to seeking medical care and reporting illness?

Percentage of Men Seeking Medical Care by Percentage of Men reporting Illness Generally 16.3% of why Jamaicans visit health care facilities in search of care is owing to their health conditions. However, for men, 35.4% of why they sought medical care was due to illhealth as 35.4% of the variability in men seeking medical care can be explained by medical care (Figure 10.3). On decomposing the data, when the least percentage of men sought medical care assistance (37.9%), the most percentage of them reported illness (16.3%) (Table 10.3). Furthermore, when the lowest percentage of men reported ill-health (health conditions/injuries) (7.4%), this was in 60% of those seeking more medical care. However, in 1999 and 2004, low self-reported illness was correlated with relatively high health seeking behaviour.

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Percentage of Women Seeking Medical Care by Percentage of Women reporting Illness Health (medical) care seeking behaviour of women is lowly correlated with self-reported illness (injury) (Figure 10.4). The scatter plot revealed that generally, the more women reported health conditions the less likely they are to seeking medical care. Some 8.8% of the variability in medial care seeking behaviour of this cohort can be explained by a change in self-reported health conditions. Self-reported illness of women accounted for 54% less of the explanatory reason for seeking medical care compared to that of the both sexes (16.3%), suggesting that women’s health care behaviour is driven by other factors than ill-health. There are some similarities between health care seeking behaviour and self-reported illness of both sexes as when women reported the least percentage of health care seeking behaviour, this was corresponding to the most reported health conditions (Table 10.3). Furthermore, when the least percentage of ill-health was reported, this earmarked 59th percentage of the highest seeking medical care behaviour of women. These were also the case for men. Deconstruction the Self-Reported Health Status of Jamaicans by Gender, 1989-2006 Over the last 2 decades (1988-to-2007), a small proportion of Jamaicans have reported illness (or dysfunction) (Table 10.5). This has been has high as 168 per 1,000 (in 1989) to a low of 88 per 1,000 (in 1997), and the figure was 155 per 1,000 in 2006 (Table 10.5). On deconstruction the population self-reported health status, it was revealed that women continue to report more health conditions than men. In 1989, there 123 women (or women) who reported health conditions to 100 men (or men), and in 2004, the ratio was as high as 153 women per 100 men. This indicates that 53% more women reported health conditions than men in the latter year and there was an increase of 30% more women reporting dysfunctions over the 2 decades. Over the studied period, in 1992, the disparity in self-reported health conditions between men and women was

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very close of which there were 114 women to 100 men as it relates to self-reported health conditions. On the other hand, over the last decade (1997-to-2006), the disparity was 136 or 153 women per 100 men, and in the last 2 years the value has been relatively stable (136 or 137 women per 100 men). Percentage of People Seeking Medical Care by Percentage with Health Insurance Health Insurance is one indicator of people’s intent to access care. On examination of the data (Table 10.2), only a small percentage of Jamaicans in 2007 had health insurance (21.1%). This meant that more people who will become ill would need to meet their medical expenses out of savings, current income and assistance from social support agent(s). Table 10.2 revealed in 8.6% of Jamaica had health insurance coverage during the period when the inflation rate was at its peak (80%) and when it fell to 40.2%, health insurance coverage increased by only 0.4%. Further investigation of health seeking behaviour and health insurance coverage showed that the ownership of health insurance was positively related to health seeking behaviour. A bivariate correlation between the two aforementioned factors revealed that 56.1% of the variability in people seeking medical care was as a result of ownership of health insurance (Figure 10.5).

Ownership of Health Insurance and Prevalence of Poverty Poverty does not only mean ones inability to purchase consumption items, but also nonconsumption items such as health insurance. On examining a scatter diagram with a best fit line to establish any correlation between the two aforementioned variables, it was observed that a moderately strong correlation existed (R-squared = 0.597) – Figure 10.5. This means that 60% of the variability in ownership of health insurance can be accounted for by prevalence of poverty, suggesting that poor is less likely to have health insurance coverage.

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Discussion In the conclusion of the health chapter in one of the JSLC’s reports
[8]

it reads “Gender

differentials with respect to self-reported illness and health seeking behaviours need to be investigated.” This is the rationale for this study, to provide an assessment of differences in subjective health and medical seeking behaviour of men and women in Jamaica. Globally, regionally and in particular Jamaica, women seek more health care than men[1,
2, 4-7]

This is not alarming as it commences from at childhood. In 1998, one health organization

wrote that girls are less likely to be injured and have broken bones compared to boys[2], which continue during the life span. So when the mortality rates show a higher rate for men than women [2, 6], this is just a continuation of early socialization. Health, therefore, is gender bias. One of the rationales for the emphasis on health care by women is reason for male’s abstinence, the culture. Within many cultures, men are not to display any form of weakness which includes ill-health. This culturalization has embedded in boys and avoidance of speak of illness/injury and the image of ill-health is negative and is primarily feministic in nature. This is not limited to Jamaica or African descendent societies as it is equally the case in European geopolitical zones such as Norway[9] Many cultures view (image) of health is the absence of diseases and this is sometimes linked to cure of the gods or moral rationale, suggesting that ill-health is a weakened biological state. Men who are culturalized to be strong and macho must now balance ill-health within a plural culture. The 21 st century has seen the exponential increase in life expectancy of men compared to women in nineteenth and earlier centuries, but what about high mortality for this group. There has always been feminization of life expectancy in Jamaica since 1880 (Table 1) and the disparity in life expectancy has double from 1880-1882 to 2002-2004 from 3 years to 6 240

years respectively. Life expectancy which is an indicator of health does not only speak of longer life, there are also some cultural changes that account for this increased life span, the social milieu. Despite the advancement in medical technology, men continue to outnumber women in particular mortality rates. These include heart disease and neoplasm to name a few non-

communicable diseases. Heart disease and neoplasms are caused through either lifestyle behaviour or heredity, and the former explains more of heart disease than the latter. Globally, the fact that women outlived men by 8 years and in Jamaica by 6 years, lifestyle behaviour undoubtedly is explaining the higher morbidity in heart diseases of men. Life style behaviour is expressed in health seeking behaviour, the purchase of health insurance, preventative care and not curative care. Jamaica women continue to seek more care than men, and this concurs with the finding so other studies[2, 3, 10, 11] Women do not take their health for granted as society labels them with the nurturing role of children as well as ascribe them softer tasks. This means that health and ill-health are interpreted and viewed from within the perspective of personal experiences, and expectations. It is through the socialization process which is carried out by mothers (women) that ill-health and health will be defined which accounts for ones expectation and some percentage of how the world is viewed and interpreted by people. In a qualitative study that was done in Nairobi slums, the authors found a strong correlation between severity of illness and health seeking behaviour of children[12] These children do not seek care of themselves, but are taken for medical care by their mothers. Another study on street children (ages 5 to 13 years), who take themselves, like the Nairobi study attended health care institutions for care dependent on i) severity of illness and ii) if it stops their economic livelihood[13] Eight percentage of the sampled population of the latter study (in 241

Pakistan) were boys (men). This speaks to the image of health as viewed by men, and when care is sought by them. Ill-health, therefore, based on the image of health seen through the lens of men is weak, breaches machoism and borders on the fringes of feminism. Within the homophobis world, despite the gradual reduction of the degree in some societies, men (or boys) do not want to be labeled weak, homosexual or effeminate. Hence, there is dialectic here as men want to live which means that they must address ill-health and at the same time they must appear to be macho. Men are less likely to both report ill-healths as well as seek medical care because of its image and social labels that they may ascribe to them by society. Women also play a part in this process as they grown their boys to be strong, ‘tough’, and that they should not show weakness. Ill-health is a weakness (or negative health), and so women on seeing men visiting health practitioners especially if this is frequent construe this as weak, but his is not ascribe to a female for doing the same thing. Medical care seeking behaviour is, therefore, construed as indicating ill-health (curative care) and not preventative care for men. Chevannes[14] wanting to explain how men are as they are, opined that early socialization played a critical role in shaping men’s masculinity, image of self and interpretation of the world around them. The image of health as viewed as far back as prehistoric society is that of sickness, a curse, a plague, a weakness and a state of biological incapacitation. Men who are culturalized to be strong cannot afford to be seen as weak or incapacitate by their peers or the opposite sex as the society removes the acclaim of greater, power and prestige from any such male. This means that men must now report and display less signs of ill-health (weakness), and the only time that illness must be shown is in times of severity which is close to death. 242

Jamaican men displaying low medical care seeking behaviour as cultural underpinnings, and so does their unhealthy lifestyle practices. Unhealthy lifestyle is undoubtedly explaining high mortality of men than women. This dates back to prehistoric society, when men must hunters, heroes, warriors and fierce to defend themselves, their tribes and women. Such events meant that they would take more risk than women, and this has continued during the centuries. Although vast amount of information are available on health and health treatment, men continue to indulge in risky behaviour which accounts for their high morbidity and mortality in some conditions. The literature speaks to 80% of injuries and between 30-40% of cases with

cardiovascular conditions and diabetes mellitus could have been prevented by lifestyle practices[5] This explains much of the health conditions and increased in reported ill-health and medical care seeking behaviour. What is the role of education in health differential in the sexes? Education which is well established has directly correlated with better health[15-22] does not remove early culturalization by family, peer groups and religious affiliations. The general education level of the Jamaican populace has been improving since the last 3-decade, but this does mean the remove of the gender bias health image or stigma of weakness associated with illness. In 1989, 54.6% of Jamaicans sought care for ill-health and in 2007 that figure has increased by 9.9% (to 60%). In the same period that rate of increase for women was 29.0% compared to 41.1% for men. Nevertheless, in 2007, for every 100 men that sought care for illhealth, 108 women sought medical care. Although, we cannot divorce health from the social milieu, more men are seeking medical care for illness and this accounts for the faded difference between the mean numbers of days spent for care in both sexes. The 21 st century has aided men in their recognition for the need to seek medical care for ill-health, in spite of traditional cosmologies [23, 24]

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In contemporary societies, illness for men is not tied to health conditions such as neoplasm, heart disease, hypertension, mellitus diabetes and stroke, but is synonymous to sexuality which is a legacy of their socialization[14, 23-29] A medical doctor ascribes to the 21 st century, gender roles that are tied to sex (biological category). This means that being male is linked to being the stronger sex, fertile, and sexual prowess. Society has not removed from its men that gender stereotype, and so the image of health for them is substantially tied to sexuality. Men, therefore, do not see themselves as ill, unless they are impotent. Culturally, because impotency and infertility are a curse, men will not openly speak about those matters or/and other heath conditions. Again, male means strength, sexual potency, and these are all at the other end of the pendulum of ill-health. This explains the reason for the lower purchase of individual health insurance as this symbolizes weakness or preparation of some negative conditions. In spite of this reality, over the last one-half of a decade, there has been an increase in health insurance coverage and health seeking behaviour of both sexes. As of 2007, 2.1% more women had health insurance coverage than men (20.1%), which was more than the national average of 21.1%. Again this speaks to the differences in image of health held sexes and how their decision is based on this view. Health insurance is a component of lifestyle practices justify the advantages that women enjoy compared in men concerning health status. This is also reinforced in the fact (in 2007) that for every 133 women who indicated that they were unable to afford to seek medical care 100 men[1], showing that men are naturally, owing to their culturalization, unwilling to seek medical care and this is evident in their lifestyle practices, purchase of health insurance, reporting ill-health and visits to health care institution for preventative and curative care[1, 5] According to one scholars income buys health[30], which has some merit. The merit to this argument is linked to the fact that income affords one the ability and option to purchase better

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foods, medical care, a particularly good physical environment that are all positively correlated with good health[3, 15-18] There is a negative side to affluence and income, as it afford particular lifestyle that retard good health. Income affords one the lifestyle to purchase cigar, tobacco, speedy cars, and in the process remove the disadvantage of low income or poverty. In a study done by a group Caribbean scholars of 1,338 Jamaicans (ages 15 to 99 years), they found that greatest subjective psychosocial wellbeing was had by the middle class followed by the wealth and lastly by the poor[31] Embedded in the income and health debate, is the difficulty of the poor in seeking medical care (curative and preventative care). This study has shown that there is a moderately strong correlation between seeking medical care and prevalence of poverty, suggesting that poor men are even less likely to seek care than those in the middle to upper class. When poverty is coalescing with the cultural biases and image of health, men are likely to suffer more as they must balance ill-health which is a weakness with in affordability. The issue of affordability is seen in the percentage of those in the poorest quintile with health insurance in 2007 (6.6%) compared to 12% in quintile 2, 18% in quintile 3, 22.7% in quintile 4 and 43.4% of those in the wealthiest quintile. Embedded in this disparity is the poor’s inability to plan for the eventuality of ill-health coupled with deplorable reality of the physical environment. This physical environment is such to account for ill-health[32], and when poor nutrition is added to this situation the poor will become even more ill. Concluding Comments In summary, illness is still seen and interpreted by Jamaicans as punishment and negative health, and this explains their low self-reported health conditions and health care seeking behaviour. Men who are product of the society must abide within the image of its dictates, which justifies 245

their unwillingness to seek medical care, report illness, purchase health insurance coverage and create an image of weakness. In spite of this reality, men have become more involved that women in seeking medical care over the last 17 years. This means that the society is becoming increasingly more cognizant that ill-health is more than negative health or is simply equivalent to weakness, female or less macho men. Although men are substantially driven by health conditions to seek medical care than women, they are becoming more involved in health care treatment.

Recommendation Further efforts are needed to eliminate more of the barriers of the negative image of health and the use of medical services for ill-health in Jamaica. Medical practitioners, health care workers, social workers and researchers must integrate the image of men in their treatment, and create an atmosphere which is conducive to health care for men. A single prevalence study is needed to ascertain the influence of each of the identified variables in this study and others in order to understand the role of poverty, health insurance, ill-health, on the health seeking behaviour of Jamaicans, the media, education as well as confounding variables such as gender, age, religiosity, area of residence and subjective social class. In addition, a study is necessary to ascertain whether the increased in self-reported health is owing to unemployment, and how much of ill-health is accounted for by psychological conditions.

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References 1. Planning Institute of Jamaica (PIOJ), and the Statistical Institute of Jamaica (STATIN), 1990-2008. Jamaica Survey of Living Conditions, 1989-2007. Kingston: PIOJ, STATIN. 2. World Health Organization, (WHO), 1998. The World Health Report 1998: Life in the 21st Century, A vision for all. Geneva: WHO. 3. Bourne, PA., 2008. Medical Sociology: Modelling Well-being for elderly People in Jamaica. West Indian Med J, 57(6):596-04 4. Rudkin, L., 1993. Gender differences in economic wellbeing among the elderly of Java. Demography, 30:209-226. 5. The Health Promotion and Protection Division, Ministry of Health Jamaica (MOH), 2005. Epidemiology Profile of Selected Health Conditions and Services in Jamaica, 1990-2002. MOH. 6. WHO, 2000. WHO Issues New Healthy Life Expectancy Rankings: Japan Number One in New ‘Healthy Life’ System. WHO. 7. Statistical Institute of Jamaica, (STATIN), 2007. Demographic Statistics, 2006. STATIN. 8. WHO, 2003. Healthy life expectancy. Washington DC: WHO. 9. Planning Institute of Jamaica (PIOJ), and the Statistical Institute of Jamaica (STATIN). 2000. Jamaica Survey of Living Conditions, 1999. PIOJ, STATIN. 10. Kaasa, K. 1998. Loneliness in old age: Psychosocial and health predictors. Norwegian Journal of Epidemiology, 8:195-201. 11. Hutchinson, G., Simeon, DT., Bain, BC., Wyatt, GE., Tucker, MB., and E LeFranc, 2004. Social and health determinants of wellbeing and life satisfaction in Jamaica. International Journal of Social Psychiatry, 50 (1):43-53. 12. Hambleton, IR., Clarke, K., Broome, Hl., Fraser, HS., Brathwaite, F., and AJ. Hennis, 2005. Historical and current predictors of self-reported health status among elderly persons in Barbados. Revista Panamericana de salud Pύblic, 17(5-6):342-353. 13. Taff, N., and G. Chepngeno, 2005. Determinants of health care seeking for childhood illness in Nairobi slums. Tropical Medicine and International Health, 10:240-245. 14. Ali, M., and A. de Muynck, 2002. Illness incidence and health seeking behaviour among street children in Rawlpindi and Islamabad, Pakistan – a qualitative study. Child Care, Health & Development, 31:525-532. 15. Chevannes, B., 2001. Learning to be a man: Culture, socialization and gender identity in five Caribbean communities. The University of the West Indies Press. 16. Bourne, P., 2007. Using the biopsychosocial model to evaluate the wellbeing of the Jamaican elderly. West Indian Medical J, 56: (suppl 3), 39-40. 17. Bourne, PA., 2008. Health Determinants: Using Secondary Data to Model Predictors of Well-being of Jamaicans. West Indian Medical J, 57(5):476-481. 18. Longest BB, Jr, 2002. Health Policymaking in the United States, 3rd ed. Health Administration Press. 19. Brannon, L., and J. Feist, 2007. Health psychology. An introduction to behavior and health 6th ed. Thomson Wadsworth. 20. Grossman, M., 1972. The demand for health- a theoretical and empirical 247

investigation. National Bureau of Economic Research. 21. Smith, JP., and R. Kington, 1997. Demographic and economic correlates of health in old age. Demography; 34:159-170. 22. Ross, CE., and J. Mirowsky, 1999. Refining the association between education and health: The effects of quantity, credential, and selectivity. Demography; 36:445-460. 23. Freedman, VA., and LG. Martin, 1999. The role of education in explaining and forecasting trends in functional limitations among older Americans. Demography, 36:461-473. 24. Meryn, S., 2004. Gender Quo Vadis: 21 the first female century: The Journal of Men’s health & gender, 1: 3-5. 25. Spector, RE., 2004. Cultural diversity in health and illness, 6th ed. New Jersey. 26. Barrow, Christine. 1998. Caribbean Gender Ideologies: Introduction and Overview. In Caribbean Portraits: essays on Gender Ideologies and Identities, Ed., Christine, B, Ian Randle Publishers, pp: xi-xxxviii. 27. Chevannes, B., 1999. What we sow and what we reap – problems in the cultivation of male identity in Jamaica. Grace, Kennedy Foundation. 28. Brown, J., and B. Chevannes,1998. Why man stay so – ties the Heifer and loose the bull: an examination of gender socialization in the Caribbean. University of the West Indies. 29. Bailey, W., (ed), 1998. Gender and the family in the Caribbean. Institute of Social and Economic Research. 30. Marmot, M., 2003.The influence of Income on Health: Views of an Epidemiologist: Does money really matter? Or is it a maker for something else? Health Affairs, 21:31-46. 31. Powell, LA., Bourne, P., and L. Waller, 2007. Probing Jamaica’s Political Culture: Main Trends in the July-August 2006 Leadership and Governance Survey, volume 1. Centre for Leadership and Governance, Department of Government, the University of the West Indies. 32. Pacione, M., 2006. Urban environmental quality and human wellbeing –a social geographical perspective. Landscape and Urban Planning, 65:19-30.

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Table 10.1: Life Expectancy at Birth of Jamaicans by Sex: 1880-2004 Average Expected Years of Life at Birth Period: 1880-1882 1890-1892 1910-1912 1920-1922 1945-1947 1950-1952 1959-1961 1969-1970 1979-1981 1989-1991 1999-2001 2002-2004 Man 37.02 36.74 39.04 35.89 51.25 55.73 62.65 66.70 69.03 69.97 70.94 71.26 Woman 39.80 38.30 41.41 38.20 54.58 58.89 66.63 70.20 72.37 72.64 75.58 77.07

Sources: Demographic Statistics (1972-2006) in Bourne, P. Determinants of well-being of the Jamaican Elderly. Unpublished thesis, The University of the West Indies, Mona Campus; 2007.

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Table 10.2: Inflation, Public-Private Health Care Service Utilization, Incidence of Poverty, Illness and Prevalence of Population with Health Insurance (in per cent), 1988-2007 Year Inflation Mean Public Utilization Private Utilization Prevalence of poverty Illness Health Seeking Medical Care Days of Illness

Insurance Coverage

1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

8.8 17.2 29.8 80.2 40.2 30.1 26.8 25.6 15.8 9.2 7.9 6.8 6.1 8.8 7.2 13.8 13.7 12.6 5.7 16.8

NI 42.0 39.4 35.6 28.5 30.9 28.8 27.2 31.8 32.1 37.9 37.9 40.8 38.7 57.8 NI 46.3 NI 41.3 40.5

NI 54.0 60.6 57.7 63.4 63.8 66.7 66.4 63.6 58.8 57.3 57.1 53.6 54.8 42.7 NI 46.4 NI 52.8 51.9

NI 30.5 28.4 44.6 33.9 24.4 22.8 27.5 26.1 19.9 15.9 16.9 18.9 16.9 19.7 NI 16.9 NI 14.3 9.9

NI 16.8 18.3 13.7 10.6 12.0 12.9 9.8 10.7 9.7 8.8 10.1 14.2 13.4 12.6 NI 11.4 NI 12.2 15.5

NI 8.2 9.0 8.6 9.0 10.1 8.8 9.7 9.8 12.6 12.1 12.1 14.0 13.9 13.5 NI 19.2 NI 18.4 21.2

NI 54.6 38.6 47.7 50.9 51.8 51.4 58.9 54.9 59.6 60.8 68.4 60.7 63.5 64.1 NI 65.1 NI 70.0 66.0

NI 11.4 10.1 10.2 10.8 10.4 10.4 10.7 10.0 9.9 11.0 11.0 9.0 10.0 10.0 NI 10.0 NI 9.8 9.9

Source: Bank of Jamaica, Statistical Digest, Jamaica Survey of Living Conditions, Economic and Social Survey of Jamaica, various issues Note: Inflation is measured point-to-point at the end of each year (December to December), based on Consumer Price Index (CPI) NI – No Information Available

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Table 10.3: Seeking Medical Care, Self-reported illness, and Gender composition of those who report illness and Seek Medical Care in Jamaica (in percentage), 1988-2007 Reporting Reporting Mean Mean Seeking Seeking IllnessIllnessDays Days Seeking Health Medical Medical Men Women Of Of Medical Insurance Care Care Illness Illness Year Care Coverage Men Women Men Women NI NI NI NI 1988 NI NI NI NI 44.7 52.8 15.0 18.5 10.6 11.1 1989 54.6 8.2 37.9 39.2 16.3 20.3 10.2 10.2 1990 38.6 9.0 48.5 47.4 12.1 15.0 10.0 10.3 1991 47.7 8.6 49.0 52.5 9.9 11.3 10.7 10.9 1992 50.9 9.0 10.4 13.5 10.7 10.1 1993 51.8 10.1 48.0 54.7 11.6 14.3 10.3 10.4 1994 51.4 8.8 49.0 53.4 8.3 11.3 10.6 10.7 1995 58.9 9.7 59.0 58.9 9.7 11.8 10.0 11.0 1996 54.9 9.8 50.5 58.5 8.5 10.9 11.0 10.0 1997 59.6 12.6 60.0 59.3 7.4 10.1 11.0 11.0 1998 60.8 12.1 57.8 62.8 8.1 12.2 11.0 11.0 1999 68.4 12.1 64.2 71.1 12.4 16.8 9.0 9.0 2000 60.7 14.0 57.4 63.2 10.8 15.9 9 10 2001 63.5 13.9 56.3 68.2 10.4 14.6 10.0 10.0 2002 64.1 13.5 62.1 65.3 NI NI NI NI 2003 NI NI NI NI 8.9 13.6 11.0 10.0 2004 65.1 19.2 64.2 65.7 NI NI NI NI 2005 NI NI NI NI 10.3 14.1 9.7 10.0 2006 70.0 18.4 71.7 68.8 13.1 17.8 10.6 9.3 2007 66.0 21.2 62.8 68.1 Source: Jamaica Survey of Living Conditions, various issues NI - No Information was available

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Table 10.4: Public Health Care Visits (using the JSLC, data) and Actual Health Care Visits (using Ministry of Health Jamaica, data), 1997 and 2004 Public Health Care Visits in Jamaica Year 1997 Actual Visits, MOH1 % 33.1 Self-reported Visits, JSLC % 32.1

2004

52.9*

46.8

Source: Ministry of Health Jamaica and the Jamaica Survey of Living Conditions (JSLC)
1

The Percentages of Actual visits were computed by author

*Preliminary data were used to calculate this percentage

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Table 10.5: Self-reported Health Status per 1,000 by Population, Men and Women; Sex-Ratio of Self-reported Health Status, and Female to Male Ratio of Self-reported Health Status, 1989-2006 Year Self-reported Health Status per 1,000 Male-to-Female Female-to-Male ratio ratio of Selfof Self-reported Health reported Health Status Population Men Women Status

1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

168 183 137 106 120 129 98 107 97 88 101 142 134 126 114 122 155

150 163 121 99 104 116 83 97 85 74 81 124 108 104 89 103 131

185 203 150 113 135 143 113 118 109 101 122 168 159 146 136 141 178

81 80 81 88 77 81 73 82 78 73 66 74 68 71 65 73 74

123 125 124 114 130 123 136 122 128 136 151 135 147 140 153 137 136

Computed by Paul Andrew Bourne from Jamaica Survey of Living Conditions from various years

253

70.00

60.00

Seeking Medical Care

50.00

40.00

R Sq Linear = 0.163

30.00 8.00 10.00 12.00 14.00 16.00 18.00 20.00

Illness/Injury

Figure 10.1: Percentage of Men Seeking Medical Care by Percentage of Men reporting Illness

254

70.00

60.00

Seeking Medical Care

50.00

40.00

R Sq Linear = 0.576

30.00 10.00 20.00 30.00 40.00

Prevalence of Poverty

Figure 10.2: Percentage of People Seeking Medical Care by Prevalence of Poverty

255

70.00

Health Care Seeking Behaviour of Men

60.00

50.00

40.00

R Sq Linear = 0.354

7.50

10.00

12.50

15.00

17.50

Self-reported Health of Men

Figure 10.3: Percentage of Men Seeking Medical Care by Percentage of Men reporting Illness

256

Health Care Seeking Behaviour of Women

70.00

60.00

50.00

40.00

R Sq Linear = 0.088

10.00

12.00

14.00

16.00

18.00

20.00

22.00

Self-reported Health of Women

Figure 10.4: Percentage of Women Seeking Medical Care by Percentage of Women reporting Illness

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70.00

60.00

Seeking Medical Care

50.00

40.00

R Sq Linear = 0.561

30.00 9.00 12.00 15.00 18.00 21.00

Health Insurance

Figure 10.5: Percentage of people Seeking Medical Care by Percentage with Health Insurance

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21.00

18.00

Health Insurance

15.00

12.00

R Sq Linear = 0.597 9.00

10.00

20.00

30.00

40.00

Prevalence of Poverty

Figure 10.6: Ownership of Health Insurance and Prevalence of Poverty

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Chapter

11

Hospital Healthcare Utilisation in middle-income developing country

Health is a crucible component in any discussion on development, and public-private hospital health care utilisation accommodates this mandate of governments. The aim of the current study is to examine factors that account for people’s hospital health care utilisation in Jamaica, and to ascertain whether there is a difference between public hospital care utilisation and income quintile and area of residence.The current findings revealed that 6 factors determine 35.6% of the variability in visits to public hospital health care facilities utilisation in Jamaica. Two major findings from this study are 1) health seeking behaviour and health insurance coverage are the two most significant factors that determine public hospital health care facilities utilisation, and that 2) the two aforementioned factors and positive affective conditions inversely correlate with public hospital health care facility utilisation. In addition to the above, there is no statistical difference between the utilisation of public hospital health care facilities and area of residence while lower income quintile becomes the greater public hospital health care facilities utilisation has been. The demands for public hospital health care facility utilisation in Jamaica were primarily based on inaffordability and low perceived quality of patient care. The issue of low quality of patient care speaks not to medical care, but to the customer service care offered to clients. The greater percentage of Jamaicans who access private health care is not owing to plethora of services, higher specialized doctors, more advanced medical equipment, or low, but this is due to social environment – customer service and social interaction between staffers and clients- and physical milieu – more than one person per bed sometimes, uncleansiless of the facilities. INTRODUCTION Health is a crucible component in development. The health status of a people does not only mean personal development; but also greater economic development for the nation as healthier people are more likely to produce greater output than those who are ill, accounting for higher productivity and efficiency. Illness or injury means in-voluntary absenteeism from the productive process which accounts again for lowered production at the macro level. A substantial part of a 260

country’s Gross Domestic Product (GDP) per capita each year is loss to illnesses. The WHO has forwarded that between 3 and 10 years of life is loss owing to illnesses [1,2], suggesting that illness reduces not only output by quality of life. Hence, it is not important for observed length of life (ie. life expectancy), but it is imperative to take into consideration loss years owing to illness which means the measure of importance will be health life expectancy. And so, the public health facility can accommodate this mandate of governments. While private health care facilities supply a demand for health care, the average citizen in many countries is unable to afford the medical expenditure of those facilities and so the public care facility is not only the access of the average person is the bedrock upon which the health care system of the society relies. Public-private hospital health care utilisation in Jamaica for over the last 11-years (1996 to 2006) has been narrowing, suggesting that economic wellbeing of population has been falling as the economic cost of survivability has been increasing and this explain the narrowing gap seeing in the hospital health care facility utilisation (Figure 11.1). It is noted in the data that there is decline in medical care seeking behaviour of Jamaicans in 2006 from 70% to 66% in 2007 (In Table 11.2). Although there is an increasing demand of public hospital health care facilities utilisation by those who seek medical care (Table 11.1), within the context of an increase in selfreported illness (by 3.3%) coupled with the dialectic of reduction in medical care seeking behaviour, and decline in public health utilisation (including clinics, Table 1), there is still a positive sign as there was increase in health insurance coverage (from 21.2% in 2007 over 18.4% in 2006). In 2007 inflation increased by 194.7% over 2006 and accounts for this narrowed gap between public and private utilisation of health care in Jamaica. The exponential increase in inflation (194.7%) has accounted for higher cost of living of Jamaicans and has rationalized the

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decline in private health utilisation and the switching to public health care utilisation (Table 3). Furthermore, this goes to the core of the drastic reduction in the bed occupancy at public hospital health care facilities in 2004 over 2003 (by 33.7%), suggesting that the poor’s medical care seeking behaviours are significantly affected in tough times. This is further accounted for in the fact that data on private facilities utilisation for those in the poorest quintile fell by 36.1% in 2007 over 1991 and 37.1% for those in the poor quintile over the same period, while there was an increase in public facilities utilisation for those in the poorest quintile (by 29.8%) and by 53.6% for those in poor quintile for the same period. Inflation is not the only economic impediment that is affecting health care utilisation in Jamaica, as looking at the data on remittances which accounted for the single largest foreign exchange receipt in the nation, this fell by 7.7% in 2007 over 2006 (Figure 11.2). The poor and the poorest were the most affected by the decline in remittances as rate was 22.1% and 16.9% respectively. Despite the reduction in remittances in Jamaica, 41.8% of Jamaican received monies this way, which means that a 7.7% decline of those people whom received remittance affect some 206,522 Jamaicans which include the most vulnerable such as the poor, children, unemployable elderly and youths. When inflation is coupled with reduction in remittances, given that remittance substantially contribute to the economic income for the poor and the poorest quintile more than the other upper quintiles, this mean that health and health seeking behaviour in the poor-to-the-poorest people will take a back seat to consumption expenditure on food and non-alcoholic beverages [3]. Comparatively there has been a marginal increase in private health care facilities utilisation by 6.5% of those in the wealthiest quintile, a substantial increase (by 31%) for those in the wealth quintile (quintile 4), and a mild decline by 0.47% for those in quintile 3 (middle

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quintile). Nevertheless, there is a 3.9% increase in public health care facilities utilisation for those in the wealthiest quintile, while the middle to wealth quintiles showed increases. Therefore, emerging from these findings is a particular social profile of people who attend public health care facilities in Jamaica as in excess of 62% of those in middle-to-wealthiest quintiles attended private health care facilities compared to 66% and more of those in the poor-to-poorest quintile (Table 11.3). In 2007, 50.7% of those in the poorest quintile indicated that they were unable to afford to seek health care for ill/injury compared to 36.7% of quintile 2, 34.4% in quintile 3, 21.4% in quintile and 7.1% of those in the wealthiest quintile. Adults sometimes may not attend medical facilities for care, but they will take their children because they are protective of them. This is revealing about affordability as in 2007, 51.7% of those in the poorest quintile indicated that they sought medical care for their children (0-17 years), 52.7% in quintile 2, 61.2% in quintile 3, 61.8% in quintile 4 and 67.6% in the wealthiest quintile. Is in-affordability an issue in medical care utilisation for those in the poorest to poor quintiles? The mean annual amount spent on ‘food and beverage’ in 2002 by those in the poorest quintile was 50.4 per cent compared to 38.1 per cent of those in the wealthiest quintile. The mean annual amount expended on the same in 2006 rose by 3.6 per cent for those in the former quintiles compared to reduction of 0.1 per cent for those in the latter group [3]. Medical expenditure which is a constituent of non-consumption expenditure was 2.2% for those in the poorest quintile (in 2006) compared to 13.5% of wealthiest quintile. The economic well-being of the poor and the poorest in the population has become even more graved as this is reflected in the inflation rate as it increased by 3 times for 2007 over 2006 [4]. While the down turn the United States economy in particular the Jamaica economy has more than one-half since 2006 (growth in

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GDP at Constant (1996) prices in 2006 2.5 per cent and 1.2 per cent in 2007), those in the poorest quintiles are hard hit by this economic recession, explaining the rationale for the switching to home care or more public care. All the aforementioned arguments omit area of residence, suggesting that this is the same across geographical boundaries. Poverty has been decline since 1991 from 44.6%, when inflation rate was at the highest in the history of the nation (80.2%), to 9.9% in 2007. However, rural poverty which was 71.3% in 2007 saw an 8.5% increase over 2006 (65.7%) within the economic environment of a drastic increase in inflation, cost of living and prices of non-consumption items such as medical care. When we take into consideration the reduction of remittance by 8.7% in 2007 over 2006 (42.3%) and fact that 67% of the elderly (people age 60+ years) dwell in rural zones, remittance represents not only an income but economic living. Is this accounting for any of the narrowing of the gap between public-private hospital health care facility utilisation? And what are the factors which explain public hospital care facilities utilisation in Jamaica? This is the first study in the English speaking Caribbean and in particular Jamaica to seek to examine conditions that explain public hospital health care facility utilisation. Hence, the aim of the current study is to examine factors that account for choice of public hospital care facilities utilisation and to ascertain whether there is a difference between public hospital care utilisation and income quintile and area of residence.
MATERIALS AND M ETHODOLOGY

Data source The current study extracted a sub-sample of 1,936 respondents from a national survey. The subsample constitutes those respondents who indicated having visited public and private hospital health care facilities for medical treatment owing to ill-health. The sample is taken from a larger

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cross-sectional survey, which was conducted between June and October 2002. It was a nationally representative stratified probability survey of 25,018 respondents. The sample (N=25,018 or 6,976 households out of a planned 9,656 households) was drawn, using a 2-stage stratified random sampling technique, involving a Primary Sampling Unit (PSU) and a selection of dwelling from the primary units. The PSU is an Enumeration District (ED), which constitutes a minimum of 100 dwellings in rural areas and 150 in urban zones. An ED is an independent geographic unit that shares a common boundary. This means that the country was grouped into strata of equal size based on dwellings (EDs). Based on the PSU, a listing of all the dwellings was made and this became the sampling frame from which a Master Sample of dwellings were compiled and which provides the frame for the labour force. The survey adopted was the same design as that of the labour force. The national survey was a joint collaboration between the Planning Institute of Jamaica and the Statistical Institute of Jamaica. The data were collected by a comprehensive selfadministered questionnaire, which was primarily completed by heads of households on all household members in Jamaica. The questionnaire was adopted from the World Bank’s Living Standards Measurement Study (LSMS) household surveys and was modified by the Statistical Institute of Jamaica with a narrower focus and reflects policy impacts. The instrument assessed: (i) general health of all household members; (ii) social welfare; (iii) housing quality; (iv) household expenditure and consumption; (v) poverty and coping strategies, (vi) crime and victimization, (vii) education, (viii) physical environment, (ix) anthropometrics measurement and Immunization data for all children 0-59 months old, (x) stock of durable goods, and (xi) demographic characteristics.

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Data were stored and retrieved in SPSS 15.0 for Windows.

The current study is

explanatory in nature. Descriptive statistics were forwarded to provide background information on the sampled population. Following the provision of the aforementioned demographic

characteristics of the sub-sample, chi-square analyses were used to test statistical association between some variables; t-test statistics and analysis of variance (ie ANOVA) were also use to examine the association between a metric dependent variable and either a dichotomous variable or non-dichotomous variable respectively. Logistic regression was used to examine the statistical association between a single dichotomous dependent variable and a number of metric or other variables (Empirical Model). In order to test the association between a single dichotomous dependent variable and a number of explanatory factors simultaneously, the best technique to use was logistic regression. Empirical Model Given a plethora of factors that simultaneously affect health care visits, the use of bivariate analyses will not capture this reality. Therefore, in order to capture those factors that influence visits to public hospital health care facility, we used a logistic regression instead. The regression model examines several factors that might affect visits to public health care facilities. The data source was from the Jamaica Survey of Living Conditions of 2002 on health, consumption, social programme, physical environment, education, public-private hospitalisation utilisation, and crime and victimization. The rationales for the use of 2002 data were (1) it was the second largest national representative survey that was conducted in the history of data collection by the Statistical Institute of Jamaica and the Planning Institute of Jamaica to assess policy impacts (25,018 respondents), and (2) it was inclusive of issues on crime and victimization, and physical environment that were not in the post-2002 survey, nor the preceding

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years. Although there are more recent data (2004 to 2007), these have excluded many of the factors that are present in the 2002 data (that is physical milieu, crime, victimization and mental health), and wanting to establish factors that influence health care, we needed more possible factors that less as well as crime and victimization as these are crucible issues that have been facing the country increasingly since 2002. Ergo, the 2002 consist of more possible factors that determine people’s decision to visit public hospital health care facilities utilisation compared to private hospital health care facilities utilisation. Explanatory factors include psychological factors conditions self-reported health insurance coverage; area of residence; educational level; and other variables. specification for the model was: VPHCF i = ƒ (αjiDEM i, βjiPSYi , ƏP mci , πSS i , γjiHSBi, εi) (1) The basic

Where VPHCF i is visits to public or private hospital health care facilities of person i is a function of demographic vector factors, DEM i; psychological factors of person i, PSYi, medical expenditure, P mc; social support of individual i, SS i; health seeking behaviour of person i, HSBi; εi is the residual term. Αji, βji, γji, are coefficient vectors for person i of variables j and Əi, π, are coefficient of vector for person i. VPHCF i is a binary variable, where 1= self-reported visits for public hospital health care facilities for medical care and 0=self-reported visits to private hospital health care facilities. [I am not so clear on this sentence]. Measure Public Hospital Health Care Utilisation variable measures the total number of self-reported cases of visit to either public hospital health care facilities or private hospital health care facilities in the last 4-weeks (whereby the survey period is used as the reference point). Public Hospital

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Health utilisation was dummied to read 1=visits to public hospital health care facilities, and 0=private hospitals health care facilities. Income Quintile Categorization. This variable measures the per capita population income quintile that each individual is categories. There are 5 categories, from the poorest to the wealthiest income quintile. For the purpose of the regression analysis, the variable was measured as: 1= Middle Quintile, 0=otherwise

1=Two Wealthiest Quintiles, 0=otherwise The referent group is the two poorest income quintiles Crowding. This is the total number of persons living in a room with a particular household. , where represents each person in the household and r is is the number of rooms excluding kitchen, bathroom and verandah. Age: This is a continuous variable in years, ranging from 15 to 99 years. Positive Affective Psychological Condition: Number of responses with regards to being optimistic about the future and life generally. Negative Affective Psychological Condition: Number of responses from a person on having loss a breadwinner and/or family member, loss of property being made redundant, failure to meet household and other obligations. Private Health Insurance Coverage (or Health Insurance Coverage) proxy Health Seeking Behaviour is a dummy variable which speaks to 1 if self-reported ownership of private health insurance coverage and 0 if did not report ownership of private health insurance coverage. Health Seeking Behaviour. Visits to health care practitioners. This is a binary variable where 1 = self-reported seeking medical care and 0 = not reporting seeking medical care

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R ESULTS The sub-sample for the current study was 1,936 respondents of which 39.4% were males (N=762) and 60.6% females (N=1,174), suggesting that females are 1.5 times more likely to seek medical care from public or private hospitals compared to males. The findings (indicated in Table 4) revealed that marginally more Jamaicans who visited hospital facilities for medical care went to public facilities (53%, N=1,021). In addition to the aforementioned issues, 56%

(N=1,086) of the sample reported health care insurance coverage compared to 44% (N=850) who did not. The mean age of the sample was 44 years (SD=27.5 years). Some 45% of the

population were never married (N=671), 36% married (N=532), and 20% were divorced, separated or widowed. Furthermore, Table 4 reveals that two-thirds of the population dwelt in rural Jamaica, 22% (N=424) in Other Towns and 12% Kingston Metropolitan area (N=223). On the matter of the psychological state of Jamaicans, this was classified into two main conditions - positive and negative psychological conditions. The mean negative psychological conditions of population was 4.9 (out of 16, SD=3.3), suggesting that the negative psychological conditions of the population was low. On the other hand, the mean value for the positive affective psychological condition of the population was 3.2 (out of 6, SD = 2.4) indicating that positive affective conditions of the population was moderate (Table 11.4). The examination between public-private hospital health care facility utilisation and area of residence found no statistical correlation between the two aforementioned variables – χ 2(2) =0.385, ρ-value=0.825 > 0.05 – (Table 11.5). The no correlation between the two conditions indicates that Jamaicans, irrespective of their places of abode attended public-private hospital health care facilities for care of ill-health. (Table 11.5)

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A cross tabulation between visits to health care facilities and per capita population income quintile showed a statistical association - χ 2(4)=157.024, p<.001. The findings revealed that people in the poorest income quintile was 2.4 times more likely to visit public health care facilities compared to those in the wealthiest per capita income quintile; people in the poorest income quintile was 1.5 times more likely to visit public facilities compared to those in the second wealthiest quintile. However, the findings revealed that those in the second poorest income quintile indicate no statistical difference themselves and those in the middle income quintile - quintile 3 (Table 11.6). Nevertheless, people in the poorest income quintile were 1.3 times more likely to visit public facilities compared to those in the middle income quintile. There is a substantial difference between those who visit public health institutions, who are in the poorest income quintiles (73.8%, N=251) and those in the second poorest income quintile (58.4%, N=208). Embedded in the aforementioned finding is the increase in switching from public to private hospital health care facilities the more income quintile shifts to the wealthiest category (Table 11.6). The aforementioned findings raise concern about the extent of publicprivate hospital health care expenditure Of the sample (N=1,707), 912 people visited private hospital health care facilities and reported that they spent on average $2,977.41 (SD=$4,053.01) compared to $1,376.12 (SD=$2,547.93, N=1,019) for a visit to a public hospital care facility, suggesting that those who attend private hospital health care institutions spent about 2.2 times more than those who visit the public hospital health care facilities. Using t-test analysis, there is a difference between

expenditure on public hospital health care and private hospital health care – t 10.5 [1929] = ρvalue < 0.001.

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Using analysis of variance (ANOVA), generally, it was found that a statistical association exists between negative psychological conditions and per capita income quintile (F statistic [4, 1926] =28.793, ρ-value< 0.001). (Tables 11.1 – 11.2). Further investigation of the negative affective conditions by per capita quintile revealed that there is no difference between the negative affective psychological conditions of those in three bottom quintiles (quintiles 1 to 3), p> 0.05 (Table 7.2). In addition to the aforementioned issue, there is no difference between the negative psychological state of people in quintiles 3 and 4 (ρ-value>0.05) and quintiles 1, 2 and 3, indicating that negative affective conditions can be classified into 3 groups (1) high for those in quintiles 1, 2 and 3; (2) moderate for quintile 4 and (3) low for those in quintile 5. However those classified in quintile 5 has the lowest negative affective conditions compared to those in the other quintiles (ρ-value<0.001). Embedded in this finding is that as people move to the wealthiest quintile, they experience less negative trauma such as the loss of breadwinner, owing to abandonment, death or incarceration, crop failure, redundancy, loss of remittances, inability to meet household expenses, and less hopeless about the future.

There is statistical association between positive affective psychological conditions and per capita income quintile - F statistic [4, 1492] =12.366, ρ-value< 0.001. (Table 11.1). Further examination of the two aforementioned variables revealed that there is no statistical difference between the positive affective psychological conditions for those in quintiles 1 and 2; and between quintile 2 and quintiles 3 and 4. Hence the statistical difference in positive affective conditions is between those who are classified into two poorest quintiles and those in the wealthy quintiles (Table 11.2).

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Overall, there are statistical differences among health care expenditure of rural, urban and periurban residences in Jamaica – F-statistic [2, 1928] = 4.902, ρvalue < 0.001. Rural area dwellers spent on an average $2,009.98 (SD=$2,999.88, N=1286) per visit on medical care compared to peri-urban residents who spent $2,593.13 (SD=$4,587.67, N=423) and $1,963.68 was spent by urban dwellers (SD=$3,188.31, N=222). Further examination revealed that there is a difference between the medical expenditure made by rural residence and those in other towns – p value <0.05. The former on an average spent $583.17 less than those in other towns.

However, there are no statistical differences between medical expenditure of urban residents and that of rural dwellers (ρvalue >0.05) and other towns (ρvalue >0.05).

Empirical Results The regression analytic model was established in order to simultaneously examine a number of explanatory variables’ impact on those who attend public hospital health care facilities for illhealth. Table 11.6 and Table 11.7 provide information on empirical model (Eq (1)) and in the process answers the suitability of the model (Table 11.6), while Table 11.7 answers to the question of which of the variables are factors and their importance. Before embarking on the report of the regression model which contains all the predisposed variables and which those that are statistical significant (ie pvalue<0.05), we will examine the ‘goodness’ of fit of the data in regard to the model. Table 11.6 reports a ‘classification of visits to hospital health facilities owing to illhealth’ and contained examination of observed compared to predicted classification of the dependent variable (that is visits to hospital health care facilities in due to negative health). Of the 1,051 respondents that were used to establish the model (using the principle of parsimony,

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that is only those variables that have a pvalue < 0.05 will be used in the final model), 73% (N=767) were correctly classified: 71.6% (N=374) of those who visit private hospital health care facilities for care owing to illnesses or injuries and 74.3% (N=393) of those who visited public hospital health care institutions for treatment of dysfunctions or injuries. Therefore, the data is a ‘good’ fit for the model (ie. 73% were correctly classified). Table 11.10 contained the answers the empirical model (Eq. (1)) VPHCF i = ƒ (αjiDEM i, βjiPSYi , ƏP mc , πSS i , γjiHSB i, εi) (1)

which shows that 35.6% of the variability in visits to health facilities for care are affected by a number of factors- Chi-square (24) = 326.58, p-value < 0.001, -2Log likelihood = 1130.37. Of all the demographic variables contained in the current study, only total expenditure was found to be a factor of visits to public hospital health care facilities for ill-health (Wald statistic=4.458; OR=1.00: 1.00, 1.00). The cost of medical care was directly related to reason for patients’ visits to public hospital health care facilities for treatment against ill-health (Wald statistic=13.959; OR=1.00: 1.00, 1.00) likewise was the positive statistical relationship between social support and visits to health care facilities (Wald statistic=13.419; OR=1.741: 1.29, 2.34). A direct

association was observed between negative affective psychological conditions and visits to public hospital health care facilities. This suggested that more the patients/individuals are impacted upon by the loss of a breadwinner, crop failure, redundancy, loss of remittances. On the other hand, people who have access to private health insurance coverage (Wald statistic=89.35; OR=0.134: 0.089, 0.204), visited a health practitioners for non-ill checks (Wald statistic=72.07; OR=0.494: 0.419, 0.581), and a positive affective psychological conditions (Wald statistic=4.74; OR=0.931: 0.874, 0.993) are more likely not to attend public hospital health care facilities. These issues are all preventative and optimistic measures which are directly

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related with switching away from public to private hospital health care facilities. Embedded in these findings (based on Table 11.2) is the fact that optimistic in the study are those in the middle to the upper class. This study has shown that there is no distinction between the positive affective psychological conditions of those patients who are classified in the middle to the wealthiest class, but there is a difference between the aforementioned group and those in the poor classes (ie. quintiles 1 to 2 – poorest to poor classes). Therefore, in addressing the issue of using self-reported health (subjective health or wellbeing) to evaluate health (or wellbeing), it is imperative to note that there is an old cosmology that forwards that subjective assessment of health (self-reported health) is not a good measurement to apply to health or wellbeing. In this section of the study that discourse will not be examined as it will be done in the discussion; however, we must briefly compare and contrast self-reported visits to public facilities data collected by the Planning Institute of Jamaica and the Statistical Institute of Jamaica (in Jamaica Survey of Living Conditions, JSLC) and actual data collected by the Ministry of Health Jamaica for the period of 1996 and 2004. Using actual visits to public facilities (in Ministry of Health, Jamaica Annual Report) and that of self-reported visits to the same institutions, the data revealed that generally the statistics as collected by the Planning Institute of Jamaica and the Statistical Institute of Jamaica (in Jamaica Survey of Living Conditions, JSLC) reveals health status and conditions of Jamaicans. Based on Table 11.9, in 1997, the actual visits to public facilities were 33.1% as reported by the Ministry of Health and the self-reported figure for the same period was 32.1% (in JSLC). The difference between the actual and the subjective visits was 1%, which has no statistical difference. Some eight years post 1997 (2004), another comparison was made to assess whether the self-reported data is still good to use to proxy not only perception but reality of hospital

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health care facility utilisation in Jamaica. The figures were 52.9% for actual visits and 46.8% for subjective visits. This indicates that in 2004 Jamaica marginally report lower visits to facilities (6.1%) than the data published by the Ministry of Health. Despite the under reporting of health visits to public facilities in 2004 in Jamaica, there is no statistical difference between the year and the figures by the aforementioned institutions – χ 2(4) =157.024, p<0.05 Discussion In view of life expectancy for both genders in Jamaica (71.3 for males and 77.1 for females) (5), this study indicates that health status of the populace are high as life expectancy means living or denying the odds of disease causing pathogens. In order for a populace to defy the odds of morality or to delay it, the following life expectancy precursors must be considered; namely: healthy lifestyle behaviour or levels of health seeking behaviour, and hospital health care facility must meet universal health standard. The foregoing suggests that health seeking behavior and hospital health care facility utilisation plays a crucial role in embracing such reality. In 2007, Jamaicans sought less medical care for ill-health by 4% over 2006 (70%) They reported more health conditions over the same period (15.5% in 2007 and 12.2% in 2006). Although this is suggesting that they are using more home (or herbal) remedy, It leaves concern about health care facilities utilisation and factors that may be Influential. Data on health care facilities utilisation in Jamaica have been reported on and so this paper is seminal. Over the last 2 decades (ending 2007), Jamaicans preference for private hospital health care facility utilisation has been lower, narrowing towards public facility utilisation. Within the global economic climate which is accounting for the lowered remittances [3], people must spend more for increased consumption goods while at the same time, maintaining good health. The World Health Organization (WHO), in recognizing the role of 275

income on health, postulated that the unfinished agenda for health, poverty remains the main item [6], thus suggesting that poverty means increased hunger, malnutrition and by extension illhealth. This study evidences that there is a correlation between public-private hospital health care facility utilisation and per capita income quintiles which is in keeping with the literature [6-17]. The data showed that 74% of those in the poorest quintile used public facilities compared to 31.3% of those in the wealthiest quintile. Embedded in the hospital health care facility

utilisations are socio-demographic characteristic (social standing) of demanders. Some 2.8 (≈3) more people of the poorest quintile attended public facilities than private facilities, and that 2.4 more of the poorest than the wealthiest people attended the former than the latter facilities. The typological of hospital health care facility utilisation in the nation is a reflection of inability (ability) and than inflation (increase prices) wills substantially lower the poorest demand for medical care. It is well established in the literature that income affects health, and lower income direct correlates with poor health [7], which was reinforced in a study conducted by Powell, Bourne and Waller [8] who found that the those in the lower subjective social class reported the least health status. Those in the poorest income quintile are more concerned and able to primarily have difficulty purchasing the necessary nutrients from the required foods groups, and this accounts for their high consumption of public facilities, owing to low cost medical services. This study found that the cost of medical care strongly correlated with public hospital health care facility utilisation, and further explains this potency as it was revealed that the more people spending, the more they will attend public facility. An individual who spends more has less income to save as well as use for medical expenditure that account for increased utilisation of private facility with movement along the rung of per capita income quintile.

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With less income coupled with more spent on consumption items, health seeking medical behaviour becomes less. Within this reality, the negative correlation between health seeking behaviour and public hospital health care facility utilisations expected as public facility demand is strongly correlated with income or affordability of health care. Private facility consumption depends on one’s ability to pay the cost for the care, and it is this which bars the poorest from highly accessing this facilities. This study has revealed that public hospital health care facility utilisations substantially demanded by the poorest and those who are experiencing negative affective conditions and positive affective psychological conditions. Studies have shown that one psychological state affects his/her health [18-21]. This was further refined into negative and positive affective conditions [18, 21, 22]. Being positive directly correlated to health as people who entertain positive affective conditions are more likely to view like a more optimistic manner and this enhance their health status. In seeking to unearth ‘why some people are happier’ Lyubomirsky [21] approached this study from the perspective of positive psychology. She noted that, to comprehend disparity in self-reported happiness between individuals, “one must understand the cognitive and motivational process that serves to maintain, and even enhance happiness and transient mood’ [21]. Using positive psychology, Lyubomirsky identified comfortable income, robust health, supportive marriage, and lack of tragedy or trauma in the lives of people as factors that distinguish happy from unhappy people, which was discovered in an earlier study by Diener, Suh, Lucas and Smith [23]. In an even earlier study by Diener, Horwitz and Emmon [24], they were able to add value to the discourse of income and subjective well-being. They found that the affluent (those earning in excess of US 10-million, annually) self-reported well-being (personal happiness of the wealthy affluent) was marginally more than that of the lowly wealthy.

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Studies revealed that positive moods and emotions are associated with well-being [20] as the individual is able to think, feel and act in ways that foster resource building and involvement with particular goal materialization [21]. This situation is later internalized, causing the

individual to be self-confident from which follows a series of positive attitudes that guide further actions [25]. Positive mood is not limited to active responses by individual, but a study showed that “counting one’s blessings,” “committing acts of kindness”, recognizing and using signature strengths, “remembering oneself at one’s best”, and “working on personal goals” all positively influence well-being [25, 26]. Happiness is not a mood that does not change with time or situation; hence, happy people can experience negative moods [27, 28]. This takes the study to the next area, psychological conditions and per capital income quintile. Those with negative psychological conditions are from the lower class (poor), and studies have shown that there is a correlation between health and psychological conditions. Now, additional issues have emerged from this study as poor are negative and attend public facility more than those at the greater per capita income quintile. On the other hand, those who are more likely to report positive affective psychological conditions are greater for those at the highest level of the income quintile, the findings also show that those who attend private facility are experience greater positive conditions. It follows that public facilities in Jamaica service and service quality are more in keeping with particular psychological state and subjective social class. Hence, private facilities are not only more expensive but the service that it affects is in keeping with the high social standings of its clients, and the reverse is equally the case for public facilities staffers and their clients.

278

CONCLUSION Health seeking behaviour (ownership of private health insurance coverage and visited a health practitioners for non-ill checks) is the most important factor that determines visits to public health facilities or private health facilities for care for illnesses (or injuries). Following the value of health seeking behaviour is the cost of medical care; reinforcing the reality for financial inability among people is it lower class, middle class or upper class will see a switching from private to public facilities for ill-treatment. In continuing this discourse, social support is directly related to visits to public hospital health care facilities and so offers some explaining for the large number of people visiting the said institutions to support the patients who visit for treatment of negative health conditions. Again the positive association that exists between expenditure and visits to public facilities further reinforces the point that the more people spent which is the less income they have for saving and further speaks about the poor, they will be less likely to visit private hospital health care facilities. The poor who are less hopeful about the future (unlike those in the middle class) are more optimistic because of financial stability and are ergo able to access private hospital health care because of expenditure of private health care does intimate better health care, which they are willing to pay for. In sum, the demands for public hospital health care facility utilisation in Jamaica are primarily based on in affordability and low perceived quality of patient care. The issue of low quality of patient care speaks to not medical care, but to the customer service care offered to client. The greater percentage of Jamaicans who access private health care is not owing to plethora of services, higher specialized doctors, more advanced medical equipment, or low, but this is due to social environment – customer service and social interaction between staffers and clients- and physical milieu – more than one person per bed sometimes, uncleansiless of the 279

facilities. These issues accommodate for the lowly particular persons visiting public and private facilities for medical care.

Acknowledgement The researcher would like to extend sincere gratitude to staff of the documentation centre at the Sir Author Lewis Institute of Social and Economic Studies, Faculty of Social Sciences, University of the West Indies, Mona, Jamaica for making available the dataset from which this study was based.

280

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282

Figure 11.1: Public-Private Health Care Utilisation in Jamaica (in %), 1996-2002, 2004-2007 Source: Taken from Jamaica Survey of Living Conditions, various issues

283

Figure 11.2: Remittances By Income Quintiles and Jamaica (in Percent): 2001-2007 Source: Extracted from the Jamaica Survey of Living Conditions, 2007

284

Table 11.1 Discharge, Average Length of Stay, Bed Occupancy and Visits to Public Hospital Health Care Facilities, 1996-2004 Year Discharge Average Bed Occupancy Visits to Public Facility Length of Stay Rate 1996 145,656 5.7 56.1 546,933 1997 153,101 5.8 57.3 598,004 1998 158,851 5.5 58.0 634,792 1999 163,714 5.1 52.2 654746 2000 173,700 4.9 74.9 643,101 2001 171,963 6.0 84.6 667,321 2002 173,614 6.9 80.2 695,239 2003 179,322 6.4 84.5 746,844 2004 182,053 6.8 56.0 775,727 2005 NI NI NI NI 2006 NI NI NI NI 2007 NI NI NI NI Source: Ministry of Health, Jamaica, Planning and Evaluation Branch, various issues NI No information available

285

Table 11.2 Inflation, Public-Private Health Care Service Utilisation, Incidence of Poverty, Illness and Prevalence of Population with Health Insurance (in per cent), 1988-2007 Year Inflation Mean Public Utilisation Private Utilisation Prevalence of poverty Illness Health Seeking Medical Care Days of Illness NI 54.6 38.6 47.7 50.9 51.8 51.4 58.9 54.9 59.6 60.8 68.4 60.7 63.5 64.1 NI 65.1 NI 70.0 66.0 NI 11.4 10.1 10.2 10.8 10.4 10.4 10.7 10.0 9.9 11.0 11.0 9.0 10.0 10.0 NI 10.0 NI 9.8 9.9

Insurance Coverage NI 16.8 18.3 13.7 10.6 12.0 12.9 9.8 10.7 9.7 8.8 10.1 14.2 13.4 12.6 NI 11.4 NI 12.2 15.5 NI 8.2 9.0 8.6 9.0 10.1 8.8 9.7 9.8 12.6 12.1 12.1 14.0 13.9 13.5 NI 19.2 NI 18.4 21.2

1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

8.8 17.2 29.8 80.2 40.2 30.1 26.8 25.6 15.8 9.2 7.9 6.8 6.1 8.8 7.2 13.8 13.7 12.6 5.7 16.8

NI 42.0 39.4 35.6 28.5 30.9 28.8 27.2 31.8 32.1 37.9 37.9 40.8 38.7 57.8 NI 46.3 NI 41.3 40.5

NI 54.0 60.6 57.7 63.4 63.8 66.7 66.4 63.6 58.8 57.3 57.1 53.6 54.8 42.7 NI 46.4 NI 52.8 51.9

NI 30.5 28.4 44.6 33.9 24.4 22.8 27.5 26.1 19.9 15.9 16.9 18.9 16.9 19.7 NI 16.9 NI 14.3 9.9

Source: Bank of Jamaica, Statistical Digest, Jamaica Survey of Living Conditions, Economic and Social Survey of Jamaica, various issues Note: Inflation is measured point-to-point at the end of each year (December to December), based on Consumer Price Index (CPI) NI – No Information Available

286

Table 11.3 Hospital Health Care Utilisation (Using Jamaica Survey of Living Conditions Data) By Income Quintile (%): 1991-2007 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2004 2006 2007 Public Quintile 1=Poorest 2 3 4 5=Wealthiest Private Quintile 1=Poorest 2 3 4 5=Wealthiest

57.8 43.3 29.0 35.8 20.6

48.8 41.8 28.8 27.1 12.3

57.5 36.9 29.3 20.6 16.5

54.1 34.9 17.0 25.6 15.7

49.4 25.3 22.7 21.7 16.8

54.8 42.7 32.8 29.5 11.9

44.5 39.9 37.3 26.3 12.4

59.1 49.0 40.7 35.1 17.2

61.0 46.3 37.5 37.7 15.4

55.7 44.3 41.3 44.6 12.8

67.6 53.5 32.1 35.3 24.4

73.4 57.5 58.6 46.5 30.9

70.9 53.6 57.3 36.7 27.6

71.0 51.1 50.6 27.5 21.7

75.0 66.5 22.1 27.0 21.4

34.4 52.9 64.5 53.1 73.8

46.3 48.4 65.9 65.4 78.1

32.3 58.7 62.2 74.2 82.5

41.2 57.0 77.0 72.2 81.5

47.1 66.3 69.7 68.0 80.0

40.4 54.1 62.5 63.8 84.6

49.1 51.1 51.8 62.5 80.0

35.5 45.0 56.6 58.3 78.4

34.7 50.3 59.8 57.1 75.4

38.7 53.8 48.8 48.8 78.4

29.3 38.7 62.9 59.1 66.5

22.8 37.5 37.4 46.3 52.5

26.8 35.7 35.7 55.6 65.1

24.3 42.3 42.9 65.4 73.9

22.0 33.3 64.2 69.6 78.6

Source: Jamaica Survey of Living Conditions, various issues (a joint publication of the Planning Institute of Jamaica and the Statistical Institute of Jamaica)

287

Table 11.4 Demographic Characteristic of Sampled Population, n=1,936 N Sex Male Female Income Quintile Categorization Two Poorest Quintiles Middle Quintile Two Wealthiest Quintiles Marital Status Married Never married Divorced Separated Widowed Visitors to hospital health care facilities Private hospital Public hospital Private Health Insurance Coverage No Yes Area of residence Rural areas Other Towns Kingston Metropolitan area Educational Level Primary and below Secondary or post-secondary Tertiary 762 1174 696 376 864 532 671 20 25 250 915 1021 1086 850 1289 424 223 563 813 53 39.4 60.6 36.0 19.4 44.6 35.5 44.8 1.3 1.7 16.7 47.3 52.7 56.1 43.9 66.6 21.9 11.5 39.4 56.9 3.7 44.0 ± 27.5 1.7 ± 1.3 4.9 ± 3.3 3.2 ± 2.4 Percent

Age (Mean ± SD) Crowding (Mean ± SD) Negative Affective Psychological condition (Mean ± SD) Positive affective Psychological condition (Mean ± SD)

288

Table 11.5 Public Hospital Health Care Facility Utilisation by Area of Residence (in percentage), n =1,936 Area of Residence

Variable

Rural areas

Other towns

Urban areas

Total

Private Hospital Utilisation Public 46.9 48.6 47.1 47.3

53.1

51.4

52.9

52.7

Total 1289 χ 2(2) =0.385, ρ-value=0.825 > 0.05 424 223 1936

289

Table 11.6 Public Hospital Health Care Facility Utilisation By Per Capita Population Income Quintile (in per cent), N=1,936 Per Capita Population Quintile

Variable

Poorest 20%

2.00

3.00

4.00

Wealthiest 20%

Total

Hospital Utilisation

Private

26.2

41.6

41.2

51.7

68.8

47.3

Public

73.8

58.4

58.8

48.3

31.3

52.7

Total χ 2(4) =157.024, p < 0.001

340

356

376

416

448

1936

290

Table 11.7.1 Descriptive Statistics of Negative Affective Psychological Conditions and Per capita Income Quintile Std. Deviation 2.9 3.2 3.3 3.1 3.4 3.3 Std. Error 0.16 0.17 0.17 0.15 0.16 0.07 95% Confidence Interval Lower Bound Upper Bound 5.5 6.1 5.3 6.0 4.8 5.5 4.4 5.0 3.4 4.0 4.8 5.1

Income Quintile 1.00=Poorest 20% 2.00 3.00 4.00 5.00=Wealthiest 20% Total

N 338 355 375 415 448 1931

Mean 5.8 5.7 5.2 4.7 3.7 4.9

F statistic [4, 1926] =28.793, ρ-value< 0.001

Table 11.7.2 Multiple Comparison of Negative Affective Psychological Condition by Per Capita Income Quintile
Per Capita Population Quintile 1.00=Poorest 20% Per Capita Population Quintile 2.00 3.00 4.00 5.00 2.00 1.00 3.00 4.00 5.00 3.00 1.00 2.00 4.00 5.00 4.00 1.00 2.00 3.00 5.00 5.00=Wealthiest 20% 1.00 2.00 3.00 4.00 Std. Error 0.24 0.24 0.23 0.23 0.24 0.24 0.23 0.23 0.24 0.24 0.23 0.22 0.23 0.23 0.23 0.22 0.23 0.23 0.22 0.22 Sig. 0.98 0.07 0.00 0.00 0.98 0.23 0.00 0.00 0.07 0.23 0.24 0.00 0.00 0.00 0.24 0.00 0.00 0.00 0.00 0.00 95% Confidence Interval Upper Bound -0.53 -0.03 0.45 1.47 -0.79 -0.16 0.33 1.35 -1.27 -1.13 -0.15 0.87 -1.73 -1.58 -1.09 0.41 -2.72 -2.58 -2.08 -1.60 Lower Bound 0.79 1.27 1.73 2.72 0.53 1.13 1.58 2.58 0.03 0.16 1.09 2.08 -0.45 -0.33 0.15 1.60 -1.47 -1.35 -0.87 -0.41

291

Table 11.8.1 Descriptive Statistics of Total Positive Affective Psychological Conditions and Per Capita Income Quintile
Per Capita Income Quintile 1.00=Poorest 2.00 3.00 4.00 5.00=Wealthiest Total N 243 273 278 313 386 1493 Mean 2.42 2.81 3.22 3.28 3.69 3.15 Std. Deviation 2.66 2.51 2.30 2.40 2.22 2.44 Std. Error 0.17 0.15 0.14 0.14 0.11 0.06 95% Confidence Interval Lower Bound Upper Bound 2.08 2.51 2.95 3.02 3.47 3.03 2.75 3.10 3.49 3.55 3.92 3.27

F statistic [4, 1492] =12.366, p< 0.001 Table 11.8.2 Multiple Comparisons of Positive Affective Conditions by Per Capita Income Quintile
Per Capita Population Quintile 1.00=Poorest 20% Per Capita Population Quintile 2.00 3.00 4.00 5.00 2.00 1.00 3.00 4.00 5.00 3.00 1.00 2.00 4.00 5.00 4.00 1.00 2.00 3.00 5.00 5.00=Wealthiest 20% 1.00 2.00 3.00 4.00 Std. Error 0.21 0.21 0.21 0.20 0.21 0.20 0.20 0.19 0.21 0.20 0.20 0.19 0.21 0.20 0.20 0.18 0.20 0.19 0.19 0.18 Sig. 0.35 0.00 0.00 0.00 0.35 0.25 0.11 0.00 0.00 0.25 1.00 0.09 0.00 0.11 1.00 0.16 0.00 0.00 0.09 0.16 95% Confidence Interval Upper Bound -0.97 -1.38 -1.43 -1.82 -0.19 -0.98 -1.02 -1.41 0.23 -0.14 -0.60 -0.99 0.31 -0.06 -0.48 -0.91 0.74 0.37 -0.04 -0.09 Lower Bound 0.19 -0.23 -0.31 -0.74 0.97 0.14 0.06 -0.37 1.38 0.98 0.48 0.04 1.43 1.02 0.60 0.09 1.82 1.41 0.99 0.91

292

Table 11.10 Logistic Regression: Predictors of Public Hospital Health Care facility utilisation in Jamaica Std. Error 0.4 0.7 0.0 0.2 0.2 0.4 Wald Statistic 2.4 0.3 14.0*** 89.4*** 0.9 0.01 OR 0.54 0.69 1.00 0.13 1.20 1.03 1.00 95% CI 0.249 - 1.181 0.166 - 2.886 1.000 - 1.000 0.089 - 0.204 0.818 - 1.765 0.514 - 2.079

Explanatory variables Retirement Income Household Head Cost Health Care Health Insurance Other Towns Urban areas †Rural area

Social support 0.2 13.4*** 1.74 1.294 - 2.343 Crowding 0.1 1.2 1.13 0.910 - 1.394 Crime Index 0.01 2.7 1.02 0.996 - 1.048 Landownership 0.2 1.7 0.80 0.568 - 1.120 Environment 0.2 1.9 0.75 0.502 -1.132 Gender 0.2 0.0 1.01 0.728 - 1.402 Negative Affective 0.1 7.1** 1.07 1.019 - 1.129 Positive Affective 0.03 4.7 0.93 0.874 - 0.993 Number of males in house 0.1 0.9 1.09 0.913 - 1.293 Number of females in house 0.1 1.8 1.14 0.944 - 1.369 Number of children in house 0.1 0.02 1.01 0.868 - 1.178 Assets owned 0.04 1.5 0.96 0.894 - 1.026 Age 0.0 0.7 0.99 0.988 - 1.005 Total Expenditure 0.0 4.5* 1.00 1.000 - 1.000 Health Seeking Behaviour 0.1 72.1*** 0.49 0.419 -0.581 Model Chi-square (df = 21) = 326.58, p-value < 0.001 -2Log likelihood = 1130.37 Nagelkerke R-square = 0.356 Overall correct classification = 73.0% Correct classification of cases of public utilisation =74.3% Correct classification of cases of not public utilisation (private) = 71.6% Hosmer and Lemeshow Test of goodness of fit, χ2(df = 8) = 5.395, 0.715 †Reference group *p < 0.05, **p < 0.01, ***p < 0.001

293

Table 11.11 Public Hospital Facility Visits (using the JSLC and Ministry of Health Jamaica) By 1997 and 2004 Public Facilities in Jamaica Year 1997 Actual Visits, MOH1 % 33.1 Self-reported Visits, JSLC % 32.1

2004

52.9*

46.8

Source: Ministry of Health Jamaica and the Jamaica Survey of Living Conditions (JSLC) χ 2(df = 4) = 0.083, p > 0.05
1

The Percentages of Actual visits were computed by author *Preliminary data were used to calculate this percentage

294

Chapter

12
Introduction

Inflation, Public Health Care and Utilization in Jamaica

Inflation is the persistent upward movement in general prices. It results in lowered standard of living (wellbeing), increased cost of living and is equally synonymous with socio-economic challenges such as readjustment of consumption spending, saving patterns, lowered nutritional intakes, reduced real wage rates, and income-wealth redistribution. During the last 2 decades (1988-2007), inflation in Jamaica has been moderate (average inflation was 19.6 (SD=17.1) and reached a maximum in 1991 of 80.2 per cent which was a 169.13 per cent increase over 1990. A year later (1992), inflation fell substantially by 49.9 per cent (to 40.2 per cent). Since 1993 to 1999, it has been falling; however, this pattern was broken when in 2001, inflation rate increased by 44.3 per cent over 2000 (Table 12.1). Between 2000 and 2007, average inflation was 11.8 per cent, compared 32.3 per cent between 1988 and 1995 suggesting that socio-economic difficulties on people during those periods have lessen but still remained a reality. Much of the economic gains that have been attained during 2000 to 2007 have been eroded over 2006 to 2007 as general price level in Jamaica increased by 194.7%. This coupled with the economic downturn in the American means a number of challenges for Jamaicans. Many studies that have sought to examine inflation have done so from the perspective of production, economic growth, monetary policy, real wages, interest rates, retards competitiveness, and lower socio-economic activities1-6. 295

We have seen none that examine inflation and public and private health care utilization, inflation and illness/injury from a Caribbean perspective or even in particular Jamaica. No one can deny the association between inflation and increased prices and inflation and unemployment because these are well established in the literature7-17, but what about inflation and health care utilization? Among the many challenges with which a populace must tackle is the increasing cost of medical care. In periods when there is inflation, the cost of health care is one of the many cost that rise. Is the substitution of health care utilization (public and private health care visits) as a result of inflationary changes? During the period of the 1990s, Jamaica saw inflation as high as 80.2 per cent and despite this being the high in 2 decades (Table112.), average inflation for that period was 27.4 per cent compared to 10.6 per cent between 2000 and 2007. In spite the high inflation in the 1990s, private health utilization cost - which is more than public health care service - had a greater demand (Table 12.1). However, in the last seven years (2000 to 2007), there has been a convergence of public and private health care utilization even though inflation has been lower than in the 1990s (Table 12.1). Does inflation accounts for a proportion of this pattern (Table 12.1)? This study aims to contribute to the literature by investigating the

aforementioned issues. Utilizing statistical data for 2 decades, this study will examine inflation’s role in accounting for public and private health care utilizations of Jamaicans as well as public and private health care utilizing switching owing to inflation. Secondly, the study will examine the correlation between inflation and illness/injury. Method and Measure The research design used secondary data taken from the last 2 decades of the Jamaica Survey of Living Conditions (JSLC) to examine whether a correlation exists between inflation and public and private health care utilization and secondly to investing if there is a substitution from private

296

health care utilization to public health care utilization in inflationary periods. The data were taken from publications of the JSLC from 1988 to 2007. The JSLC began in 1988 when the Planning Institute of Jamaica (PIOJ) in collaboration with the Statistical Institute of Jamaica (STATIN) adopted with some modifications the World Bank's Living Standards Measurement Study (LSMS) household surveys. The JSLC has its focus on policy implications of government programmes, and so each year a different module is included, evaluating a particular programme. The JSLC is a self-administered instrument (questionnaire) where respondents are asked to recall detailed information on particular activities. The questionnaire covers demographic variables, health, immunization of children 0 to 59 months, education, daily expenses, non-food consumption expenditure, housing conditions, inventory of durable goods, and social assistance. Interviewers are trained to collect the data, which is in preparation of the household members. The survey is usually conducted between April and July annually. Furthermore, the instrument is posted on the World Bank’s site to provide information on the typologies of question and the (http://www.worldbank.org/html/prdph/lsms/country/jm/docs/JAM04.pdf). The current study extracted data on the percentage on public and private health care utilization, mean cost for visits to public and private health care facilities in the last 4-week of the survey period, and health insurance coverage from the JSLC. Information was extracted on annual inflation rate from 1988 to 2007. Scatter diagrams (graphical plots) were on variations of public and private health care utilization by inflation, mean cost of care for visits as well as other graphic presentations were used to assess whether any statistical association exists between the dependent variable and the independent variable; and some of the graphs were only interpreted. In the current study, number of hypotheses was tested to provide explanation for the narrowing of the public and private health care utilization in Jamaica over the last 2 decades.

297

Measure Health Insurance Coverage: This variable is conceptualized as self-reported ownership of health insurance coverage by members of the population. For the purpose of the study, the variable is measured as a percentage of the general population. Inflation: This is measured as the per cent increase in prices from December to December of each year. Health Service Utilization: This denotes an individual demand and use of health care resources and services and indicates the way customers (patients) interaction with health care providers. Therefore health service utilization (utilization of health care services) is a proxy of health status of a population and use of health care services. Health care service utilizations are provided by public, private or public-private facilities. Public Health Care utilization: This is the percentage of the total population of individuals who reported having visited public health care institutions owing to illness/injury over the 4-week period of the survey. Private Health Care utilization: This is the percentage of the total population of individuals who reported having visited private health care institutions owing to illness/injury over the 4-week period of the survey. Results: Bivariate Analysis Hypothesis 1: There is direct statistical association between inflation and public health care utilization The statistical correlation between public health care utilization and inflation (Figure 12.1) is curvilinear. There is a positive association between the two aforementioned variables, when inflation is less than 40%, and changes to positive after an inflation rate of approximately 50%.

298

However, when inflation increases from 40 per cent to 80 per cent, there is a significant increase in demand for public health care facilities for care.

60.00

50.00

public

40.00

30.00

R Sq Quadratic =0.357

20.00 0.00 20.00 40.00 60.00 80.00 100.00

Inflation

Figure 12.1: Inflation By Public Health Care Utilization

299

Hypothesis 2: There is an indirect association exits between inflation and private health care utilization Generally the correlation between private health care utilization and inflation (Figure 12.2) is curvilinear. A particular inflation rate (40 per cent) and beyond, people reduce their demand for private health facility and below this rate, the demand for private health care was positively related to inflation rates.

70.00

65.00

60.00

private

55.00

50.00

45.00 R Sq Quadratic =0.454

40.00 0.00 20.00 40.00 60.00 80.00 100.00

Inflation
Figure 12.2: Inflation by Private Utilization Care

300

Hypothesis 3: A strong statistical correlation exists between cost of medical care for services offered by public health care facilities and private health care facilities. Based on Figure 12.3, there is a strong positive statistical association between cost of medical care for public health care and that of private health care (R-squared = 0.741). This means that 74.1% of the variance in cost of public health care services is owing to a 1% change in the cost of private health care services in Jamaica.

600.00

500.00

400.00

COST_PUBLIC

300.00

200.00

100.00 R Sq Linear = 0.741

0.00 250.00 500.00 750.00 1000.00 1250.00

COST_PRIVATE

Figure 12.3: Cost of Medical care for Public and private health Care

301

Hypothesis 4: There exists an inverse statistical correlation between public health care and private health care utilization On examination of the data (Figure 12.4), there is a strong inverse statistical correlation between public and private health care utilization of Jamaicans (R-squared = - 0.89). Based on figure 5, 89% of the change in public health care utilization of Jamaicans is due to a 1% change in private health care utilization. Continuing, the rate of change between public and private health care switching is constant (or linear).

60.00

50.00

public

40.00

30.00

R Sq Linear = 0.89

20.00 40.00 45.00 50.00 55.00 60.00 65.00 70.00

private

Figure 12.4: Public and private health Care Utilization

302

Hypothesis 5: There is a direct association between utilization of public health care facilities and self-reported illness/injury Based on Figure 12.5, the correlation between self-reported illness (or self-reported injury) is a positive one. The statistical association is a weak one (R=0.2520, and that only 6.4% of the variability in public health care utilization by Jamaicans can be explained by self-reported illness (or self-reported injuries). Here, self-reported illness is a weak predictor (R-squared = 0.064) of the rationale for public health care utilization in Jamaica. With a weak R-squared between the two aforementioned variables, illness/injury is not a good explanatory for public health care utilization in Jamaica as significantly more people attend public health care utilization (57.8 per cent) when 12.6 per cent of the population reported illness/injury compared to 39.4 per cent when 18.3 per cent of the populace indicated suffering from illness/injury.

60.00

50.00

public

40.00

30.00

R Sq Linear = 0.064

20.00 8.00 10.00 12.00 14.00 16.00 18.00 20.00

illness_injury

Figure 12.5: Visits to Public Health Care Facilities and the Number of Reported Illness/Injury

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Hypothesis 6: Increases in inflation rates reduces the ownership of health insurance coverage

On examination of the correlation between health insurance coverage and inflation it was revealed that a non-linear relationship existed. The findings revealed that people purchase less health insurance in periods of high inflation (Figure 12.6) except when inflation increases beyond 60 per cent, suggesting that less is spent on health seeking behaviour (proxied by the purchase of health insurance coverage) in period of high inflation.

20.00

18.00

16.00

Health Insurance

14.00

12.00

10.00 R Sq Quadratic =0.477

8.00 0.00 20.00 40.00 60.00 80.00 100.00

Inflation

Figure 12.6: Health Insurance Coverage and Inflation

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Hypothesis 7: There is a strong correlation between incidence of poverty and inflation

The data revealed a strong statistical correlation between incidence of poverty and inflation (R squared 0.777) (Figure 12.7). This means that 77.7 per cent of ‘incidence of poverty’ can be explained by a one per cent change in the inflation rate. In addition, inflation is not only synonymous with increased prices but increased incidence of poverty, suggesting that in periods of persistently high inflation, more people will become poorer. The association between the two aforementioned variables is a linear one.

50.00

40.00

INCIDENCE_POVERTY

30.00

20.00

R Sq Linear = 0.777

10.00 0.00 20.00 40.00 60.00 80.00 100.00

inflation

Figure 12.7: Incidence of Poverty and Inflation, 1988-2007

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Hypothesis 8: There is a strong positive correlation between public health care utilization and incidence of Poverty The findings (in Figure 12.8) have disproved the hypothesis as there is weak negative correlations between public health care utilization and incidence of poverty (R2= 0.236). The relationship is a curvilinear one, indicating that as the incidence of poverty increase people switch from visiting public health facilities. Furthermore, only 23.6 per cent of public health care utilization is explained by a 1% change in ‘incidence of poverty’. Embedded in this finding is the role of switching from health care to home care in periods of increased poverty, suggesting that when the people become poorer (or increases in poverty rates), people will be highly likely to spend more for public health care utilization. Nevertheless, when incidence of poverty increases beyond approximately 35%, people begin to switch to the services of public health care facilities.

60.00

50.00

public

40.00

30.00

R Sq Quadratic =0.236

20.00 10.00 20.00 30.00 40.00 50.00

Incidence of Poverty

Figure 12.8: Public Health Care Utilization and Incidence of Poverty 306

Hypothesis 9: There is a weak statistical correlation between private health care utilization and incidence of poverty

The correlation between private health care institution and incidence of poverty is a moderate one (R=0.56) (Figure 12.9). The relationship between the two variables is a non-linear one, indicating that the rate of change is not constant over the event, as there is a positive association between the aforementioned variables up to poverty rates of approximately 32% and beyond this is private health care utilization begins to fall at an increasing rate. Furthermore, for every 1 percentage change in incidence of poverty, private health care utilization increases by 31.6 percentage points.

70.00

65.00

60.00

private

55.00

50.00

45.00 R Sq Quadratic =0.316

40.00 10.00 20.00 30.00 40.00 50.00

Incidence of Poverty

Figure 12.9: Private Health Care Utilization and Incidence of poverty 307

Hypothesis 10: There is a positive correlation between illness/injury and inflation

Based on Figure 12.10, there is a weak positive correlation between illness/injury and inflation. The data revealed that 4.4 per cent of illness/injury is explained by a 1 per cent change in inflation suggesting that in period of high and persistent increases in inflation, more people will become ill or injured (self-reported illness or injury).

20.00

18.00

16.00

illness_injury

14.00

12.00

10.00 R Sq Linear = 0.044

8.00 0.00 20.00 40.00 60.00 80.00 100.00

inflation

Figure 12.10: Illness/Injury and Inflation

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Hypothesis 11: There is a negative correlation between cost of Public and private health Care Cost and Inflation

The findings revealed that in period of low inflation the cost of expenditure on private health care is higher than expenditure on public health care utilization, suggesting that switching occurs in those periods. The reverse is the case in periods of high inflation (Figure 12.11). There is a remarkable disparity between expenditure on private health care and public health care in periods of low and high inflation. The data revealed that in periods of low inflation the rate of substitution for private health care utilization is substantial; however in periods of persistently high inflation the rate of substitution is smaller than substitution rate in low inflationary periods.

COST_PRIVATE COST_PUBLIC

1,250

1,000

750

500

250

0
6.10 7.20 8.80 9.20 13.70 15.30 16.80 25.60 29.80 40.20

Inflation

Figure 12.11: Cost of Public and private health Care Cost and Inflation 309

Hypothesis 12: There is a positive correlation between home remedy and inflation

The relationship between seeking medical care and inflation is twofold. Firstly, when inflation rates range from 0 and 60 per cent, there was an inverse correlation with seeking medical care. However, when inflation increases beyond 60 per cent, it positively associated with seeking medical care. Secondly, 68.9 per cent of people seeking medical care can be explained by inflation. The findings show (Figure 12.12) is a strong association between seeking medical care and inflation (R squared=0.689). The data were better fitted by a curvilinear diagram than a linear one (Figure 13), and this explain why we did not use the linear valuation in any interpretation for this examination. If the inflation rate of 80.2 per cent for 1991 is taken as an outlier, the linear relationship between the two variables will be a strong moderate one, indicating that 56.5 per cent of the medical health care seeking behaviour of Jamaicans can be explains by a 1 per cent change in inflation rate.

70.00

65.00

Seeking Medical Care

60.00

55.00

50.00

R Sq Linear = 0.565 R Sq Quadratic =0.689

45.00 0.00 20.00 40.00 60.00 80.00 100.00

Inflation

Figure 12.12: Seeking Medical Care By Inflation

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Hypothesis 13: There is a correlation between People Seeking Medical Care and Incidence of Poverty

The relationship between people ‘seeking medical care’ and ‘incidence of poverty’ is a curvilinear one. This correlation is a strong negative one (R = 0.871). This finding revealed that the more ‘incidence of poverty’ increases, the less likely it is that Jamaicans will demand medical care whether public or private. Furthermore, there is a minimum percentage of ‘incidence of poverty’ beyond which people begin to demand more medical care suggesting that reduction in ‘incidence of poverty’ explains 75.9 per cent of the reason for people seeking medical care (Figure 12.13).

70.00

65.00

Seeking Medical Care

60.00

55.00 R Sq Quadratic =0.759

50.00

45.00 10.00 20.00 30.00 40.00 50.00

Incidence of Poverty

Figure 12.13: Seeking Medical Care and Incidence of Poverty

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Hypothesis 14: There is a positive correlation between health seeking behaviour and health insurance coverage

There is a strong statistical correlation between people ‘seeking medical care’ and ‘health insurance coverage’ (Figure 12.14). The relationship between the two aforementioned variables is curvilinear as people will seek more medical care with the ownership of more health insurance coverage. The demand for health insurance optimizes at 18.4 per cent, after which the

population begins to seek less medical care. This means that health insurance coverage is a good predictor of people willingness to demand (or seek) health care in Jamaica.

70.00

65.00

Seeking Medical Care

60.00

55.00

50.00 R Sq Quadratic =0.751

45.00 8.00 10.00 12.00 14.00 16.00 18.00 20.00

Health Insurance

Figure 12.14: Seeking Medical Care and Health Insurance

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Limitation of study The current study is affected by a number of limitations which influence its findings. The use of secondary data limits the investigators to analyzing issues within the dataset. In addition to the aforementioned issue, owing to the number of data points were limited to bivariate correlations as the data did not lend itself to multivariate analysis. This limitation means that we do not simple a single markers of factors that simultaneously determine public and private health care utilization. Furthermore, Jamaica does not have statistics on depression rates in the period of the study and so we were unable to disaggregate illness/injury in order to establish whether the increase in illness/injury in inflationary periods is owing to psychological or physiological symptoms. Discussion Generally, Jamaicans have a preference for private health care service utilization than public health care service utilization (Table 1). For the past 2 decades [1988 to 2007], Jamaicans have an ostensibly preference for private health care service. During 1991 to 1998, the minimum selfreported usage of private health care facilities was 60 per cent with the highest being 67 per cent in 1994. However over the last decade [1998 to 2007], this preference has been declining indicating that a switch has been occurring to public health care service utilization. In order to understand the substitution of private for public health care utilization within the context of reduced ‘incidence of poverty’, the phenomenon of inflation must be taken into account within this discourse that seek to explain the rationale for the switching of public and private health care utilization. Inflation in the last one half decade [2003 to 2007] has been increasing unlike the first from 1988 to 1992 when the rate was as high as 80.2 per cent. It is well established in literature

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that inflation retards production, reduce real wages and lower standard of living1-17. It also creates socio-economic challenges such as reduced real wage, unemployment, increased prices, lowered rate of ownership of health insurance, declining health seeking behaviour, increased poverty, and then there is the issue of in affordability of goods and services. With the increase in prices (costs) owing to inflation, there will be many challenges for customers, clients and patients but it must be noted here that some inflation is good in an economy. This study is not examining some inflation but persistent inflation. Again inflation retard Gross Domestic Product, increased costing of goods and services in an economy, which speaks to the economic challenges of poor and other people with that society. Despite the high inflationary period of the early 1990s, Jamaicans demand for private health care utilization was higher than that of public health care utilization. The current study has revealed a strong negative statistical correlation between ‘seeking medical care’ and inflation as well as a strong association between ‘seeking medical care’ and ‘incidence of poverty’. This is coupled with the reality that private health care costing is greater than that of public health care, which accounted for the high utilization of private health care in the 1990s. The problem arises, when inflation becomes persistent as people’s real wage will be lowered, unemployment rises, a downturn in the world economy in particular America, and this provide all the economic challenges to borne on health utilization. A group of scholars10 have found a positive correlation between unemployment and low income11-12 and suicides18-21 and when this is juxtaposed with these research findings, persistent inflation and the economic recession in America coupled with the higher prices of ‘food and non-alcoholic beverages’ as well as fuel in addition to the time lag between price reduction in the global economy and Jamaica, these economic challenges are accounted for the substitution of public and private health care utilization. Another explanation

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for the increase in private health care utilization in periods of high inflation is owing to the positive correlation between inflation and illness, suggesting that although costs are increasing there is the need for medical care. There is a critical finding that emerged when we examine the statistics as periods of high inflation ‘seeking medical care’ is lower indicating that people resort to more home remedy. This is evident as in 1991when inflation was the highest (80.2 per cent); seeking medical care was at its lowest (47.7 per cent) in the 2 decades of statistics reviewed for this study. The current study showed that inflation is positively correlated with ‘incidence of poverty’ which concurs with the literature1 and within the context that inflation is directly associated with lowered real wages coupled with increased pricing of goods, and a marginal increase in seeking medical care. Noting this it should not be surprising that there is a switching from private health care utilization to public health care utilization. This study revealed a strong indirect correlation between private health care service utilization and public health care service utilization, with a fixed income or lowered real wages and increased prices of ‘food and beverage’, inflation which is expressed through prices changes all commodities is explain reduced health care seeking behaviour as well as the purchase of health insurance as decision to buy ‘food’ is filled first before health care is sought by people. This study showed that when inflation is low the demand for private health care facilities is significantly greater than public health care services. It was also found that when inflation rises beyond a certain percentage (40 per cent), there is a substitution of private health care services with public health care service utilization. Embedded in this finding is the strong preference for private health care services of Jamaicans as they do not merely substitute private for public health care services when inflation is low or it is not sustained over a year. Thus, what this study

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has highlighted is the fact that if inflation continues to rise over many years people will switch from private to public health care services. Inflation does not only influence the cost of private health care services as this equally affects the cost of medical care of public health care services. Costing is an important ingredient in decision to utilize public and private health care services and what emerged from this study is fact that poverty increases when inflation increases and this suggest that substitution has to do with affordability. This fact is supported by the statistics from the Jamaica Survey of Living Conditions that have showed that over the last one half decade, the poorest Jamaicans have increased their spending on ‘food and beverage’ from 50 per cent to approximately 54 per cent and lower their demand for health care. On the other hand, the wealthy and wealthiest Jamaicans have increased their spending on ‘food and beverage’ but their expenditure was less than 40 per cent. It follows that with the increase spending on ‘basic food’ within the context of persistent rise in inflation, this accommodates for the substitution of private health care facilities to public health care services. Health care seeking behaviour falls in periods of persistently high inflation. Using health insurance as a proxy for health care seeking behaviour, over the last one half decade health insurance coverage has been falling and this support the private-public health care substitution. There is an important finding here as there is a positive correlation between inflation and illness/injury and this justifies the increase in public health care utilization as in periods of inflation this means increased prices even in medical care. Inflation mean higher prices and people will have less disposable income to spend on health care as they must spend more for consumption goods (food and beverage). One scholar argued that the Jamaican economy underperformed in comparison to other Latin American and Caribbean societies in the 1990s1, and inflation did not only reached a record 80.2 per cent in 1991, but private health care

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utilization was the highest in that period. There is a crucible fact in this high private health care utilization as demographic compositions of those who access this facility are private middle-toupper class individuals. This is inferred from the statistic of the Planning Institute of Jamaica and the Statistical Institute of Jamaica (Jamaica Survey of Living Conditions) (Table 5) that showed that approximately 68 per cent of consumption of the poorest Jamaicans is spent on food, beverage and household expenses, with a maximum of 7 per cent spent on health care. Hence, in period of persistently inflation, the wealth and the wealthiest suffer from more injuries as the current study revealed a positive correlation between private health care service demand and inflation, and it was found that direct association exists between injury/illness and inflation. The poor on the other hand in periods of high inflation will resort more to spending on ‘food and nonalcoholic beverage’ than on health care, which justify reduce public in periods of persistently high inflation. For the poor in periods of low inflation they will attend to health care more than in periods of high inflation and this is equally the case for the middle class. Furthermore, in periods of low inflation the addition amount that is available to the individual coupled with lower cost of health care explains the influx of people attending public health care because they are able to afford their natural preference for private health care services that becomes difficult in times of exorbitantly high prices. Given that increased cost of medical care is not only synonymous with private health care utilization, and Jamaican preference for private health care utilization is evident as the rate of substitution in periods of low inflation for the services of private health care facilities is such that it is wider than in periods of persistently high inflation. Embedded in this reality is the society low appetite for utilizing public health care services. One of the rationale for public health care utilization not been overtaken by public health care utilization is the fact that private health care

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costing has been reducing and this as well as the composition of the those who attend former facilities accounts for the reduction but not the total substitution. Private health care facilities provide a product in a different milieu and the service quality is different from that provided by public health care facilities; hence, the substitution from attending public health care facilities is substantial in the periods of low inflation but in high inflationary periods, the rate of substitution away from private health care facilities is lower than that of substitution rate in periods of low inflation. The performance of public and private health care services was never assessed in this study, but it can be extrapolated from the findings that Jamaicans are dissatisfied with the services offered by public health care facilities and this is borne out from the high substitution rate in period of low inflation, suggesting that if they were able to afford it in period of inflation they would have maintain utilizing the services of private health care facilities. The poorest in any society is the most affected in periods of inflation (persistent or otherwise) and this is also reflected in the health seeking behaviour statistics. In 1991, when inflation was 80.2 per cent statistics revealed that Jamaicans seek the least health care in 2 decades (47.7 per cent – Table 6). On the contrary, when inflation was at the least in the 2 decade period (5.7 per cent), Jamaicans sought medical care the most in the period (70.0 per cent). One of the findings of this study is the strong correlation between medical care seeking behaviour and inflation and within the context that inflation affects the poorest the most, the findings revealed that in the period of the highest inflation, incidence of poverty stood at its peak and medical care demand was at its least. Public health care demand Jamaica is substantially a poor people phenomenon and this is embedded in the statistics as periods of high inflation (40 to 81 per cent) which corresponds to high incidence of poverty, public health care utilization was at its least will private health care utilization was between 1.6 to 2.2 times more than that of visits

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to public health care facilities. Another issue that emerged from this finding is the stressed level of those in the middle to upper classes in period of high inflation and how they resort to medical care to address their psychological state. The poor, on the other hand, because they are unable to afford medical care compared to the middle class or the affluent resort to home care and violence. Using Anthony Harriott’s work22, we found that the rates of violent crimes (per 100, 000) in Jamaica increased from 1988 to 1990, and over 1990 to 1992 during the period in which inflation and incidence of poverty were high and health seeking behaviour of the poor was low. Costing of health care services23 is not the only deterrent to the utilization of public health care services in Jamaica as the operation of public health facilities is a part of the rationale for the switching in periods of affordability. A study conducted in Jamaica using a mixed methodology (survey of 1,017 respondents and a focus group) revealed that loudness of staffers, embarrassments, aggressive behaviour, physical layout of the public facilities including the cleanliness of the facilities were among some of the reasons given for dissatisfaction with public health utilization23, and these were concurred by the World Development Report24. The World Development Report identified a number of factors – credibility of public health staffers, unprofessional treatment of patients, abuse, corruption- that we will title switching factors that account for the substitution of private to public health care utilization. Those are some of the reasons why Jamaicans prefer utilizing private health care services as the treatment of the staffers is highly professional, respectful and accommodating unlike the aforementioned issues that are synonymous with public health care. Another deterrent factor that emerged from Bailey and her colleagues’ work was transportation cost. This speaks to the accessible of health care for some residents who dwell in rural areas coupled with their economic state of poverty.

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What accommodates for the narrowing of the gap between public and private health care utilization in Jamaica within the context of an economy has been experiencing lowered rates of ‘incidence of poverty’ and lower rate of inflation than in the 1990s? In September 2001, American experienced the 9/11 and the year proceeding that remittances was 26.6 per cent and this was the lowest in six years [2001 to 2006] (Table 3). Now with the downturn in the world economy in particular the American economy, this explains why Jamaicans have received lower remittances in 2007 (Table 4). Remittance is a source of income for many Jamaicans, and the downturn in the American economy is negatively impacting on the amount that is received by Jamaicans. For 2007, the per cent of Jamaicans receiving remittances fell (Tables 3 & 4). Remittance normally is an income subsidy for countless Jamaicans and this accounts for lowered expenditure on health care and other goods (or services). Although inflation rates are not generally comparable to that of the 1990s, again the recession in the American economy is resulting in lowered income for many Jamaicans and inflation for 2007 over 2006 has increased by 289.04 per cent. It should be noted here that less Jamaicans in 2007 utilize both public and private health care services, suggesting more people were resorting to home remedy. This is supported by the statistics which revealed that 66 per cent of Jamaicans seek medical care compared to 70 per cent in 2006. The lowered economic growth in the United States coupled with the increases in global food prices, the rise in prices of foods; beverage and fuel are forcing Jamaicans to substitute utilizing private health care services for home care. Recently (2007), the Jamaica removes the cost associated with medical care from all public health care institutions and this would not be captured in the 2007 public health care utilization but this would be catering to a few people who wanted to attend those institutions but were not able to afford it. Primarily those who attend private health care institutions are those of

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the middle-to-upper class who still do not have a preference for public health care services (visits). The lowering of the cost of public health care means a lowering of health care cost of private health care services. This adjustment in prices accommodate for the lowering of substitution away from private health care to public health care despite the reality of economic recession in the world economy. Based on Table 2, annual inflation on ‘food and non-alcoholic beverage’ has increased by 24.7 per cent in 2007; cost of medical care has increased by 3.4% coupled within the context of massive general annual rate of 16.8 per cent inflation, the challenges of survivability is becoming increasing more difficult and so more people are resorting to traditional care (home remedy). Jamaica Survey of Living Conditions (2006) had that 28.5 per cent of Jamaicans indicated that they used home remedy as it was the preferred way to go compared to 16.8 per cent in 2004; and in 2006, 22.2 per cent reported that they were unable to afford medical costing compared to 19.6 per cent in 2004. In a national survey that was conducted in 2006, Powell, Bourne, & Waller25, using probability sample of technique drew a sample of 1,338 Jamaicans (respondents), when the respondents were asked “How would you describe your present economic situation ad that of your family?”, 69% indicated at most average and this figure 19% indicated bad and very bad. Another question that was asked is “Does you salary and the total of your family’s salary allow you to satisfactorily cover your needs?” only 38.1% of Jamaicans said that their salary was able to cover their needs. In the same study, when the respondents were asked “[Do you] feel secure about the state [your] health?”, out of a maximum 10 points, those who classify themselves as in the lower class had a score of 5.8, the middle class had a score of 6.7and the upper class, 6.6.

Concluding Remarks

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This paper has presented an exploration of public and private health care utilization in Jamaica and in the process provides an understanding of the role of inflation on health seeking behaviour as well as an explanation for the narrowing of the gap between the two aforementioned utilizations. While inflation accounts for a low percentage of the explanation for the switching, when it is persistent it results in increased unemployment, cost of living, downturn in the economic, forfeiture in the payment of debts, and the increased in deprivation of the poor. This research is advantageous to policy makers, medical practitioners and other scholars as we provide information on this critical matter, but there are many areas that we were unable to examine given that we used secondary data. It would be interesting to see whether suicides increase in periods of persistently high inflation or depression increases in periods of inflation but data on the matter are not consistent over the period. Nevertheless, we provide pertinent information within the context of the available data for 2 decades (1988to 2007). We will now conclude on the important issues of the study. There is an increasing concern in the world about economic recession, lowered real wages, redundancies, increased prices, declining consumer demand for good (or services) and poverty, but in our quest to stimulate economic growth because of its influence on all aspects of socio-economic development, and now there is a study that has examined the relationship between inflation and public and private health care utilization. Using two decades of statistics, the findings of showed that persistently increased inflation results in substitution from private to public health care utilization, and that in periods of low inflation (single digit), the rate of substitution for private health care utilization away from public health care services is significantly greater. One of the fundamental aspects to development is people, and people are

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primarily concerned about their survivability which explains a critical aspect to this study. One of the crucible finding of the current research is the positive correlation between inflation and illness/injury. Within the context that persistent inflation over the last one half decade in Jamaica (2003 to 2007) coupled with the increased prices in ‘food and non-alcoholic beverages’, Jamaican are resorting to home care. Jamaicans have a preference for private health care utilization, and within the context of the economic recession in America that influences the survivability of tourism industry, remittances and the economic opportunities of countless Jamaicans, people are resorting more to home care instead of substantially substituting private for public health care utilization. In keeping with the natural instinct to survive with the aforementioned issues, Jamaicans have taken the decision to fulfill their basic physiological needs (food, shelter, and health) and with the persistent increase in those commodities, they have taken decisions to spend on food, shelter, clothing and less on health care except if their ill-health depends on their state of survivability. Food and beverage fulfill fundamental needs, and in case of increased prices this will automatically mean they will spend more on those commodities, and reduce their spending on health care. Powell, Bourne & Waller’s work25 when the respondents were asked “[Do you] feel secure about affording necessities” out of a maximum score of 10, those who classified themselves as lower class indicated 5.2, the middle class and the upper class indicated 6.7. Poverty (poor) means deprivation from resources – income, health insurance coverage, schooling, poor sanitation and drinking water, and nutrition - and this account for them demanding less health care in period of high inflation. They will be unable to afford ‘food and beverage’ and this they would prefer to purchase as against demand medical care and so explain their low access to health care which accounts for more home care in this cohort. Therefore, poor

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who equally prefers private health care services in Jamaica is unable to afford this, and their state accounts for lowered public health care utilization in high inflationary period. In inflationary periods the middle class to the wealthiest class demand more health care which is in keeping with the psychological stressors of the time. Accordingly, the narrowing of the gap between public and private health care in Jamaica is owing to (i) persistent increases in the inflation rates, (ii) increase prices for consumption and non-consumption goods – including foods, fuel and transportation costs, (iii) the downturn in the American economy and (iv) increases in illness/injury within the aforementioned context. With education, despite the challenges of economic shortfalls in the nation, people realize the importance of seeking medical care and in order to accomplish this reality, the substitution of private for public health care utilization is in keeping with health consciousness and increases costing of foods and non-consumption commodities. Poverty in Jamaica is synonymous with rural residents (Table 7) and although there has been a substantial decline in the prevalence of poverty over the years and more so in 2007 (Table 1), it increased in rural Jamaica. With the downturn in the America economy which is having an inverse effect on remittances, increases in prices of food and non-alcoholic beverages coupled with the increased poverty in rural Jamaica, a part of the decline in public and private health care utilization and expenditure (Table 5) is owing to economic difficulties faced by rural residents. Some Jamaicans continue to purport that among the difficulties for not seeking health care is affordability – in 2007 over 2006, real mean public expenditure on public health care (in 1990 $) decline by 40.5% while in the same period mean amount spent on drug fell by 20.8%- and this reality is compounded for the elderly populace. Unlike the working age population, a small proportion of the elderly are employed in addition to increased prices, downturn in the

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Americans, lowered remittances and increased poverty in rural Jamaica, the elderly who constitute of approximately 47 per cent of the rural Jamaica (Table 8) are having to facing the economic challenges of the time. Within the context of those realities, the lowering of health care seeking in Jamaica is due to elderly residents’ withdrawal from seeking health care accounted for the lowered public and private health care utilization and expenditure. This research has many unresolved questions that are felt for further studies. One, we know that there is a correlation between illness/injury but we are not cognizant whether or not this is owing to physical or psychological conditions. Two, the study assumes that males and females are similar experiences and with the context of studies that have shown that there is disparity between the socio-economic conditions of the sexes, the research is needed to clarity any similarities (or dissimilarities). Third, poverty is synonymous with rural areas and so any study that seeks to understand Jamaicans experiences must disaggregate this by area of residence and age cohorts. Fourthly, Jamaica is an island that is interdependent on the global economies and so it would be interesting to inco-operatate this on public and private health care utilization in Jamaica. ACKNOWLEDGEMENT The author would like to thank the Data Bank in the Sir Arthur Lewis Institute of Social and Economic Studies, the University of the West Indies, Mona, Jamaica for making the dataset (Jamaica Survey of Living Conditions, 2002) available. It was used for the current study.

Disclosure Statement The authors have no conflicts of interest to report.

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Reference 1. King D. The Evolution of Structural Adjustment and Stabilisation Policy in Jamaica. Social and Economic Studies. 2001; 50: 1-53. 2. Bourne P. Inflation: Causes and Influences on the Jamaican Economy. Unpublished Essay, University of the West Indies, Mona, Jamaica; 2004. 3. Wilson GW. Inflation-Causes, Consequences, and Cures. Indiana University Press; 1982. (http://www.guestia,com) 4. Thomas D. Jamaica: Macroeconomic Policy environment (March 1998). http://www.iadb.org/exr/sep/ja981.htm - 59k - Cached) 5. Alleyne D. The Dynamics of Growth, Employment and Economic Reforms in Jamaica. Social and Economic Studies. 2001; 50: 55-125. 6. United Nations Development Programme (UNDP). Human Development Report, various years. New York: UNDP; various years. 7. Zoega G. Inflation and unemployment in Iceland in the Light of Natural-Rate Theory. Central Bank of Iceland, Working Papers No. 17; 2002. Access on December 10, 2008 from http://www.sedlabanki.is/uploads/files/Wp-17.pdf. 8. Phelps ES, Winter SG. Optimal price policy under atomistic competition, in E.S. Phelps et al. Microeconomic Foundations of Employment and Inflation Theory, New York: Norton; 1970. 9. Leman E. A Search Model of Unemployment and Inflation. Mimeo. 10. Luca R, Jr. Inflation and Welfare. Econometrica. 2000;68, 247-274. 11. Friedman M. Inflation and unemployment. Nobel Memorial Lecture, December, 1976, The University of Chicago, Illinois, USA; 1976. 12. Friedman M. Inflation and unemployment. Journal of Political Economy. 1977. 13. Gordon RJ. Productivity growth, Inflation, and Unemployment. New York: Cambridge University Press. 2003. 14. Phillips AW. The relationship between unemployment and the Rate of Change of Money Wage Rates in the United Kingdom, 1861-1957. Economica, 1958: 283-299. 15. Phelps ES. Phillips Curve, Expectations of Inflation and Optimal Unemployment Over Time. Economica (N. S.).1967; 34: 254-281. 16. Gordon RJ. Recent Developments in the Theory of Inflation and Unemployment. Journal of Monetary Economics.1976; 2:185-219. 17. Mankiw NG. The Inexorable and Mysterious Tradeoff Between Inflation and Unemployment. This paper was presented as the Harry Johnson Lecture at the annual meeting of the Royal Economic Society, July 2000. Accessed on December 10, 2008 from http://www.economics.harvard.edu/faculty/mankiw/files/royalpap.pdf. 18. Burke AW. Suicide in Jamaica. West Indian Medical J. 1985;34:48-53. 19. Mahy G. Suicide in the Caribbean. Int Rev Psychiatr. 1993;5:261-9. 20. Yoshio N. The present statistics of suicide – necessity for preventive activities. Rechtsmedizin. 2005; 4: 279. 21. Yamaskai A, Sakai R, Shirakawa T. Low income, unemployment, and suicide mortality rates for middle-age persons in Japan. Psychol Rep. 2005; 96:337-48.

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22. Harriott A. The Jamaican Crime Problem: Some Policy Considerations. In Harriott A, Brathwaite F, Wortley S, eds. Crime and Criminal Justice in the Caribbean. Kingston: Arawak Publishers; 2004. 23. Bailey W, Lalta S, Gordon-Strachan G, Henry-Lee A, Ward E, Barnett J. The Impact of User Fee for Preventative Care on Health Seeking and Coping Behaviour of Patients in Jamaica. Unpublished essay, University of the West Indies; 2004. 24. United Nations Development Programme. World Development Report, 2006. New York: UNDP; 2006. 25. Powell LA, Bourne P, Waller L. Probing Jamaica’s Political Culture: Main Trends in the July-August 2006 Leadership and Governance Survey, volume 1. Kingston: Centre for Leadership and Governance, Department of Government, the University of the West Indies; 2007

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Table 12.1: Inflation, Public and private health Care Service Utilization, Incidence of Poverty, Illness and Prevalence of Population with Health Insurance (in per cent), 1988-2007

Year

Inflation

Public Utilization

Private Utilization

Prevalence of poverty

Illness

Health Insurance

1988 8.8 NI NI NI 1989 17.2 38.0 54.0 30.5 1990 29.8 39.4 60.6 28.4 1991 80.2 35.6 57.7 44.6 1992 40.2 28.5 63.4 33.9 1993 30.1 30.9 63.8 24.4 1994 26.8 28.8 66.7 22.8 1995 25.6 27.2 66.4 27.5 1996 15.8 31.8 63.6 26.1 1997 9.2 32.1 58.8 19.9 1998 7.9 37.9 57.3 15.9 1999 6.8 37.9 57.1 16.9 2000 6.1 40.8 53.6 18.9 2001 8.8 38.7 54.8 16.9 2002 7.2 57.8 42.7 19.7 2003 13.8 NI NI NI 2004 13.7 46.3 46.4 16.9 2005 12.6 NI NI NI 2006 5.7 41.3 52.8 14.3 2007 16.8 40.5 51.9 9.9 Source: Bank of Jamaica, Statistical Digest, Jamaica Survey of Living and Social survey of Jamaica, various issues

NI NI 16.8 8.2 18.3 9.0 13.7 8.6 10.6 9.0 12.0 10.1 12.9 8.8 9.8 9.7 10.7 9.8 9.7 12.6 8.8 12.1 10.1 12.1 14.2 14.0 13.4 13.9 12.6 13.5 NI NI 11.4 19.2 NI NI 12.2 18.4 15.5 21.2 Conditions, Economic

Note: Inflation is measured point-to-point at the end of each year (December to December), based on Consumer Price Index (CPI) NI No Information available

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Table 12.2:Annual Inflation in Food and Non-Alcoholic beverages and Health Care Cost, 20032007

Food and Non-Alcoholic beverage 2002 2003 2004 2005 2006 2007 7.8 10.0 13.7 11.7 5.0 24.7

Health Care Cost 5.2 9.7 6.4 7.5 9.7 3.4

Source: Planning Institute of Jamaica, Economic and Social Survey of Jamaica, various issues Note: Inflation is measure using point-to-point at the end of the year (December to December).

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Table 12.3 Percentage of Households Receiving Remittances By Region, 2001-2005 YEAR Region 2001* 2002* 2003* 2004* 2005* 2006 2007

KMA Other Towns Rural Area Jamaica

28.7 34.2 41.6 35.8

22.2 27.9 28.9 26.6

27.9 32.7 33.0 31.5

30.2 38.9 32.1 32.9

38.4 43.3 36.9 38.7

50.4 45.0 42.3 45.3

41.5 48.6 38.6 41.8

Source: Jamaica Survey of Living Conditions, 2006 *Revised Figures 2001-2005

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Table 12.4 Percentage of Households Receiving Remittances By Quintile, 2001-2005 YEAR Quintile Poorest 2 3 4 5 Jamaica 2001* 26.0 35.3 44.0 35.8 35.0 35.8 2002* 19.8 25.9 28.4 29.9 26.4 26.6 2003* 20.6 28.1 35.7 37.0 32.1 31.6 2004* 22.5 29.6 34.7 35.2 35.7 32.9 2005* 21.2 38.8 38.9 42.1 43.4 38.7 2006 30.4 40.3 41.5 47.4 54.9 45.3 2007 26.0 33.0 44.2 46.6 48.6 41.8

Source: Jamaica Survey of Living Conditions, 2006-2007 *Revised figures 2000-2005

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Table 12.5 Mean Patient Expenditure ($) on Health Care in Public and Private Facilities in the Four-Week Reference Period, JSLC 1993-2004, 2006 Year Visits Drugs Private Public Private Public Nominal Real Nominal Real Nominal Real Nominal Real
(1990$) (1990$) (1990$) (1990$)

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2004 2006 2007

298 461 496 598 693 832 1301 1081 1103 1339 2278 1406 1679.5

85 109 99 104 95 106 154 120 115 132 191 101 114.2

115 91 130 148 283 315 339 309 546 464 489 860 539.9

33 21 26 26 39 40 40 34 57 46 41 62 36.9

331 417 509 685 946 1050 1196 1241 1698 1501 2181 2212 2573.1

94 98 101 119 129 134 142 138 177 148 183 158 174

131 163 234 176 575 316 401 468 742 541 843 1174 929.7

37 38 47 31 78 40 47 52 77 56 71 84 66.5

Source: Jamaica Survey of Living Conditions 2002, 2006 and 2007

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Table 12.6 Purchased medication and Seeking Medical Care (Per Cent), 19-2006 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2004 2006 2007

Per cent purchased medication Public NI 8.9 Private NI 58.5 Seeking medical care 47.7 50.9 51.8

21.4 75.6 51.4 58.9

19.1 78.0 54.9

22.0 74.3 59.6

19.7 76.6 60.8

18.5 77.0 68.4

20.8 73.3 60.7

20.0 76.9 63.5

26.5 68.0 64.1

19.1 74.3 65.1

15.9 76.6 70.0

13.7 80.3 66

Source: Jamaica Survey of Living Conditions 2002, 2006 and 2007 NI No Information Available

Table 12.7 Distribution of Poverty By Region (Per cent), 1997-2007 1997 Region KMA Other Town Rural Area 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

13.6 13.1 73.3

12.5 15.1 72.5

18.2 12.5 69.3

17.2 16.0 66.8

14.7 13.7 71.6

15.8 15.7 68.5

12.8 13.2 74.0

26.3 9.9 64.7

20.3 9.3 70.2

21.2 13.1 65.7

19.9 8.9 71.3

Source: Jamaica Survey of Living Conditions 2002, 2006 and 2007

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Table 12.8 Distribution of Elderly Population (ages 60 years and older) By Region (Per Cent), 1997-2007 Year KMA Other Towns Rural Area 1997 27.2 18.5 54.3 1998 18.4 16.1 65.6 1999 26.6 18.0 55.4 2000 28.4 19.0 52.6 2001 25.4 19.4 55.2 2002 27.0 14.7 58.3 2003 25.0 13.8 61.2 2004 29.1 21.5 49.4 2005 30.9 21.4 47.7 2006 30.8 22.7 46.5 2007 32.5 20.9 46.6 Source: Jamaica Survey of Living Conditions, 2007

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Chapter

13

Self-evaluated health and health conditions of rural residents in a developing country

In Jamaica in 1989 the national poverty rate was 30.5% and this exponentially fell by 208.1% in 2007, but in the latter year, rural poverty was 4 times more than peri-urban and 3 times more than the urban poverty rate. Yet there is no study on health status and health conditions in order to examine changes among rural residents. The present study aims to (1) examine epidemiological shifts in the typology of health conditions in rural Jamaicans, (2) determine correlates and estimates of the self-evaluated health status of rural residents, (3) determine correlates and estimates of self-evaluated health conditions of rural residents and (4) assist policy-makers in understanding how intervention programmes can be structured to address some of the identified inequalities among rural residents in Jamaica. The survey was drawn using stratified random sampling. This design was a two-stage stratified random sampling design where there was a Primary Sampling Unit and a selection of dwellings from the primary units. Statistical analyses were performed using the Statistical Package for the Social Sciences. Descriptive statistics such as mean, standard deviation, frequency and percentage were used to analyze the socio-demographic characteristics of the sample. Chi-square was used to examine the association between non-metric variables, and multiple logistics were used to establish factors that explain a dichotomous dependent variable. In 2002, 14% of respondents indicated having an illness in the 4-week period of the survey compared to 17% in 2007. For 2002, there are 12 determinants of health: 11 social and 1 psychological, whereas in 2007, there were 7 determinants of health: 6 social and 1 biological. The determinants accounted for 22.6% of the explanatory power of the health model for 2002 and 44.7% for 2007. With the exponential increase in diabetes mellitus and health inequalities that exist today in rural Jamaica, public health authorities and other policy-makers need to use multidimensional intervention strategies to address those inequalities.

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Introduction
The health of a population is critical to all forms of development. This is a justifiable rationale for governments’ investing in health care and the health system. Despite governments in Latin America and the Caribbean increasing their investment in health since the 1980’s [1], there are still many inequalities in health among and within their nations [2]. This is evident in the health disparities indicators as well as the social determinants of health [3-6]. The advancement in technology and medical sciences has not removed the disparities in infant mortality, poverty, health service utilization, and health differentials within and among Latin American and Caribbean nations or within and among the social hierarchies. Casas et al. [4] cited that the improvements in health in the region are not in keeping with the region’s economic development rates, and the same can be said of the health differences between the wealthy and the poor. In Jamaica, which is an English-speaking country in the Latin America and Caribbean region, the national poverty rate in 1989 was 30.5% and this fell exponentially by 208.1% in 2007, but in the latter year rural poverty was 4 times more than peri-urban and 3 times more than the urban poverty rate [9], and that most of the wealthy reside in urban or peri-urban than rural areas. Statistics from the World Health Organization (WHO) for 2007 showed that both life expectancy, and healthy life expectancy at birth was at least 4 years more for females than males, and that these were greater in developed than in developing countries as was the case for infant mortality [7]. The health disparity is aptly demonstrated by the WHO [8], they opined that 80% of chronic illnesses were in low and middle income countries, 60% of global mortality is caused by chronic illness, and that “In reality, low and middle income countries are at the centre of both old and new public health challenges” [8]. They went on that “...People who are already poor are

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the most likely to suffer financially from chronic diseases, which often deepen poverty and damage long term economic prospects”[8]. Many empirical studies have found that rural residents have lower health status and/or more health conditions, higher levels of poverty and lower levels of education compared to their urban counterparts [8-18], and this is also the case in Jamaica [19]. Statistics from the Planning Institute of Jamaica and the Statistical Institute of Jamaica, since 1989, demonstrate that poverty is area and gender specific (rural and female). These disparities speak to socio-economic and health inequalities within and among states. Although there are empirical findings which reveal that health inequalities and inequities do exist between rural and urban residences, as well as among social hierarchies and between the sexes in Latin America and the Caribbean, particularly Jamaica, only a few studies were found to have examined the health status of rural people in the region [14, 19-28]. Inequities and/or inequalities in health can only be addressed in the region if they are understood through research within each nation, and policy-makers cannot rely on the funding of studies outside of their region or in developed countries in order to effectively remedy the challenges that they face. The relationship between poverty and ill health is empirically established, but the focus of the region since the 1980s has been poverty reduction, and while this has been progressing, the health disparities are still evident today [3]. Embedded in the literature, therefore, are income mal-distribution, working conditions and health outcome inequalities, inequalities in health determinants, and lower material wellbeing and poverty, which have a direct influence on health. Poverty also indirectly influences health service utilization, the quality of received care and healthy life expectancy. With poverty being substantially a rural

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phenomenon [9], investment in health in rural areas requires an understanding of the changes occurring in health conditions among the residents.

The WHO [8] opined that 80% of chronic illnesses were in low and middle income countries, suggesting that illness interfaces with poverty and other socio-economic challenges. Poverty does not only impact on illness, it causes premature deaths, lowers the quality of life, creates lower life and unhealthy life expectancy, low development and other social ills such as crime, high pregnancy rates, and social degradation of the community. According to Bourne & Beckford [15], there is a positive correlation between poverty and unemployment, poverty and illness; and crime and unemployment. Embedded in those findings are the challenges of living in poverty, and the perpetual nature of poverty and illness, poverty and unemployment, economic deprivation and the psychological frustration of poor families. Sen [18] encapsulated this well when he postulated that low levels of unemployment in the economy are associated with higher levels of capability. This highlights the economic challenge of unemployment and equally explains the labour incapacitation on account of high levels of unemployment, which goes back to the WHO’s perspective that chronic illnesses are more often experienced by low-to-middle income people. According to the WHO [8], 60% of global mortality is caused by chronic illness, and this should be understood within the context that four-fifths of chronic dysfunctions are in low-to-middle income countries.

Within the aforementioned findings, area of residence, in particular rural areas, is too much of an important variable to be treated as an explanatory concept. Montgomery [17] opined that urban causes of mortality and disability provide an understanding of urban-rural health differentials. The paper provides answers to some of the urban health disparities in developing

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countries, and compares these situations with those faced by rural residents. Montgomery’s findings [17] were generally on developing countries, and while his work does give some insights into urban-rural health inequalities, it cannot be used to formulate policies or intervention strategies specifically for Jamaica. The rationale embedded in this argument is the fact that not all developing countries are at the same socio-economic stage of development, and therefore research is required for any intervention techniques chosen for effecting health changes. Concurrent investment in health is critical to economic development [29]; once again this has not resulted in the removal of health inequalities in Latin America and the Caribbean, in particular Jamaica [3-5]. Therefore, the present study aims to (1) examine epidemiological shifts in the typology of health conditions in rural Jamaicans, (2) determine correlates and estimates of rural residents’ self-evaluated health status, (3) determine correlates and estimates of rural residents’ self-evaluated health conditions, and (4) assist policy-makers in understanding how intervention programmes can be structured to address some of the inequalities identified among rural residents in Jamaica.

Methods and materials
Setting and design
The current study extracted samples of 15,260 and 3,322 rural residents from two surveys, collected jointly by the Planning Institute of Jamaica and the Statistical Institute of Jamaica for 2002 and 2007 respectively [30,31]. The method of selection of the sample from each survey was solely based on rural residence. The survey (Jamaica Survey of Living Conditions) was begun in 1989, and collected data from Jamaicans in order to assess government policies. Each year since 1989, the JSLC has added a new module in order to examine that phenomenon which is so critical to the nation. In 2002, the foci were on 1) social safety nets and 2) crime and 339

victimization; and for 2007, there was no focus. The sample for the earlier survey was 25,018 respondents, and for the latter it was 6,783 respondents. The survey was drawn using stratified random sampling. This design was a two-stage stratified random sampling design where there was a Primary Sampling Unit (PSU) and a selection of dwellings from the primary units. The PSU is an Enumeration District (ED), which is comprised of a minimum of 100 residences in rural areas and 150 in urban areas. An ED is an independent geographical unit that shares a common boundary. This means that the country was grouped into strata of equal size based on dwellings (EDs). Based on the PSUs, a listing of all the dwellings was made, and this became the sampling frame from which a Master Sample of dwellings was compiled, which in turn provided the sampling frame for the labour force. One third of the Labour Force Survey (. the LFS) was selected for the JSLC [30, 31]. The sample was weighted to reflect the population of the nation. The 2007 JSLC [30] was conducted in May and August of that year, while the 2002 JSLC was administered between July and October of that year. The researchers chose this survey based on the fact that it is the latest survey on the national population, and that it contains data on the self-reported health status of Jamaicans. An administered questionnaire was used to collect the data, which were stored and analyzed using SPSS for Windows 16.0 (SPSS Inc; Chicago, IL, USA). The questionnaire was modelled on the World Bank’s Living Standards Measurement Study (LSMS) household survey. There are some modifications to the LSMS, as the JSLC is more focused on policy impacts. The questionnaire covered areas such as socio-demographic variables, for example, education, daily expenses (for the past 7days), food and other consumption expenditures, inventory of durable goods, health variables, crime and victimization, social safety nets, and anthropometry. The questionnaire contains standardized items such as

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socio-demographic variables, excluding crime and victimization which were added in 2002 and later removed from the instrument, with the exception of a few new modules each year. The nonresponse rate for the survey for 2007 was 26.2% and 27.7%. The non-response section includes refusals and cases rejected in data cleaning. Measurement Dependent variable Self-reported illness (or self-reported dysfunction): The question was asked: “Is this a diagnosed recurring illness?” The answering options are: Yes, Influenza; Yes, Diarrhoea; Yes, Respiratory diseases; Yes, Diabetes; Yes, Hypertension; Yes, Arthritis; Yes, Other; and No. A binary variable was later created from this construct (1 = no 0 = otherwise) to be applied in the logistic regression. This was used to indicate health status (dependent variable) for 2002. Self-rated health status is measured using people’s self-rating of their overall health status [32], which ranges from excellent to poor health status. The question that was asked in the survey was “How is your health in general?” And the options were very good; good; fair; poor and very poor. For the purpose of the model in this study, self-rated health was coded as a binary variable (1 = good and fair, 0 = Otherwise) [33-38]. The binary good health status was used as the dependent variable for 2007. Covariates Age is a continuous variable which is the number of years alive since birth (using last birthday) Social hierarchy: This variable was measured based on income quintile: The upper classes were those in the wealthy quintiles (quintiles 4 and 5); middle class was quintile 3 and the poor classes were those in the lower quintiles (quintiles 1 and 2).

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Medical care-seeking behaviour was taken from the question ‘Has a health care practitioner or pharmacist been visited in the last 4 weeks?’ with there being two options Yes or No. Medical care-seeking behaviour therefore was coded as a binary measure where 1 = Yes and 0 = otherwise.

Crowding is the total number of individuals in the household divided by the number of rooms (excluding kitchen, verandah and bathroom). Age is a continuous variable in years.

Sex: This is a binary variable where 1 = male and 0 = otherwise.

Social supports (or networks) denote different social networks with which the individual is involved (1 = membership of and/or visits to civic organizations, or having friends who visit one’s home, or with whom one is able to network, 0 = otherwise).

Psychological conditions are the psychological state of an individual, and this is subdivided into positive and negative affective psychological conditions [39, 40]. Positive affective psychological condition is the number of responses with regard to being hopeful, and optimistic about the future as well as life generally. Negative affective psychological condition is the number of responses from a person on having lost a breadwinner and/or family member, having lost property, being made redundant or failing to meet household and other obligations.

Statistical Analysis Descriptive statistics such as mean, standard deviation (SD), frequency and percentage were used to analyze the socio-demographic characteristics of the sample. Chi-square was used to examine the association between non-metric variables. Multiple logistic regressions were used to analyze factors that explain the current usage of a contraceptive method. Odds ratios were determined 342

from the use of a binary logistic regression model. Where collinearity existed (r > 0.7), variables were entered independently into the model to determine those that should be retained during the final construction of the model. To derive accurate tests of statistical significance, we used SUDDAN statistical software (Research Triangle Institute, Research Triangle Park, NC), and this was adjusted for the survey’s complex sampling design. A P-value < 0.05 (two-tailed) was used to determine statistical significance.

Results
Demographic Table 13.1 examines the demographic characteristics of the samples for 2002 and 2007. The samples were 15,260 and 3,322 rural respondents for 2002 and 2007 respectively. The findings revealed that 96.3% of the sample for 2002 responded to the question ‘Have you had any illness in the past 4 weeks, and the rate was 97% for 2007. In 2002, 14% of those who responded to the question of illness claimed yes, compared to 17% in 2007. When the respondents were asked to state the health conditions they experienced in 2002, 1.3% answered compared to 14.8% in 2007. Self-reported health conditions showed exponential increases in influenza and respiratory conditions in 2007 over 2002. Hypertensive and arthritic cases fell by 44.1% and 75.7% respectively, while diabetes mellitus increased by 150% over the studied period. Eighty-one percentage points of the sample claimed to have at least good health status and 6% at least poor health. Of those who indicated at least good health, 37% stated very good (or excellent) health compared to 1.1% who claimed very poor health, of those who indicated at least poor health status. When respondents were asked ‘Why did you not seek medical care for your illness?’ in 2002, 23.2% stated that they could not afford it; 41.3% were not ill enough and 22.2% used

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home remedies. For 2007, 17.4% claimed that they were unable to afford it, 43.3% were not ill enough and 16.8% stated that they used home remedies.

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Table 13.1. Demographic characteristics, 2002 and 2007 2002 Variable Sex Male Female Marital status Married Never married Divorced Separated Widowed Social hierarchy Lower Middle Wealthy Self-reported illness Yes No Self-reported health conditions Acute Influenza Diarrhoea Respiratory diseases Chronic Diabetes mellitus Hypertension Arthritis Other Medical care-seeking behaviour Yes No Medical care utilization Public hospitals Private hospitals Public health care centres Private health care centres Health insurance coverage Yes No Age median, in years, range) Length of illness, in days, median (range) N 7,727 7,524 2,460 6,436 56 104 610 7,298 3,169 4,791 1,987 12,713 % 50.6 49.3 25.6 66.6 0.6 1.1 6.3 47.8 20.8 31.4 13.5 86.5 n 1,654 1,668 513 1,462 22 20 112 1,828 650 844 536 2,688 2007 % 49.8 50.2 24.1 68.7 1.0 0.9 5.3 55.0 19.6 25.4 16.6 83.4

1 4 6 10 82 48 40 1,302 740 499 80 285 528

0.5 2.1 3.1 5.2 42.9 25.1 20.9 63.8 36.4 39.1 6.3 22.3 41.3

80 19 51 64 118 30 130 349 202 127 8 76 158

16.3 3.9 10.4 13.0 24.0 6.1 26.4 63.3 36.7 37.2 2.3 22.3 46.3

1,036 7.0 13,714 93.0 23 (0 to 99) 7 (0 to 90)

464 14.5 2,715 85.5 25 (0 to 99) 7 (0 to 99)

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Bivariate analyses Table 13.2 presents self-reported health conditions by sex, age, health care-seeking behaviour, and length of illness of sample. Females were more likely to indicate suffering from different health conditions than males, except for respiratory diseases. Of those who stated particular health conditions, those with chronic illnesses such as hypertension and arthritis were more likely to spend more time suffering from the diseases.

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Table 13.2: Self-reported health conditions by particular social variables Health conditions Acute conditions Influenza Diarrhoea Respiratory Diabetes mellitus Chronic HyperArthritis tension

Variable

Other

P

2002
Sex (%) Male Female Total Age - in years- mean (SD) Health care-seeking behaviour Yes (%) Total Length of illness – in days – Mean (SD) Sex (%) Male Female Total Age - in years- mean (SD) Health care-seeking behaviour Yes (%) Total n Length of illness – in days – Mean (SD) 0.0 100.0 1 80.0 (0.0) 25.0 75.0 4 1.8 (1.7) 83.3 16.7 6 14.0 (24.6) 20.0 80.0 10 63.7 (13.2) 30.5 69.5 82 68.7 (13.7) 79.3 82 16 (11) 20.8 79.2 48 68.4 (12.60 83.3 48 18 (11) 0.045 35.0 65.0 40 56.0 < 0.0001 (23.4) 65.0 40 19 (12) 0.05 0.045

0.0 10 3 (0)

75.0 14 4 (2)

100.0 6 11 (5)

88.9 9 12 (11)

2007
<0.0001 42.5 57.5 80 19.5 (24.8) 41.3 80 8 (6) 36.8 63.2 19 20.1 (28.5) 56.9 43.1 51 24.3 (23.8) 20.3 79.7 64 56.5 (17.4) 27.1 72.9 118 64.0 (17.1) 64.4 118 104 (239) 46.7 53.3 30 68.3 (12.0) 46.7 30 112 (217) 43.1 56.9 130 36.0 (25.0) 70.5 129 57 (188)

<0.0001 < 0.0001

52.6 19 5 (2)

62.7 51 42 (172)

75.0 64 76 (135)

0.004

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Table 13.3 examines health care-seeking behaviour by sex, self-reported illness, health coverage, social hierarchy, educational levels, age and length of illness for 2002 and 2007. Based on Table 3, the mean age of someone who sought medical care is greater than someone who did not. There is no significant statistical association between medical care-seeking behaviour and self-reported illness, but there is a relationship between length of illness and medical care-seeking behaviour.

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Table 13.3. Health care-seeking behaviour by sex, self-reported illness, health coverage, social hierarchy, education, age and length of illness, 2002 and 2007 2002 2007 Variable Health care-seeking behaviour Health care-seeking behaviour Yes No P Yes No P N (%) N (%) N (%) N (%) 0.011 0.112 Sex Male 511 (39.2) 333 (45.0) 134 (38.4) 89 (44.1) Female 791 (60.8) 407 (55.0) 215 (61.6) 113 (55.9) 0.360 0.130 Self-reported illness Yes 1261 (97.0) 713 (96.6) 335 (96.3) 199 (98.5) No 39 (3.0) 25 (3.4) 13 (3.7) 3 (1.5) 0.197 0.013 Health insurance coverage Yes 89 (6.9) 40 (5.4) 270 (77.4) 173 (86.1) No 1210 (93.1) 700 (94.6) 79 (22.6) 28 (13.9) <0.0001 0.104 Social hierarchy Lower 545 (41.9) 363 (49.1) 167 (47.9) 115 (56.9) Middle 248 (19.0) 157 (21.2) 79 (22.6) 41 (20.3) Wealthy 509 (39.1) 220 (29.7) 103 (29.5) 46 (22.8) <0.0001 0.623 Educational level Primary or below 402 (40.5) 208 (41.5) 336 (96.3) 191 (94.6) Secondary 569 (57.4) 279 (55.7) 11 (3.2) 9 (4.5) Tertiary 21 (2.1) 14 (2.8) 2 (0.6) 2 (1.0) Age mean (SD) – in years 46.4 (27.4) 40.4 (28.3) <0.0001 43.5 (27.5) 37.9 (146.8) 0.025 Length of illness mean (SD) – in days 12 (11) 10 (9) <0.0001 7 (20) 5 (15) 0.01

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Multivariate analyses Table 13.4 represents information on the social and psychological determinants of health of rural residents for 2002 and 2007. Based on Table 4, in 2002 there were 12 determinants of health: 11 social and 1 psychological. On the other hand, in 2007, there were 7 determinants of health: 6 social and 1 biological. The determinants accounted for 22.6% of the explanatory power of the health model for 2002 and 44.7% for 2007. Sixty-eight percentage points of the health status model can be accounted for by self-reported illness (R squared = 30.4%).

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Table 13.4. Stepwise Logistic regression: Social and psychological determinants of self-evaluated health, 2002 and 2007 2002 2007 Explanatory variables: Coefficient Std. Odds 95% CI Coefficient Std. Odds 95% CI Error ratio Error ratio Income 0.000 0.000 1.00 1.00-1.00 0.000 0.000 1.00 1.00-1.00 Age -0.044 0.002 0.96 0.93-0.96 -0.052 0.004 0.95 0.94-0.96 Middle NS NS NS NS 0.321 0.196 1.38 0.94-2.02 Wealthy -0.311 0.090 0.73 0.61-0.88 NS NS NS NS †Lower 1.00 1.00 Total Durable good 0.058 0.013 1.06 1.03-1.09 NS NS NS NS Separated, divorced or widowed -0.367 0.109 0.69 0.56-0.86 NS NS NS NS Married -0.307 0.077 0.74 0.63-0.86 NS NS NS NS †Never married 1.00 NS NS NS NS Tertiary -0.175 0.065 0.84 0.72-0.98 NS NS NS NS †Primary or below 1.00 Social support -0.229 0.070 0.80 0.70-0.90 NID NID NID NID Male 0.803 0.011 2.23 1.95-2.56 0.563 0.134 1.76 1.35-2.28 Negative affective conditions -0.062 0.037 0.94 0.92-0.96 NID NID NID NID Number of females in household 0.123 0.025 1.13 1.05-1.22 NID NID NID NID Number of children in household 0.056 0.006 1.06 1.01-1.11 NID NID NID NID Length of illness -0.039 0.193 0.96 0.95-0.97 NS NS NS NS Crowding NS NS NS NS -0.081 0.029 0.92 0.87-0.98 Medical care-seeking = yes NS NS NS NS -1.01 0.26 0.36 0.21-0.60 Self-reported illness -2.225 0.15 0.11 0.08-0.15 -LL 6,381.3 1,562.6 N 12,666 2,817 Nagelkerke R square 0.226 0.447 2 χ 1220.5 670.0 NS – not significant (P > 0.05) NID – not in dataset and/or could not be measured based on the available data

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Table 13.5 shows the contribution of each explanatory variable to the model for 2002 and 2007. Based on Table 5, of the social and psychological determinants of health, age explains more of the variability in health than any other determinant. Income contributed at most 0.2% to the health of respondents. Using the non-reporting of an illness to measure the health of rural respondents, age accounted for 77% of their health; but when self-reported health status was used to measure health, age accounted for only 11.5%.

Table 13.5. Stepwise Logistic regression: R-squared for social and psychological determinants of self-evaluated health, 2002 and 2007 2002 2007 Explanatory variables: R squared R squared Income 0.1 0.2 Age 17.4 11.5 Middle NS 0.4 Wealthy 0.1 NS Total Durable good 0.2 NS Separated, divorced or widowed 0.1 NS Married 0.2 NS Tertiary 0.1 NS Social support 0.2 NS Male 2.2 1.2 Negative affective conditions 0.4 NID Number of females in household 0.5 NID Number of children in household 0.1 NID Length of illness 1.0 NS Crowding NS 0.2 Medical care-seeking = yes NS 0.8 Self-reported illness 30.4 NS – not significant (P > 0.05) NID – not in dataset

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Discussion
The current health status of rural respondents was good (. 81 out of every 100), but 17 out of every 100 had an illness. In spite of reporting an illness, the present study found that 36 out of every 100 ill respondents had not sought medical care. Of those who did not utilize medical care although they indicated an illness, at least 41% claimed financial inadequacies, and in 2007, 17% used home remedies. The results revealed that rural respondents have a conceptualization of illness that medical care outside of the home should be utilized based on length of illness and not merely on the ailment. Similarly, illness accounted for most of the current health status, an indication of the dominance of the biomedical perspective in viewing health and health care in rural Jamaica. While self-reported chronic health conditions fell by over 41% in 2007 over 2002, the percentage of those who reported acute conditions increased by over 436%. Of the higher number of cases of acute conditions, respiratory diseases accounted for 235% while influenza accounted for a 3160% increase over 2002. Although overall self-reported chronic health conditions saw a decline for 2007 over 2002, diabetes mellitus was the only condition that showed an increase in the study (. 150%). Interestingly, the current findings showed that 107.1% more rural residents were covered by health insurance in 2007 than in 2002, but this reflected a minimal reduction in those seeking medical care. The number of rural residents who were classified into the lower (. working) class increased by 15.1% and 19.1% of those in the wealthy class dwelled in rural areas With income being positively correlated with good health, an increase in the number of people in the lower class highlights the diminished health noted for 2007. Males continue to report better health status than females, but this fell from 2.3 times more in 2002 to 1.8 times in 2007, which suggests that the reduction in income substantially influences the quality of life of rural males.

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The current findings concur with the literature in demonstrating that severity of illness (or length of illness), age, and health coverage are more positively related to medical care-seeking behaviour than illness [41-43]. Statistics from national cross-sectional surveys in Jamaica since 1989 [9] revealed that females were approximately twice as likely to report an illness and utilize medical care than males. When the absolute figures from the surveys were cross-tabulated, it was found that the statistical association which existed in 2002 disappeared in 2007. This is not atypical to Jamaica, as a qualitative study in Pakistan on street children found that boys who attended formal health care were more likely to do so based on severity of illness than on whether it affected their economic livelihood [41]. Another study conducted in Anyigba, NorthCentral Nigeria, found that [42] 85 out of every 100 respondents waited for less than a week after the onset of illness to seek medical help, and that 57 out of every 100 were confident that they would recover without treatment. In this research it was revealed that 43 out of every 100 rural residents indicated that they were not ill enough, which suggests that they believed they would recover in time. Health care facilities in Jamaica are primarily operated by females, and with the perception in the culture that males must be masculine, which includes exhibiting strength and power and avoiding weakness, it explains the rationale for severity of illness accounting for medical care-seeking behaviour as against actual illness [41-43]. Dunlop et al.’s work, which found that females utilize health care facilities more than males [44], partially concurs with this research, in discovering this to be the case in 2002. In 2002, 1.6 times more females sought medical care than males, but the study found that there was no significant association between sex and medical care-seeking behaviour for 2007. The explanation for this is embodied in (1)

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income, (2) inflation and (3) the increased number of people who were classified into the lower class. Income is positively correlated with social hierarchy, health, and employment status [16, 45-50]. Income, which is among the social determinants of health, is directly associated with health through material wellbeing, but it is also associated with occupational and social hierarchies. The poor receive less income than the middle and wealthy classes, which indicates that with an increase in the number of people in the lower class, their income will be reduced and so will their health status. It should be noted here that poverty, which affects health, is exponentially greater in rural Jamaica, and also that there are more females in rural households. In 2007, inflation increased by 194% over 2006 [20] and coupled with the lower income, rural respondents, in particular females who are more likely to be unemployed, own less material resources and are increasingly becoming single parents [9]. This would justify the narrowing of the health care-seeking gap that existed in 2002. Williams et al. [42] found that medical careseeking behaviour did not differ significantly between the sexes, a factor which is in keeping with the situation for 2007 in this study. The WHO [8] found that poverty is associated with increased health conditions. Empirical evidence existed showing that poverty is related to low levels of choice, income, access to health care services, and opportunities, and this is highlighted in the present study. Latin American and Caribbean governments have increased their investment in health care, and in 2006 the Jamaican government removed public health care utilization fees for children (0 to 18 years) and expanded the ‘drugs for the elderly’ programme to include all people who suffer from specific chronic illnesses. While these undoubtedly increase the health outcomes which

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would have been lower without those opportunities, health inequalities still exist among rural residents. With all the investment in health from decentralization of the health care system, drugs for the elderly programmes, and removal of health care user fees for public health care interventions, there is a rise in acute health conditions, in particular influenza and respiratory diseases. The good news is the reduction in chronic health conditions. But this good news is nothing to celebrate, as diabetes mellitus has increased exponentially in the last half a decade. The reduction in numbers of hypertensive and arthritic cases corresponds to lowered ages in reporting having those illnesses. The mean age of reporting hypertension has declined by 5 years (to 64 years) and 7.2 years (to 56.5 years). Furthermore, Morrison [51] postulated that hypertension and diabetes are now twin problems in the Caribbean, and although the current study has shown a reduction in self-reported hypertension in rural Jamaica, 24 out of every 100 health conditions were accounted for by hypertension. Diabetes mellitus accounted for 13 out of every 100 health conditions, which speaks to a future rural health problem. Another researcher found that 50% of people with diabetes had a history of hypertension, and this too suggests a future health challenge for policy-makers and public health practitioners. The lowered ages of reporting particular chronic illnesses indicate that rural residents will be living longer with those conditions, and this will measurably increase the burden on the health care system in the future. A critical issue emerging from this study is the value that rural residents ascribed to illness in determining their health status. There is a strong negative statistical correlation between self-reported illness and good health status. The findings indicated that 68% of the explanatory power of good health status can be accounted for by illness. This is not atypical, as research by Hambleton et al. on the Barbadian elderly population found that illness accounted for 88.0% of

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health status. It can be extrapolated from those findings that (1) the older one gets, the more emphasis one places on illness in the evaluation of health status, (2) the relationship between illness and health appears to be more a causal one than an associative one, (3) the biomedical approach to measuring health still predominates in people’s perceptions, and (4) the culture which fashions the conceptualization of health is influencing health care-seeking behaviour. Those issues are among the principal reasons why care is curative and not preventative in Jamaica, and this is captured in the finding which showed that health care-seeking behaviour is negatively correlated with good health. Rural respondents who seek medical care are 64% less likely to report good health status, pointing to the embedded cultural dominance of the biomedical approach in the conceptualization of health. The dominance of the biomedical approach to the study of health in Jamaica is even high among medical researchers, as a study conducted in 2007/08 examined medical history; health care-seeking behaviour; health (. diseases, medication consumption), mental health, sexual practices, dietary habits; lifestyle (. violence and injury; smoking, narcotics and alcohol consumption), community and home milieu, suggesting the greater weight on health from the perspective of illness, its treatment and measurable outcome, as against people’s assessment of their health status [53]. Another limitation of the ‘Jamaica Health and Lifestyle Survey II’ was that the area of residence disaggregation of the health data collected, even though limited, was omitted. The current study bridges this gap, and goes further by using self-assessed heath status in addition to self-rated health and health care-seeking behaviour, and provides other pertinent health information on rural Jamaicans.

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Conclusion
Health inequalities in rural Jamaica still exist today. The current study found that in the future health care institutions will be called on to invest more in the health system, in order to address the health challenges of increased diabetes mellitus as well as respiratory diseases. On the other hand, despite government investments in health, progress in technology, public health services, increased levels of education and income since the last century, decision-makers, public health practitioners and other health care providers need to recognize that increased life expectancy and lowered infant mortality rates have not addressed the challenges inherent in the health of the rural population in Jamaica. General financial investment in health is needed, to control communicable diseases that are particularly detrimental to children, such as diarrhoea and respiratory diseases, which are on the increase in rural areas. This means that the level of economic development since the 20th Century does not provide answers to the differences in health outcomes within a country. The identified health disparities in rural Jamaica denote that investments in health and health intervention strategies are not effectively addressing the health inequalities which underlie the health statistics. This means that the health inequalities in those areas in Jamaica will fuel future public health challenges for society, as well as increasing the economic burden borne by the health care system. The analyses provided in the current study clearly highlight the need for thinking that will incorporate the health realities of rural populations into the agenda of policy-makers.

The way forward
The present work highlights the lingering dominance of the biomedical perspective that continues to influence health and health care in rural Jamaica. Hence, the way forward for government and policy-makers, including health care practitioners as well as public health 358

educators, in order to reduce health inequalities, is a multi-dimensional approach to health and health care, as the current mechanism is not working. The researcher is proposing (1) mobile clinics, (2) community and house visits from medical practitioners, (3) restructuring health care facilities to reflect a new preventative thrust, (4) the introduction of a preventative care approach as a subject in all schools, (5) focusing not only on the extreme of income poverty and health care access, but on opportunities, empowerment and the security of poor and rural residents, (6) recognition of the need for a social security network that brings nutritious foods to rural residents, and (7) recognition of the need for a modification to the way public health programmes are fashioned and operated, as well as extending and re-defining the boundaries of public health intervention. These new mechanisms will be costly, but a reorganization of expenditure means that some of the money spent for curative care will be saved, as preventative care is the focal point, and not curative health treatment. Another important thing which is needed is research on the value system of rural residents, and this should be done using a longitudinal study in order to provide information for health care intervention strategies.

Conflict of interest
The author has no conflict of interest to report.

Disclaimer
The researcher would like to note that while this study used secondary data from the Jamaica Survey of Living Conditions, none of the errors in this paper should be ascribed to the Planning Institute of Jamaica or the Statistical Institute of Jamaica, but to the researcher.

Acknowledgement
The author thank the Data Bank in Sir Arthur Lewis Institute of Social and Economic Studies, the University of the West Indies, Mona, Jamaica for making the dataset (Jamaica Survey of Living Conditions, 2002) available for use in this study. In addition to the aforementioned, the author would also like to extend sincere appreciation to Samuel McDaniel, Ph.D (Harvard), Biostatistician, Department of Mathematics, the University of the West Indies, who reviewed the statistics for accurateness, and made suggestions for its improvements.

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19. Bourne PA. A theoretical framework of good health status of Jamaicans: using econometric analysis to model good health status over the life course. North Am J of Med Sci 2009; 1: 8695. 20. Bourne PA. Impact of poverty, not seeking medical care, unemployment, inflation, selfreported illness, health insurance on mortality in Jamaica. North Am J of Med Sci 2009; 1:99-109. 21. Bourne PA. An epidemiological transition of health conditions, and health status of the oldold-to-oldest-old in Jamaica: a comparative analysis. North Am J of Med Sci 2009; 1:211219. 22. Bourne PA. Socio-demographic determinants of Health care-seeking behaviour, self-reported illness and Self-evaluated Health status in Jamaica. Int Journal of Collaborative Research on Internal Medicine & Public Health 2009;1: 101-130. 23. Bourne PA, Rhule J. Good Health Status of Rural Women in the Reproductive Ages. Int J of Collaborative Research on Internal Medicine & Public Health 2009;1:132-155. 24. Bourne PA. Health Determinants: Using Secondary Data to Model Predictors of Well-being of Jamaicans. West Indian Med J. 2008; 57:476-481. 25. Bourne PA. Medical Sociology: Modelling Well-being for elderly People in Jamaica. West Indian Med J 2008; 57:596-604. 26. Asnani MR, Reid ME, Ali SB, Lipps G, Williams-Green P. Quality of life in patients with sickle cell disease in Jamaica: rural-urban differences. J of Rural and Remote Health 2008; 8: 890-899. 27. Hutchinson G, Simeon DT, Bain BC, Wyatt GE, Tucker MB, LeFranc E. Social and Health determinants of well-being and life satisfaction in Jamaica. Int J of Soc Psychiatry 2004; 50:43-53. 28. Bourne PA, McGrowder DA. Rural health in Jamaica: examining and refining the predictive factors of good health status of rural residents. J of Rural and Remote Health 2009; 9: 1116. 29. WHO. Macroeconomics and health: Investing in health for economic development. Geneva: WHO; 2001. 30. Statistical Institute Of Jamaica. Jamaica Survey of Living Conditions, 2007 [Computer file]. Kingston, Jamaica: Statistical Institute Of Jamaica [producer], 2007. Kingston, Jamaica: Planning Institute of Jamaica and Derek Gordon Databank, University of the West Indies [distributors], 2008. 31. Statistical Institute Of Jamaica. Jamaica Survey of Living Conditions, 2002 [Computer file]. Kingston, Jamaica: Statistical Institute Of Jamaica [producer], 2002. Kingston, Jamaica: Planning Institute of Jamaica and Derek Gordon Databank, University of the West Indies [distributors], 2003. 32. Kahneman D, Riis J. Living, and thinking about it, two perspectives. In: Huppert, F.A., Kaverne, B. and N. Baylis, The Science of Well-being, Oxford University Press; 2005. 33. Finnas F, Nyqvist F, Saarela, J. Some methodological remarks on self-rated health. The Open Public Health J 2008; 1: 32-39. 34. Helasoja V, Lahelma E, Prattala R, Kasmel A, Klumbiene J, Pudule I. The sociodemographic patterning of health in Estonia, Latvia, Lituania and Finland. European J of Public Health 2006; 16:8-20. 35. Molarius A, Berglund K, Eriksson C, et al. Socioeconomic conditions, lifestyle factors, and self-rated health among men and women in Sweden. European J Public Health 2007; 17:12533. 361

36. Leinsalu M. Social variation in self-rated health in Estonia: a cross-sectional study. Soci Sci and Medicine 2002; 55:847-61. 37. Idler EL, Benjamin Y. Self-rated health and mortality: A Review of Twenty-seven Community Studies. J of Health and Social Behavior 1997; 38: 21-37. 38. Idler EL, Kasl SV. Self-ratings of health: Do they also predict change in functional ability. J of Gerontology: Soc Sci 1995; 50B:S344-S353. 39. Diener E. Subjective well-being: The science of happiness and a proposal for a national index. Am Psychological Association 2000; 55: 34-43. 40. Harris PR, Lightsey OR Jr. Constructive thinking as a mediator of the relationship between extraversion, neuroticism, and subjective wellbeing. European J of Personality 2005; 19: 409-426. 41. Ali M, de Muynck A. Illness incidence and health seeking behaviour among street children in Rawalpindi and Islamabad, Pakistan – a qualitative study. Child: Care, Health & Development 2005; 31:525-532. 42. Williams RE, Black CL, Kim H-Y, Andrews EB, Mangel AW, Buda JJ, Cook SF. Determinants of health-care-seeking behaviour among subjects with irritable bowel syndrome. Alimentary Pharmacology & Therapeutics 2006; 23:1667-1675. 43. Chevannes B. Learning to be a man: Culture, socialization and gender identity in five Caribbean communities. Kingston, Jamaica: University of the West Indies Press; 2001. 44. Dunlop DD, Manheim LM, Song J, Chang RW. Gender and ethnic/racial disparities in health care utilization among older adults. J of Gerontology: Soci Sci 2002; 57B: S221-S233. 45. Grossman M. The demand for health - a theoretical and empirical investigation. New York: National Bureau of Economic Research; 1972. 46. Smith JP, Kington R. Demographic and Economic Correlates of Health in Old Age. Demography 1997; 34:159-70. 47. Wilkinson RG, Marmot M. Social Determinants of Health. The Solid Facts, 2nd ed. Copenhagen: World Health Organization; 2003. 48. Graham H. Social Determinants and their Unequal Distribution Clarifying Policy Understanding The Milbank Quarterly 2004; 82;101-124. 49. Pettigrew M, Whitehead M, McIntyre SJ, Graham H, Egan M. Evidence for Public Health Policy on Inequalities: 1: The Reality According To Policymakers. J of Epidemiol and Community Health 2004; 5:811 – 816. 50. Stronks K, Van de Mheen H, Van de Bos J, Mackenbach JP. The interrelationship between income, health and employment status. Int J of Epidemiol 1997; 26:592-600. 51. Morrison E. Diabetes and hypertension: Twin trouble. Cajanus 2002; 33:61-63. 52. Callender J. Lifestyle management in the hypertensive diabetic. Cajanus 2000; 33:67-70. 53. Wilks R, Younger N, Tulloch-Reid M, McFarlane S, Francis D. Jamaica health and lifestyle survey 2007/08. Kingston: Epidemiology research unit, Tropical Medicine Research Institute, University of the West Indies, Mona; 2008.

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Chapter

14

Self-reported health and health care utilization of older people

Paul A. Bourne, Christopher A.D. Charles, Cynthia G. Francis & Stan Warren

Introduction
In the Caribbean and Latin America, issues on the elderly (ages 60+ years) have been reviewed by scholars such as Alvarado et al. [16]; Bourne [12-15]; Brathwaite [10, 11]; Eldemire [1-6]; Grell [7]; Hambleton and colleagues [9]; Lawson [8]; and others [17-20]. However, Bourne [15], Hambleton et al. [9] and Menéndez et al. [20] have examined health status of the elderly in the Latin America and the Caribbean with only the former investigating the health status of the oldto-oldest elderly (ages 75+). While Hambleton and colleagues, and Menéndez and collaborators have examined health status, health conditions and functional capacity of people 60+ years, Bourne [15] studied health and health conditions of elderly 75+ years which means that none of those studies have researched the changing pattern of acute and chronic diseases, health careseeking behaviour and health status for the population 80+ years. Many studies examine the elderly age cohort as a single entity, indicating that they treat health challenges facing the elderly population (60+ year) as though they are the same across the elderly age cohort - young-old (ages 60-74 years); old-old (ages 75-84 years) and oldest-old (ages 85+). In 2000, statistics revealed that there were 1.4% of the Caribbean population 80+ years, 1.8% of Jamaica, 0.9% of Latin America and the Caribbean and 6.9% of the World [21]. 363

Based on Figures 14.1 and 14.2, the rate of growth in the population 60+ years is greater than that for the 65+ and 80+ years in the Caribbean as well as in Jamaica; but this does not mean that the 80+ age cohort given that they constituted less than 2% should be excluded from research inquiry. The reality is they do exist, and information are needed on them in order to guide public health policies and programmes as current plans are made for this age cohort using information on the general elderly population. Data from the Statistical Institute of Jamaica (STATIN) on mortality goes up to age 75+ years [22], but no mortality data are available for those 80+ years. Mortality which is used to compute life expectancy is therefore not presented for people 80+ years neither are health status nor health conditions. United Nations’ publication reported data on survival rates, life expectancy, growth rate, sex ration, population and percentage of people in older ages for those up to 80+ age cohort which is not the case for STATIN. Neither of the two institutions has examined in a single study the health, health conditions and health care-seeking behaviour of those 80+ years. Statistics from Pan American Health Organization (PAHO) [23] presented information on health of people 60+ years and again no data is available on those 80+ years and they constituted 2% of the Jamaica’s population and 1.1% of the world’s population. The traditional approach is life expectancy, and health status of the elderly population (60+ years) by disaggregating the old population and this assumes that the conditions affecting this age cohort remains constant during old age. Bogue opined that the health problems, health conditions and health care-seeking behaviour (ie health demand) increases with ageing [24], suggesting that aggregating elderly in 60+ and examining this age cohort will not provide the health practitioner with a better understanding of the different ageing segment and issues surrounding that age cohort. Statistics

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from the Planning Institute of Jamaica (PIOJ) and the Statistical Institute of Jamaica revealed that elderly Jamaicans had the greatest hospital visits and, health conditions than all other age cohorts [25]. Again the data were not disaggregated by the three elderly age cohorts, which meant that information is lost in the aggregated data. Concomitantly, 37.9% of all new diabetic cases and 39.8% of new hypertensive cases between January and June 2007 seen in public health facilities were accounted by senior Jamaicans (ages 60+ years) [26]. At the same time, 43.8% of elderly (ages 65+ years) in 2007 reported an illness in the 4-week reference period and 75.9% indicated that the illness was a recurring one compared to 74.2% of those 60-64 years who reported that they were suffering from a recurring illness and 36.6% revealed that they were ill [25]. There is a gap in the literature about the health status, health conditions and health careseeking behaviour of people 80+ years in the Caribbean in general and Jamaica in particular. The health literature that evaluates functional capacity, health status, health conditions and health care-seeking behaviour of the elderly 60+ years or even 65+ year span the 3 categories of elderly (young-old; old-old and oldest-old) and does not provide a comprehensive understanding of the elderly cohorts. Hypertension, diabetes mellitus and arthritis are among the five leading cause of morbidity in the elderly (ages 60+ years) population in Jamaica [26] and this is also the case in Barbados, St. Lucia, Guyana, and Trinidad and Tobago, and Uruguay [13, 27]. Using data on a PAHO/WHO survey on health, wellbeing and aging (SABE), Rossi and Triunfo [28] disaggregated the data for the three elderly age cohorts but like previous studies, they did not use this to ascertain information on chronic illness, or health status. While this data provides invaluable information on the population 60+ years, by not disaggregating the elderly into the 3 aforementioned categories the data assume that they are affected at the same rate across the life course.

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Outside of South America, and Latin America and the Caribbean, using information on elderly 75+ years from Israel, Benyamini et al. [29] found that the health status of young-old (75-84 years) was lower than that for the old-old (85-94 years). A study in Newcastle conducted by Collerton et al. [30] on elderly 85+ years revealed that 77.6% of them rate their health status as at least good, indicating that the remainder were experiencing at least poor health. A study by Bourne et al. [14], using data for Jamaicans 55+ years, they found that as people age increases, their poor health status increases.. However, Bourne et al’s work [14] found that 52% of elderly 70+ years reported poor health compared to 22% of the participants 85+ years in the Newcastle study. Extrapolation from the two studies suggests that there is a positive relationship between increased health conditions and age of old people. Inspite of the literature, there is a gap in the health literature on the health status, health conditions and health care-seeking behaviour of those 80+ years. Therefore, the aims of this study are to (1) examine health status of the 80+ year population in Jamaica, (2) evaluate whether there are shifts in the typology of dysfunctions over the last 6 years (2002-2007), (3) examine whether health status and self-reported dysfunctions are correlated for those 80+ age cohort, (4) evaluate the health care-seeking behaviour of those 80+ years, and (5) compare and contrast the results of the 80+ year cohort with the general 60+ year cohort. We now turn to the material and methods we used in the current study (Figure 14.2).

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Source: Extracted from Department of Economic and Social Affairs Population Divisions, United Nations, (UN). World Population Ageing 1950-2050. New York: 2002.

Figure 14.1. Caribbean Elderly population as a percentage of total population

Source: Extracted from Department of Economic and Social Affairs Population Divisions, United Nations, (UN). World Population Ageing 1950-2050. New York: 2002.

Figure 14.2. Jamaica Elderly population as a percentage of total population

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Materials and Methods Sample
The current study extracted a sample of 722 elderly participants 80+ years from the dataset of the Jamaica Survey of Living Conditions (JSLC): 566 and 159 respondents from 2002 and 2007. The JSLC is jointly administered by the Planning Institute of Jamaica (JSLC) and the Statistical Institute of Jamaica (STATIN). JSLC is a national cross-sectional probability survey which is conducted normally between April and May of each year. An-administered instrument (questionnaire) is used to collect data from Jamaicans. The questionnaire was modelled from the World Bank’s Living Standards Measurement Study (LSMS) household survey. There are some modifications to the LSMS, as JSLC is more focused on policy impacts. The questionnaire covered socio-demographic variables – such as education; daily expenses (for past 7-day; food and other consumption expenditure; inventory of durable goods; health variables; crime and victimization; social safety net and anthropometry. Survey The survey was drawn using stratified random sampling. The design was a two-stage stratified random sampling design where there was a Primary Sampling Unit (PSU) and a selection of dwellings from the primary units. The PSU is an Enumeration District (ED), which constitutes a minimum of 100 residences in rural areas and 150 in urban areas. An ED is an independent geographic unit that shares a common boundary. This means that the country is grouped into strata of equal size based on dwellings (EDs). Based on the PSUs, a listing of all the dwellings was made, and this became the sampling frame from which a Master Sample of dwelling was compiled, which in turn provided the sampling frame for the labour force. One third of the Labour Force Survey (LFS) was selected for the JSLC. The sample was weighted to 368

reflect the population of the nation. The non-response rate for the survey for 2007 was 26.2% and 27.7% for 2002. The non-response includes refusals and rejected cases in data cleaning. Statistical analysis The data were collected, stored and retrieved in SPSS for Windows 16.0 (SPSS Inc; Chicago, IL, USA). Descriptive statistics were used to provide information on the sociodemographic variables of the study; and, chi-square was used to examine association between non-metric variables and ANOVA was utilized to examine the equality of means among the nondichotomous variables. In addition to the aforementioned, elasticity of demand and income elasticity of demand were computed for health status. Measurement Elasticity of demand measures consumers’ demand responsiveness to changes in particular product attributes such as price. In this paper, the research will examine health insurance elasticity of health care-seeking behaviour, and income elasticity of health careseeking behaviour. Elasticity is calculated as a percentage of the change in demand (in this case health care-seeking behaviour) divided by the percentage change in (1) health insurance; and (2) income (ie total annual expenditure). Elasticity of health care-seeking behaviour with reference health Insurance = % Δ HSB/ %Δ HI Where HSB is health care-seeking behaviour and HI is health insurance coverage Elasticity of health care-seeking behaviour with reference to income = % Δ HSB/ %Δ Y Where Y is income (ie total annual expenditure). Elasticity of health care-seeking behaviour with reference to self-reported illness = % Δ HSB/ %Δ SRI Where SRI is self-reported illness The values below will be used to compute the elasticities (Table 14.0).

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Table 14.0. Health insurance, health care-seekers and median total annual expenditure for 2002 and 2007 20021 20072 Health insurance coverage 16 (2.9%) 45 (29%) Health care-seekers 163 (68.2%) 59 (77.6) Self-reported illness 239 (43.5%) 76 (48.7%) Median Total Annual Expenditure (Range) Ja $170,019.8 Ja $396,576.9 (Ja $1,954,053) (Ja $5,213,338) 1 Ja $50.47 + US $1.00 2 Ja $80.97 = US $1.00 Health conditions (ie. self-reported illness or self-reported dysfunction): The question was asked: “Is this a diagnosed recurring illness?” The answering options are: Yes, Cold; Yes, Diarrhoea; Yes, Asthma; Yes, Diabetes; Yes, Hypertension; Yes, Arthritis; Yes, Other; and No. Self-rated health status: “How is your health in general?” And the options were very good; good; fair; poor and very poor. Social class: This variable was measured based on the income quintiles: The upper classes were those in the wealthy quintiles (quintiles 4 and 5); middle class was quintile 3 and poor those in lower quintiles (quintiles 1 and 2). Health care-seeking behaviour. This is a dichotomous variable which came from the question “Has a doctor, nurse, pharmacist, midwife, healer or any other health practitioner been visited?” with the option (yes or no). National Health Fund (NHF). This is a health coverage provided by the Jamaican Government to reduce the burden on the health care sector. It provides prescription health benefits to all residents. This was established under the National Health Fund Act which came into being in 2003. The NHF subsidies drugs for residents who are affected by any of the 15 illnesses. These are (1) arthritis; (2) asthma; (3) benign prostate hyperplasia (BPH); (4) breast cancer; (5) diabetes mellitus; (6) epilepsy; (7) glaucoma; (8) high cholesterol; (9) hypertension; (10) ischemic heart disease; (11) major depression; (12) prostate cancer; (13) psychosis; (14) rheumatic heart disease, and (15) vascular disease. Jamaica Drug for the Elderly Programme (JADEP). The JADEP was established by the Ministry of Health in July 2004 to provide drugs for elderly Jamaicans (ages 60+ years), and this was later handed over to the NHF as an individual benefit. It enables elderly people to access drugs through subsidized payment by the government if the individual is suffering from any 370

combination of eleven dysfunctions. These are 1) arthritis; 2) asthma; 3) benign prostate hyperplasia; 4) enlarged prostate; 5) cardiac or heart disease; 6) diabetes mellitus; 7) high cholesterol; 8) hypertension (or high blood pressure); 9) psychiatric conditions; 10) vascular conditions (or circulatory problems), and 11) glaucoma.

Results
A sample of 566 elderly 80+ years was extracted for 2002 (39.9% men and 60.1% women) with a mean age of 85.4 years (4.6 years), while the sample for 2007 was 157 elderly 80+ years (37.1% men and 62.9% women) with a mean age of 85.0 years (4.5 years) (Table 1). Forty-four percent of the 2002 sample reported suffering from an illness and this increased to 48.7% in 2007. In 2002, 42.2% of the sample responded to the question of ‘have you visited a health care practitioner in the last 4-weeks’ compared to 47.8% in 2007. Of those who responded, 68.2% reported yes in 2002 and 77.2% claimed yes in 2007. Based on Table 14.1, there is a shift toward urban areas: 30.2% resided in urban areas in 2007 compared to 10.1% in 2002; 18.7% in semiurban areas in 2002 and 20.8% in 2007. Shifts were also taking placing in health conditions over the two periods studied. In 2007 over 2002, in the acute illness category, there were reductions in the number of elderly suffering from cold and asthma to increases in those suffering from asthma., Hypertension was the most prevalently diagnosed disease among chronic conditions in 2007 (46.8%) and this represented a 1% decline over 2002. Diabetes mellitus had the greatest increase by 550% over the period studied compared to +9% in unspecified diseases, and -76.6% in arthritic cases (Table 14.1). Similarly, the numbers of 80+ years widowed Jamaicans increased by 3.8% and the percentage of married sample increased to 25.8% (from 23.3% in 2002). Three percentages of the elderly 80+ years had health insurance coverage in 2002 and by 2007 this had increased exponentially to 900%. The increased in health insurance coverage can be substantially accounted for by public coverage (+782.8%).

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Based on Table 14.2, no significant statistical correlation was found between diagnosed health conditions and area of residents and that this was the case in both years. In spite of this reality, the reduction in hypertensive cases can be accounted for by the decline in number of cases in semi-urban residents, while the urban cases increased. The greatest reduction in arthritic cases were among urban residents followed by rural dwellers and an increase was also observed among semi-urban residents. Increases in diabetic cases were observed in all three geographic regions with the greatest increase in the semi-urban areas. No significant statistical association was found between health status and area of residents (χ2 (df = 8) = 11.899, P > 0.05). No comparison is possible as there were no figures for 2002 as the first time that data on health status was recorded was in 2007 (Table 14.3). Table 14.4 showed that a statistical correlation existed between health status and selfreported illness but that the relationship was a weak one (contingency coefficient = 0.278). Furthermore, 46.1% of those who indicated an illness had health status were poor-to-very-poor, with only 2.6% of them having a very good health status, 11.8% a good health status and 39.5% a moderate health status. On the other hand, the 25.1% of those who indicated that they had no illness reported poor-to-very-poor health status compared to the 10.0% who had very good health status and the 25.0% who had good health status. A cross-tabulation between health status and sex of respondents revealed no significant statistical correlation (χ2 (df = 4) = 3.867, P > 0.05) (Table 14.5). A statistical relationship exists between health status and income quintile (χ2 (df = 16) = 26.716, P < 0.045); but that the association was a weak one, cc=0.381.Further examination revealed that the wealthiest 20% had the greatest very good and good health status compared to the other social classes (Table 14.6). Table 14.6 indicated that the poorest 20% had a very good

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health status which was greater than that of the other classes. Only 17.4% of the wealthiest 20% reported a poor health status compared to 36.7% of the poorest 20%; 23.3% of the poor; 27.7% of the middle class and 25.9% of the wealthy. The greatest very poor health status was recorded by wealthy respondents (14.8%) followed by the poor (13.3%); middle class (8.8%) and the poorest 20% (3.3%). No significant statistical association was found between health status and health careseekers (χ2 (df = 4) = 3.350, P > 0.05) (Table 14.7). Based on Table 14.8, a statistical correlation existed between health status and health insurance coverage (χ2 (df = 4) = 21.913 P = 0.039); but that the relationship was a moderate weak one, contingency coefficient = 0.352. On examination, it was revealed that the those with private health insurance was most likely to have good health status; those with national health fund (NHF) was most likely to report moderate health and those with other public coverage also so likely to have moderate health status along side those without health insurance coverage. Although no significant statistical association was found between diagnosed health conditions and health care-seeking behaviour for both 2002 (χ2 (df = 5) = 5.381, P > 0.05) and 2007 (χ2 (df = 7) = 6.209, P > 0.05), in 2007, the percentage of the sample with hypertension was seeking less medical care and this also the case for the arthritic patients, and those with cold. However, increases were recorded for diabetes mellitus, diarrhoea and unspecified dysfunction cases (Table 14.9). Significant statistical difference was found between those with particular health status and the amount of money they were able to spend (F statistic [5,152] = 7.134, P < 0.001) (Table 14.10). Those with the greatest expenditure had the highest health status (ie very good) followed by those with good. However, those with moderate health status had the least mean annual

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expenditure, with those who recorded very poor health status spent more than those with a poor health status. Table 14.11 revealed that no significant statistical correlation was found between selfreported health conditions and total expenditure (F statistic [5, 30] = 0.396, P > 0.05). In 2007, a significant statistical correlation was found between self-reported health conditions and total annual expenditure (F statistic [7, 69] = 2.935, P = 0.009) (Table 11). Based on Table 14.11, of those who were diagnosed with either acute or chronic health conditions, diarrhoea patients spent the most (Ja $597,953.39) followed by diabetic patients (Ja $568,441.75) and the least was spent by asthma patient (Ja $42,703.27). No significant statistical difference existed between the expenditure on particular health care facilities and self-reported health conditions: for 2002 (F statistic [7, 53] = 0.288, P = 0.955) and for 2007 (F statistic [7, 46] = 0.119, P = 0.997) (Table 14.12). A cross-tabulation between area of residents and sex of respondents revealed no significant statistical correlation for 2002 (χ2 (df = 2) = 0.612, P > 0.05) or 2007 (χ2 (df = 2) = 3.958, P > 0.05). Although there was no statistical association between the two aforementioned variables, it was observed that in 2002 10.6% of women lived in urban areas compared to 9.3% of men and in 2007 the figures increased by 230.2% and 136.6% for women and men respectively. For 2002, 73.0% of women resided in rural areas compared to 73.0% of men and the percentages fell to 50.8 and 48.0 for men and women respectively. However, in 2007, the percentage of men who lived in semi-urban areas increased by 53.1% while the number of women declined by 12.4%. These findings indicate urbanization of 80+ year population in Jamaica.

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Based on Figure 14.3, the greatest percentage increase in the ownership of health insurance coverage was in the poor cohort (3600%) compared to the poorest 20% (2575%); middle class (855%); wealthy (640%) and the wealthiest 20% (458%).

Figure 14.3. Percentage of population 80+ years with health insurance coverage, 2002 and 2007 Elasticity of health care-seeking behaviour Health care-seeking behaviour with respect to health insurance = 0.352, which indicates that health care-seeking behaviour of Jamaicans is highly unesponsive to changes in health insurance coverage. With all other things being equal, a 1% change in health insurance will cause a less than 1% change in health care-seeking behaviour of the Jamaicans who are 80+ years of age. Health care-seeking behaviour with respect to total annual expenditure (median) = 0.382. The value denotes that health care-seeking behaviour is less responsive to changes in income. With all other things being equal, a 1% change in health insurance will cause a less than 1% change in health care-seeking behaviour of the Jamaicans who are 80+ years of age.

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Elasticity of health care-seeking behaviour with reference to self-reported illness = 0.94. This finding emphasizes the reluctance of the participants in the sample to seek medical care even when illnesses are on the rise. Over the period, the percentage change in self-reported illness was 68.2% which result in a 63.8% change in health care-seeking behaviour with all other things being held constant. Health care-seeking therefore is an inelastic commodity because more health insurance coverage or total annual expenditure will see an incremental change in health care-seeking behaviour.

Discussion
The present research highlighted that at least 1 of every 2 elderly 80+ years reported an illness and 35 out of every 100 indicated at least poor health status. There was a 5.7% reduction in number of respondents with diagnosed chronic illness and13.8% more respondents sought medical care in 2007 than in 2002. The gender differences in health status were not statistically significant as well as health conditions by area of residence, and health status by area of residence. Some 41% of those who sought medical care indicated at least poor health status with hypertension being the most prevalent health condition. In Rossi and Triunfo’s work [28], 6.5% of elderly 60+ years indicated poor (bad) health status. Benyamini et al. [29], found that one-third of elderly (75+ years) in Israel reported poor health status which is similar to the findings in the current study (35.1%). These findings indicate that as people become older their health status decline and this is supported somewhat by the findings of Collerton et al. [30]. They found that 32.4% of the elderly 85+ years reported poor health status. Comparatively, although the age cohort for the present study is not the same as that Collerton et al’s study, marginally more of the 80+ year Jamaicans had poor health compared to the elderly in Collerton et al’s study. In the present research unlike the ones mentioned earlier, 376

there is a significant statistical association between self-rated health status and self-reported illness. Almost two times more 80+ year olds in this study who reported an illness indicated poor health status compared to those who did not report an illness. This finding indicates that illness can be used to offer some explanation for the poor self-rated health status of the elderly. The prevalence of self-reported illness for the 80+ year old population in Jamaica was 3.1 times more than that of the population, 1.3 times more than that for the 60-64 years old and 1.1 times more than that for the 65+ year old Jamaicans. Concurringly, the most prevalent diseases in the current work and that of Collerton et al was hypertension, with 57.5% of elderly 85+ having the condition compared to 46.8% of 80+ years, and this was 43% in Rossi and Triunfo’s study. In Jamaica, the prevalence of people with hypertension was 2.1 less than the 80+ year population. There was even a difference in the prevalence of hypertension among those 65+years and 80+ years with hypertension 1.3 times more prevalent in the latter group compared to the former. Furthermore, 1.5 times more of the 80+ age group had diabetes mellitus compared to the population. These findings indicate the health disparity between young old and the 80+ age group as well as the population and 80+ age cohort. The high prevalence of chronic illness in older people accounts for a higher percentage of them utilising health care practitioners. Statistics from the Planning Institute of Jamaica and the Statistical Institute of Jamaica, for 2 decades (1989-2007), showed that elderly (ages 60+ or 65+ years) sought more health care services and reported greater number of cases in chronic illnesses than all other age cohorts [25]. This paper found that 78 out of every 100 of those 80+ year old sought medical care in the last 4weeks which is greater than that for those 65+ years (ie. 72%) and the population (66%). In Jamaica, the 80+ age cohort sought more medical care in the last 4-weeks compared to the 85+

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year olds in Newcastle (. one third visited outpatient clinic in the last 3 months, averaging 10% in 4-weeks). Unlike the other studies on the elderly, our study presents comparative information across two periods. It was revealed that 5.2% more of those 80+ years of age reported an illness in 2007 over 2002. Although the percentage of those diagnosed with chronic diseases declined by 5.4% over the two periods, in disaggregating the data it was found that there was a 550% increase in the number of 80+ year olds with diabetes mellitus in 2007 than in 2002; and a 76.6% decline in arthritic cases. While there were declines in chronic diseases in the 80+ age cohort, no significant statistical association was found between (1) diagnosed health condition and area of residences over the period; (2) health status and area of residence, (3) health status and gender of participants, (4) health status and health care-seeking behaviour, and (5) diagnosed health condition and health care-seeking behaviour. The World Health Organization (WHO) opined that “The health implications of healthy ageing – the physical and mental characteristics of old age and their associated problems – need to be better understood” [31]. This view implies that there should be a better understanding of the demands, preparations, and social and economic factors of ageing through policy base research to better plan for the reality of an ageing population in particular the 80+ age cohort. This study corroborates the literature that the health problems of ageing are extensive; but it goes further to show the remarkable differences between the 60+ and 80+ age cohorts in terms of health condition . In 2007, 15.5% of the elderly Jamaicans reported an illness and 66% of them sought medical care [25], suggesting that 34 out of every 100 Jamaican who indicated a health conditions did not seek health care but may have used home remedy. Statistics revealed that

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30.2% of those who indicated an illness used home remedy [25], suggesting that there were ill Jamaicans who did not seek professional medical care. For the elderly population the statistics are somewhat different as 43.8% of those 65+ and 36.6% of 60-64 year cohorts reported a health condition, with 75.1% of the 60+ population sought medical care which is 2.1% less than the number of 80+ years who visited a health care practitioners in the same 4-week period. Thirty-five in every 100 of the 80+ year cohort reported poor-to-very poor health status, yet there was no significant difference in medical expenditure. Interestingly to note is the fact that those who reported diarrhoea and diabetes mellitus spent more than those with other diagnosed health conditions but this greater spending was not used for medical expenditure. Those 80+ year olds with very poor health status had a greater total annual expenditure than the poor, with those in very good health spending the most for a year. Further examination of health status and social class (ie income quintile) showed that the wealthiest 20% had the greatest health status followed by poorest 20%. Marmot [32] opined that income is positively associated with better health status which is equally the same among 80+ year olds. Continuing, the wealthiest 20% recorded the greatest health status; and their good health was 2.4 times more than those in the poorest 20%. Those in the poor 20% evaluated their good health to be greater than that for those in the wealthy socioeconomic strata. This finding somewhat supports Marmot’s work, but shows that the upper socioeconomic strata does not always have better health compared to the poor income groups. Studies have revealed the significant statistical association between health status and gender. Although there are more studies which show that men have a greater health status than women, some have found that women having a greater health and others revealed little gender differences [29, 33-40]. Rudkin [33] found that women have lower levels of wellbeing (.

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economic) than men, and Benyamini et al [29] found that they had lower self-rated health status than men. Rudkin’s finding was further sanctioned by Haveman et al [34] whose study revealed that retired men’s wellbeing was higher than that of their female counterparts, because men usually received and had more material resources, and more retired benefits compared to women ages 65 years and older. Therefore, with men receiving more than women, and having a more durable possession than women, their material wellbeing is higher in later life. Courtenay [35] noted from research conducted by the Department of Health and Human Services [36] and the Centers for Disease Control [37] that from the 15 leading causes of death except Alzheimer’s disease, the death rates are higher for men and boys in all age cohorts compared to women and girls. Embedded within this theorizing are the differences in fatal diseases that are explained by gender characterisics [38], to which Courtenay [35] explained are due to behavioural practices of both genders. The foregoing explains the fact that men are dying 6 years earlier than females [39]. However this study does not concur with the literature in anyway because no statistical correlation was found between the health status and gender of the 80+ year cohort. This work also disagrees with Smith and Kington [40] that income can buy health as this research found that the poorest 20% among the 80+ year olds in Jamaica had greater good health that those in the wealthy socioeconomic strata. However, in the present work the self-reported good health status for those in the wealthiest 20% was 2.4 times more, and this seemingly supports Smith and Kington’s work. Health is not a product which is transferrable from one human to another, suggesting that it cannot be bought. It can be extrapolated from the present research that those in the wealthiest 20% lifestyle, income, sociophysical milieu and health choices are such that they foster greater good health, and this does not indicate a purchase of good health over those in the poorest 20%.

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Using a sample of 1,006 Jamaicans who indicated that they sought medical care in a 4week period in 2007, Bourne [41] found that there was no significant statistical association between medical care and health insurance coverage. The current study contradicts that of Bourne’s work as it was found that 12% of the variability in medical care-seeking behaviour can be explained by health insurance coverage and other studies [42]. In 2002, health insurance coverage was totally private which saw 3 out of every 100 of the 80+ year elderly having coverage. In the post-2003 period when health took on a public aspect, coverage increased to 29 out of every 100 in 2007. These findings explain the increase in health care seeking behaviour which was recorded in 2007 over 2002: 68.2% in 2002 and 77.6% in 2007. In 2007, 21 out of every 100 poorest 20% had health insurance compared to 1 in every 100 in 2002. This substantial increase was also recorded for the poor with 33 out of every 100 having health insurance compared to 1 in every 100 in 2002. Hence, the increase in the number of health care seekers is 2007 is due to the poor and poorest who were unable to previously afford health care because of financial constraints were now able to do so. In 2007, 43 out of every 100 elderly ages 60-64 years indicated that they were unable to afford medical care compared to 27 out of 100 elderly 65+ years. Concurrently, 22% of the elderly 60-64 years indicated that they used home remedy compared to 24% of the elderly 65+ years. Through the JADEP and National Health Insurance programme the out of pocket expenditure on medical care is substantially reduced, yet only 21% of the poorest 20% had accessed to this or private insurance; 33% of the poor; 28% of the middle class; 22% of the wealthy and 44% of the wealthiest 20%. This finding suggests more than cost constraint, it is a self-perception that they are not sufficiently medically ill to require care, the cultural biasesin favor of folk medicine and their perspectives on living longer. These factors may account for the

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irresponsiveness of this age cohort to seek medical care within the context of increased health insurance coverage and expenditure. This is not atypical as Borghesi and Vercelli [43] showed that elderly people have a progressively lower elasticity of aspirations to outcome, suggesting their unwillingness to carry out some functions and attain particular events is low. This view is a possible explanation for the low responsiveness of the 80+ age cohort in their health care-seeking behavior despite having more health care-choices. The issue which must be raised and addressed in this study is the validity of the selfreported health as a measure of health. The relation of self-reported health to health has been known for some time. The scientific literature has shown that self-rated health status is highly reliable to proxy for health and that this has successfully crossed cultural lines [44]. Another study conducted by O’Donnell and Tait [45] concluded that self-reported health status can be used to indicate wellbeing as all respondents who had chronic diseases reported very poor health. It is for this rationale why some studies have used self-reported health conditions and health status instead of life expectancy or other objective indices to measure health [46-48] as the latter is narrower than the former and does not encapsulate the extent life as subjective measures. This work has revealed that there is statistical relationship between health status and self-reported illnesses of elderly (80+ years) Jamaica, but that the association was a weak one. Benyamini et al. [29] found that self-reported health status was strongly associated with shorter term mortality (within the next 4 years) than longer-term mortality (9 years of follow-up) of elderly Israelis. Medical practitioners, social workers, health education and promotion specialists and public health practitioners as well as policy makers are now provided with an extensive review of the health conditions, shifts in patterns of illness, health care-seeking behaviour and practices of elderly 80+ years in Jamaica. In excess of 77% of those who reported ill-health sought

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medical care in the 4-week reference period of the survey, which indicates that there are some 80+ age individuals who are likely to use home remedy and not seekmedical care because of financial constraints, and the perception that the illness is not severe enough or they just do not want to visit a traditional medical practitioner. Close to one-half of those who reported a health condition suffered from hypertension and despite only 18 out of every 100 ill 80+ age elderly had diabetes mellitus, the number of cases of people suffering from this illness increased by 550% in 2007 over 2002. This increased number of reported cases in diabetes mellitus is alarming and must be addressed with urgency by public health specialists. With the urbanization of the 80+ age cohort to urban and semi-urban areas in Jamaica, health practitioners and other specialists must be equally cognizant of this population ageing migration phenomenon in order to effectively address the needs of the cohort within their new place of abode. There are no gender differences in the urbanization of this cohort in Jamaica. However, approximately 50% of elderly still reside in rural areas (50.8% men and 48% women). Another interesting finding of the current study is the preponderance of women to men in the 80+ age cohort. The sex ratio for this cohort was 59 men to every 100 women indicating a greater mortality of men at older ages than women. Concomitantly, the expansion of public health insurance for elderly Jamaica has seen an exponential increase in the number of 80+ aged Jamaican accessing the service; but most of the cohort is yet to subscribe for this free programme. Again this emphasize the need for a national public health campaign by the National Health Fund to inform senior citizens about the public assistance available to reduce their out of pocket cost for medical care. In Jamaica, the elderly poorest 20% to the wealthiest 20% has the same access to health insurance coverage as this is free for all persons 60+ years. In spite of this reality, the wealthiest

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20% recorded the greatest health insurance coverage (44%) compared to 21% of the poorest 20%; 33% of the poor; 28% of the middle class and 22% of the wealthy. The issue here is not access or inaffordability as is the case in other Latin Americans and Caribbean states [42]; but willingness to access such facilities owing to culturization. The loftiness in the culture explains the rationale for the greater percentage of Jamaicans using private health care facilities because in 2007, 52% of Jamaicans used private health care facilities compared 41% using the free public healthcare facilities. The elderly would be more set in their ways, and so the willingness to request and seek assistance from stranger in particular an outsider will be offensive. This unwillingness may explain the reluctance of the poorest 20% to subscribing for the free health insurance coverage compared to the wealthiest 20%. Health care-seekers are not likely to respond greater than the change in particular individual attributes because health care-seeking behaviour is an inelastic commodity. An crucial finding is the participants’ irresponsiveness to changes in health insurance coverage or more total expenditure. It is this fact that explains why health insurance coverage increased by over 180% and this results in a 64% change in health care-seeking behaviour, with all other things being held constant. Likewise, a 167% change in total annual expenditure result in a 64% change in health care-seeking behaviour with all other things being held constant.

Conclusion
In summary, money continues to explain greater health status for the wealthiest 20% of 80+ age cohort in Jamaica. One of the ironies in this study is the fact that the poorest 20% recorded the second highest health status, indicating that this social class enjoys a greater health status than the wealthy, middle and poor cohorts. Money therefore makes a difference for the wealthiest and not the wealthy or middle class that are 80+ years old. This contradicts the general perspective

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that poverty is the cause of ill-health [42] as wealthy and middle classes recorded greater poor health status that the poorest 20% of 80+ age cohort. Simply put, the poorest 20% reported less health conditions than the two aforementioned age cohorts because access to more financial resources do no mean this will be expended on medical care. The current study highlights a critical issue in that the health care-seeking behaviour of the elderly 80+ years is an inelastic product. This inelasticity suggest that health care seeking behaviour is less responsive to selfreported illness, health insurance and the amount of money that the individual is able to spend because at this age people do not aspire for much more in their lives.

Conflict of interest
The authors have no conflict of interest to report.

Disclaimer
The researchers would like to note that while this study used secondary data from the Jamaica Survey of Living Conditions, none of the errors in this paper should be ascribed to the Planning Institute of Jamaica or the Statistical Institute of Jamaica, but to the researchers.

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Caribbean. The J of Gerontology Series B: Psychological Sciences and Social Sciences 2007;62:S226-S236. 17. Peláez M. Building the foundations for health in old age in the Americas. Revista Panamericana de Salud Publica 2005;17:299-306 18. Albala C, Lebrao ML, Diaz EML, Ham-Chande R, Hennis AJ, Palloni A, Pelaez M, Pratts O. The Health, Well-Being, and Aging ("SABE") survey: methodology applied and profile of the study population. Revista Panamericana de Salud Publica 2005;17:307-322. 19. Wong R, Pelaez M, Palloni A. Self-reported general health in older adults in Latin America and the Caribbean: usefulness of the indicator. Revista Panamericana de Salud Publica 2005;17: 323-332. 20. Menéndez J, Guevara A, Arcia N, León D, Esther María, Marín C, Alfonso JC. Chronic diseases and functional limitation in older adults: a comparative study in seven cities of Latin America and the Caribbean. Revista Panamericana de Salud Publica 2005;17: 353-361. 21. Department of Economic and Social Affairs Population Divisions, United Nations, (UN). World Population Ageing 1950-2050. New York; 2002. 22. Statistical Institute of Jamaica, (STATIN). Demographic Statistics, 2007. Kingston; STATIN; 2008. 23. Pan American Health Organization, (PAHO). Health in the Americas, 2007, volume II Countries. Washington DC; 2007. 24. Bogue DJ. Essays in human ecology, 4. The ecological impact of population aging. Chicago: Social Development Center; 1999. 25. Planning Institute of Jamaica, (PIOJ), Statistical Institute of Jamaica, (STATIN). Jamaica Survey of Living Conditions, 1989-2007. Kingston: PIOJ, STATIN; 1989-2008. 26. PIOJ. Economic and social survey of Jamaica, 2007. Kingston; 2008. 27. Eldemire-Shearer D. Ageing- the reality. In: Morgan O, editor. Health issues in the Caribbean. Kingston;2005. 28. Rossi M, Triunfo P. Health status of older adults in Uruguay. dECON in its series Documentos de Trabajo (working papers) with number 1404; 2004 (December). 29. Benyamina Y, Blumstein T, Lusky A, Modan B. Gender differences in the self-rated healthmortality association: Is it poor self-rated health that predicts mortality or excellent self-rated health that predicts survival? The Gerontologist 2003;43:396-405. 30. Collerton J, Davies K, Jagger C, Kingston A, Bond J, Eccles MP, Robinson LA, Martin-Ruiz C, Von Zglinicki T, James OFW, Kirkwood TBL. Heatlh and diseases in 85 year olds: baseline findings from the Newcastle 85+ cohort study. BMJ, 2009; 339:b4904 31. WHO. The world health report, 1998: Life in the 21st century a vision of all. Geneva: WHO;1998. 32. Marmot M .The influence of Income on Health: Views of an Epidemiologist. Does money really matter? Or is it a marker for something else? Health Affairs 2002; 21:31-46. 33. Rudkin L. Gender differences in economic wellbeing among the elderly of Java. Demography, 1993; 30:209-226.

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34. Haveman R, Holden K, Wilson K, Wolfe B. Social security, age of retirement, and economic wellbeing: Inter-temporal and demographic patterns among retired-worker beneficiaries. Demography2003; 40:369-394. 35. Rozzini R, Sleiman S, Maggi M, Noale M, Trabucchi M. Gender differences and health status in old and very old patients. J of the Am Med Directors Asscn 2009; 10:554-558. 36. Department of Health and Human Services. 2000. Deaths: Final data for 1998 (DHHS Publication No. [PHS] 2000-1120) National Vital Statistics Reports, 48(11). Hyattsville, MD: National Center for Health Statistics. In: Courtenay WH. Key determinants of the health and well-being of men and boy. International Journal of Men’s Health 2003;2:1-30. 37. Centers for Disease Control. Demographic differences in notifiable infectious disease morbidity United States, 1992-1994. Morbidity and Mortality Weekly Report 1997;46:637-641. 38. Seltzer MM, Hendricks JA. On your marks: Research issues on older women. In: Hendricks JA, editor. Health and economic status of older women. New York: Baywood Publishing; 1989. 39. Xie J, Matthews FE, Jagger C, Bond J, Brayne C. The oldest old in England and Wales: a descriptive analysis based on the MRC cognitive function and ageing study. Age and Ageing 2008; 37:396-402. 40. Smith JP, Kington R. Demographic and Economic Correlates of Health in Old Age. Demography 1997; 34:159-70. 41. Bourne PA. Socio-demographic determinants of Health care-seeking behaviour, self-reported illness and Self-evaluated Health status in Jamaica. International Journal of Collaborative Research on Internal Medicine & Public Health 2009; 1:101-130. 42. Pan American Health Organization, (PAHO). Equity and health. Washington DC:PAHO; 2001. 43. Borghesi S, Vercelli A. Happiness and health: two paradoxes. DEPFID Working papers; 2008. Available at: http://www.depfid.unisi.it/images/pdf/text108.pdf. Accessed on: August 4, 2009. 44. Ringen S. Wellbeing, measurement, and preferences. Scandinavian Sociological Association 1995;38, 3-15. 45. O’Donnell V, Tait H. Wellbeing of the non-reserves Aboriginal population. Statistics Canada Catalogue 2003;89-589. 46. Grossman M. The demand for health - a theoretical and empirical investigation. New York: National Bureau of Economic Research, 1972.

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Table 14.1. Sociodemographic characteristic of sample
Variable Gender Male Female Health care-seeking behaviour Yes No Health insurance coverage Yes No Area of residence Rural Semi-urban Urban Self-reported illness Yes No Diagnosed Health conditions Acute: Cold Diarrhoea Asthma Chronic: Diabetes mellitus (ie diabetes) Hypertension Arthritis Other Not diagnosed Income quintile Poorest 20% Poor Middle Wealthy Wealthiest 20% Age Mean (SD) Length of illness Median (Range) Number of visits to health practitioner(s) median (range) Health status Very good Good Moderate Poor Very poor Marital status Married Never married Divorced Separated Widowed 2002 N= 566 39.9 60.1 68.2 31.8 2.9 97.1 71.2 18.7 10.1 43.5 56.5 2007 N=159 37.1 62.9 77.6 22.4 29.0 71.0 49.1 20.8 30.2 48.7 51.3

2.8 2.8 2.8 47.8 27.8 16.7 24 20.1 18.7 18.2 18.9 85.4 yrs (4.6 yrs) 10 days (90 days) 1.0 (7) NI NI NI NI NI 23.3 22.8 0.7 1.8 47.9

1.3 3.9 1.3 18.2 46.8 6.5 18.2 3.9 18.9 18.9 29.6 17.0 15.7 85.0 yrs (4.5 yrs) 7days (998) 1.0 (4) 6.4 18.5 40.1 26.8 8.3 25.8 19.4 2.6 2.6 49.7

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Table 14.2. Diagnosed health conditions by area of residence
Variable Rural Diagnosed Health conditions Cold Diarrhoea Asthma Diabetes Hypertension Arthritis Other No
1 2

20021 Semi-urban Urban Rural

20072 Semi-urban Urban

χ (df = 10) = 15.561, P > 0.05 χ (df = 14) = 13.607, P > 0.05

3.2 0.0 3.2 48.8 29.0 16.1 -

0.0 33.3 0.0 66.7 0.0 0.0 -

0.0 0.0 0.0 0.0 50.0 50.0 -

0.0 5.3 0.0 21.1 47.4 5.3 15.8 5.3

6.3 0.0 0.0 25.0 25.0 6.3 37.5 0.0

0.0 4.8 2.4 14.3 54.8 7.1 11.9 4.8

2 2

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Table 14.3. Health status by area of residence
Variable Rural Health status Very good Good Moderate Poor Very poor
1 2 2

20021 Semi-urban Urban Rural

20072 Semi-urban Urban

NI NI NI NI NI

NI NI NI NI NI

NI NI NI NI NI

6.4 31.9 38.3 21.3 2.1

6.1 18.2 33.3 30.3 12.1

6.5 10.4 44.2 28.6 10.4

NI χ (df = 8) = 11.899, P > 0.05

NI No information available

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Table 14.4. Health status by self-reported illness, 2007 Health status Very good Good Moderate Poor Very poor 2 2 χ (df = 4) = 13.036, P = 0.011, cc=0.278

Self-reported illness Yes 2.6 11.8 39.5 32.9 13.2 No 10.0 25.0 40.0 21.3 3.8

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Table 14.5. Health status by gender Health status Very good Good Moderate Poor Very poor 1 2 χ (df = 4) = 3.867, P > 0.05 Man 5.1 16.9 35.6 35.6 6.8

Sex1 Woman 7.1 19.4 42.9 21.4 9.2

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Table 14.6. Health status by gender Health status Poorest Poor 20% Very good 10.0 6.7 Good 13.3 10.0 Moderate 36.7 46.7 Poor 36.7 23.3 Very poor 3.3 13.3 1 2 χ (df = 16) = 26.716, P < 0.045, cc=0.381

Income quintile1 Middle Wealthy 0.0 23.4 40.4 27.7 8.5 3.7 7.4 48.1 25.9 14.8

Wealthiest 20% 17.4 39.1 26.1 17.4 0.0

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Table 14.7. Health status by health care-seeking behaviour Health status Health care-seeking behaviour1 Yes No Very good 1.7 5.9 Good 11.9 11.8 Moderate 35.6 52.9 Poor 35.6 23.5 Very poor 15.3 5.9
1 2

χ (df = 4) = 3.350, P > 0.05

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Table 14.8. Health status by health insurance coverage Health status Health Insurance Coverage1 Private Public, NHF Public, Other Very good 0.0 12.0 0.0 Good 60.0 28.0 0.0 Moderate 20.0 48.0 53.3 Poor 20.0 8.0 46.7 Very poor 0.0 4.0 0.0 1 2 χ (df = 4) = 21.913 P = 0.039, cc=0.352 Note: NHF – National Health Fund

No 5.5 17.3 38.2 28.2 10.9

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Table 14.9. Diagnosed health conditions by health care seeking behaviour
Variable 20021 Health care-seeking behaviour Yes Diagnosed Health conditions Cold Diarrhoea Asthma Diabetes Hypertension Arthritis Other No
1 2

20072 Health care-seeking behaviour Yes No

No

χ (df = 5) = 5.381, P > 0.05 χ (df = 7) = 6.209, P > 0.05

6.0 3.6 3.6 46.4 32.1 14.3 -

12.5 0.0 0.0 50.0 12.5 25.0 -

1.7 5.1 1.7 18.6 42.4 5.1 20.3 5.1

0.0 0.0 0.0 17.6 64.7 11.8 5.9 0.0

2 2

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Table 14.10. Health status by Annual total expenditure, 2007 Descriptive statistics 95% Confidence Interval Health status Very good Good Moderate Poor Very poor Total Mean 1,447,018.91 651,694.11 442,482.79 473,225.25 502,309.96 558,288.05 Std. Deviation 1,595,683.12 561,405.68 400,604.78 428,012.88 214,315.07 615,473.17 Std. Error 504,599.31 104,250.42 50,471.46 66,043.82 59,440.31 49,120.11 305,535.97 - 2,588,501.85 438,146.81 - 865,241.41 341,591.79 - 543,373.80 339,847.05 - 606,603.46 372,800.66 - 631,819.26 461,261.72 - 655,314.38

F statistic [5,152] = 7.134, P < 0.001 Values are quoted in Jamaican dollars (US $1.00 = Ja. $80.47, in 2007)

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Table 14.11. Self-reported health conditions by total expenditure, 2002 and 2007 20021 95% Confidence Interval for Mean Lower Bound Upper Bound . . . . . . 132,665.90 250,683.94 70,773.02 290,056.62 45,436.40 252,462.48 142,452.01 223,489.11

Self-reported health conditions Cold Diarrhoea Diabetes mellitus Hypertension Arthritis Unspecified Total

Mean 101,186.97 301,830.15 227,604.63 191,674.92 180,414.82 148,949.44 182,970.56

Std. Deviation . . . 114,769.48 153,268.67 98,636.87 119,752.91 20072

Std. Error . . . 27,835.69 48,467.81 40,268.33 19,958.82

Cold 236,103.72 . Diarrhoea 597,953.39 98,902.35 Asthma 42,703.27 . Diabetes mellitus 568,441.75 417,728.90 Hypertension 310,082.28 233,719.82 Arthritis 188,747.40 123,903.88 Unspecified 496,102.96 343,771.70 No 1,103,454.01 1,320,420.17 Total 420,692.91 398,170.68 1 Values are quoted in Jamaican dollars (US $1.00 = Ja. $50.97, in 2002) 1 F statistic [5, 30] = 0.396, P > 0.05 2 Values are quoted in Jamaican dollars (US $1.00 = Ja. $80.47, in 2007) 2 F statistic [7, 69] = 2.935, P = 0.009

. 57,101.30 . 111,642.74 38,953.30 55,411.50 91,876.86 762,344.94 45,375.76

. 352,266.33 . 327,252.26 231,002.88 34,900.41 297,615.09 2,176,651.5 330,319.25

. 843,640.45 . 809,631.23 389,161.69 342,594.40 694,590.83 4,383,559.56 511,066.57

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Table 14.12. Self-reported health conditions by medical care expenditure (public and private health care expenditure), 2002
Mean Self-reported health conditions Upper Bound Cost at Public Health Facility1 Cold Diarrhoea Asthma Diabetes mellitus Hypertension Arthritis Unspecified No Total Cost at Private Health Facility2 Cold Diarrhoea Asthma Diabetes mellitus Hypertension Arthritis Unspecified No Total
1 2

Std. Deviation Lower Bound . 0.00 . 145.68 3124.79 520.42 406.71 57.73 1983.53 . 3404.41 . 7762.10 6564.29 763.763 3151.291 919.24 5482.01

Std. Error Upper Bound . 0.00 . 46.07 698.72 300.46 122.63 33.33 277.75 . 1965.54 . 2587.37 1368.75 440.96 909.70 650.00 746.01

95% Confidence Interval Lower Bound . 0.00 . 15.79 -464.95 -876.12 -32.32 -110.09 -64.74 . -4157.03 . -3110.93 -690.78 -1063.96 314.43 -6609.03 785.18 Upper Bound . 0.00 . 224.21 2459.95 1709.45 514.14 176.75 1051.01 . 12757.02 . 8822.0378 4986.44 2730.62 4318.90 9909.03 3777.78

0.00 0.00 0.00 120.00 997.50 416.67 240.91 33.33 493.14 1600.00 4300.00 0.00 2855.55 2147.83 833.33 2316.67 1650.00 2281.48

F statistic [7, 53] = 0.288, P = 0.955 F statistic [7, 46] = 0.119, P = 0.997

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Chapter

15

An Epidemiological Transition of Health Conditions, and Health Status of the Old-Old-To-Oldest-Old in Jamaica: A comparative analysis

Introduction
The elderly population (ages 60+ years) constituted 10.9% of Jamaica’s population, which means that this age cohort is vital in public health planning [1]. Eldemire [2] opined that “The majority of Jamaican older persons are physically and mentally well and living in family units”. This view was substantiated in an early study; when Eldemire [3] found that approximately 81 percent of the seniors reported that they were physically competent to care for themselves, without any form of external intervention. Eldemire’s work revealed that 88.5 percent being physiologically independent. Many elderly persons are more than physically independent as Eldemire [3] found 65.5 percent of them supported themselves, with males reporting a higher self-support (82.6%) compared to females, 47.7%. A study conducted by Franzini and colleague [4] found that social support was directly related to self-reported health, which is collaborated by Okabayashi et al’s study [5]. The aforementioned situation can explain why many elderly are offered socioeconomic support. Eldemire [3] found that approximately 71 percent of children were willing to 401

accept responsibility for their parents, with seniors who were older than 75 years being likely to need support. Seniors ages 75-84 years are referred to as old-old and those 85+ are referred as oldest-old. The 2001 Population Census of Jamaica found approximately 66 percent of the elderly live in private households [6], which imply that the aged are physically and mentally competent. This is in keeping with Eldemire’s studies [2, 3]. The functional independence of the elderly is not atypical to Jamaica as DaVanzo and Chan [7], using data from the Second Malaysian Family Life Survey which includes 1,357 respondents of age 50 years and older living in private households, noted that some benefits of co-residence range from emotional support, companionship, physical and financial assistance [8]. Embedded in DaVanzo and colleague’s work is the issue of ‘Is it functional independence or stubbornness?’ that accounts for the elderly persons’ report that they are physically and mentally well in order that family and onlookers will not request that they live in home care facilities. This brings into focus the issues of health status and health conditions of elderly Jamaicans. Physical disability and health problems increase with age [9]. Bogue [9] opined that demand for medical care increases with ageing and that this is owing to health deteriorations. He [9] also noted that as an individual age, the demands on their children increases and likewise their demand on the public services also increases. Statistics revealed that 15.5% of Jamaicans reported suffering from an illness/injury in 2007; this was 2.8 times more for individuals ages 65+ and 2.4 times for those people ages 60+ years [10]. This further goes to concurs with Bogue’s perspective that ageing is associated with increased illness. Concurrently, in 2007, 51.9% of Jamaicans who reported an illness, in the 4-week period of the survey, indicated that this was recurring compared to 75.1% of the elderly. The elderly also sought more medical care

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(72%) compared to the general population (66%), purchased more medication (78.3% compared to the general population, 73.3%) and had more health insurance coverage (27.8%) compared to the general population (21.1%) [10]. The aforementioned findings only concur with the work of Bogue, and still does not provide us with changing in health conditions of the elderly in particular the old-old-to-oldest old. Using a sub-sample of 3,009 elderly Jamaicans, Bourne [11] found that the general wellbeing was low; but, within the context of Bogue’s work, raised the question of the old-old or the oldest-old’s health status. Bourne [12], using a sub-sample of 1,069 respondents ages 75+ years, found that 51.3% of those 75-84 years had poor health status compared to 52.6% of the oldest-old. There was no significant statistical difference between the poor health status of oldold and oldest-old Jamaicans. While poor health status comprised of health conditions, Bourne’s works do not provide us with an understanding of the health conditions over time and whether these are changing or not. A study on elderly Barbadians by Hambleton and colleagues [13] found that current health conditions (diseases) were the most influential predictor of current health status and adds value to discourse that health conditions provide some understanding of health status. However, this finding does not clarify the epidemiological transition of health conditions affecting the old-old-to-oldest-old Caribbean nationals, in particular Jamaicans. An extensive review of health and ageing literature in the Caribbean revealed no study that has examined an epidemiological transition of health conditions of people 75+ years. In Jamaica, 4% of the population in 2007 were older than 75+ years, indicating that over 100,000 Jamaicans have reached 75 years or older. This is a critical group that must be studied for public health planning as more elderly have chronic dysfunctions than any other age cohort in the population. The aims of the current study are 1) provide an epidemiological profile of health

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conditions affecting Jamaicans 75+ years, 2) examine whether there is an epidemiological transition in health conditions affecting old-old-to-oldest-old Jamaicans, 3) evaluate particular demographic characteristic and health conditions of this cohort, 4) assess whether current selfreported illness is strongly correlated with current health status, 5) mean age of those with particular health conditions, 6) model health status and 7) provide valuable information upon which health practitioners and public health specialists can make more informed decisions.

Materials and Methods
The current study utilized a sub-sample of approximately 4% from each nationally crosssectional survey that was conducted in 2002 and 2007. The sub-sample was 282 people ages 75+ years from the 2007 cross-sectional survey (6,783 respondents) and 1,069 people ages 75+ years from the 2002 survey (25,018 respondents). Living Conditions which began in 1989. The survey was drawn using stratified random sampling. This design was a two-stage stratified random sampling design where there was a Primary Sampling Unit (PSU) and a selection of dwellings from the primary units. The PSU is an Enumeration District (ED), which constitutes a minimum of 100 residences in rural areas and 150 in urban areas. An ED is an independent geographic unit that shares a common boundary. This means that the country was grouped into strata of equal size based on dwellings (EDs). Based on the PSUs, a listing of all the dwellings was made, and this became the sampling frame from which a Master Sample of dwelling was compiled, which in turn provided the sampling frame for the labour force. One third of the Labour Force Survey (. LFS) was selected for the JSLC [14, 15]. The sample was weighted to reflect the population of the nation. The survey is known as the Jamaica Survey of

404

The JSLC 2007 [14] was conducted May and August of that year; while the JSLC 2002 was administered between July and October of that year. The researchers chose this survey based on the fact that it is the latest survey on the national population and that that it has data on selfreported health status of Jamaicans. A self-administered questionnaire was used to collect the data, which were stored and analyzed using SPSS for Windows 16.0 (SPSS Inc; Chicago, IL, USA). The questionnaire was modelled from the World Bank’s Living Standards Measurement Study (LSMS) household survey. There are some modifications to the LSMS, as JSLC is more focused on policy impacts. The questionnaire covered areas such as socio-demographic variables – such as education; daily expenses (for past 7-day; food and other consumption expenditure; inventory of durable goods; health variables; crime and victimization; social safety net and anthropometry. The non-response rate for the survey for 2007 was 26.2% and 27.7%. The nonresponse includes refusals and rejected cases in data cleaning. Measures Age: The length of time that one has existed; a time in life that is based on the number of years lived; duration of life. Or it is the total number of years which have elapsed since birth [16]. Elderly (or aged, or seniors): The United Nations defined this as people ages 60 years and older [17]. Old-Old. An individual who is 75 to 84 years old [9] Oldest-old. A person who is 85+ years old [9]. Health conditions (. self-reported illness or self-reported dysfunction): The question was asked: “Is this a diagnosed recurring illness?” The answering options are: Yes, Cold; Yes, Diarrhoea; Yes, Asthma; Yes, Diabetes; Yes, Hypertension; Yes, Arthritis; Yes, Other; and No.

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Self-rated health status: “How is your health in general?” And the options were very good; good; fair; poor and very poor. Good health status is a dummy variable, where 1=good to very good health status, 0 = otherwise Income Quintile can be used to operationalize social class. Social class: The upper classes were those in the wealthy quintiles (quintiles 4 and 5); middle class was quintile 3 and poor those in lower quintiles (quintiles 1 and 2). Health care-seeking behaviour. This is a dichotomous variable which came from the question “Has a doctor, nurse, pharmacist, midwife, healer or any other health practitioner been visited?” with the option (yes or no). Statistical Analysis Descriptive statistics, such as mean, standard deviation (± SD), frequency and percentage were used to analyze the socio-demographic characteristics of the sample. Chi-square was used to examine the association between non-metric variables, and Analysis of Variance (ANOVA) was used to test the relationships between metric and non-dichotomous categorical variables whereas independent sample t-test was used to examine a statistical correlation between a metric variable and a dichotomous categorical variable. The level of significance used in this research was 5% (95% confidence interval).

Result
Sociodemographic characteristics of sample Of the sample for 2002, 57.6% was female compared to 57.4% females in 2007. The mean age in 2002 was 81.3 years (SD = 5.6 years), and this was 81.4 years (SD = 5.4 years) in 2007. More than two-thirds of the 2002 sample dwelled in rural areas, 20.8%. In 2007, the percent of sample who resided in urban areas increased by 169.7%, and a reduction by 25.9% of those who dwelled

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in rural zones compared to a marginal reduction of 4.3% in semi-urban areas (Table 15.1). Concurrently, in 2007, 51.6% of sample reported suffering from an illness which was a 22% increase over 2002. Five percent more people sought medical care in 2007 over 2002 (ie 69.2%). Illness (or health conditions) A number of shifts in diagnosed health conditions were observed in this study. The number of cases of hypertension and arthritis were observed between the two periods. The most significant increase in health conditions was in diabetes mellitus cases (576%, Figure 15.1). A cross tabulation between self-reported illness and sex revealed that there was no significant statistical correlation between the two variables (Table 15.2). Although no statistical associated existed between the self-reported illness and sex, the percent of men who reported an illness in 2007 over 2002 increased by 30.5% compared to 16.4% for females. No significant statistical relationship existed between self-reported illness and marital status (Tables 15.4, 15.5). In spite of the aforementioned situation, the divorced sample reported the greatest percentage of increased in self-reported illness (16.7%) followed to married people (15.7%); separated individuals (11.6%), widowed (5.8%) and those who were never married reported the least increase in self-reported illness (5.2%). No significant statistical correlation existed between self-reported illness and age cohort of respondents – P >0.05 – (Table 15.5). Although the aforementioned is true, the percent of oldold who reported illness in 2007 over 2002 increased by 23.6% compared to a 16.6% increased in the oldest-old cohort over the same period. A cross tabulation between diagnosed self-reported health conditions and age of respondents revealed a significant association between the two variables (Table 15.6). On examination, in 2002, the lowest mean age was recorded by people who indicated that they had

407

arthritis. However, for 2007, the mean age was the lowest for old-old-to-oldest-old who had reported the common cold. A shift which is evident from the finding is the mean age of those with diabetes mellitus in 2002 (79.5 yrs. ± 2.5 yrs), which was the second lowest age of person with illness in 2002 to the greatest mean age for people with the same dysfunction in 2007 (90.20 yrs ± 3.54 yrs) (Table 15.6). Based on Table 15.7, no significant statistical association was found between diagnosed health conditions and age cohort of the sample – P >0.05. In spite of this reality, some interesting findings are embedded in the data across the two years. The findings revealed an exponential increase in diabetes mellitus and the common cold. However, the most significant increase occurred in diabetic cases in the oldest-old. Reductions were recorded in hypertension, arthritis and unspecified categorization. A cross-tabulation between self-reported illness (in %) and Income Quintile revealed a significant statistical correlation between both variables for 2002 (χ2 (df = 4) = 11.472, P =0.022) and 2007 (χ2 (df = 4) = 10.28, P < 0.05). Based on Figure 15.2, the poor had highest self-reported cases of illness compared to the other social groups. Although this was the case for 2002 and 2007, the wealthy reported more illnesses than the wealthiest 20% of sample. Concurrently, the poorest 20% reported the greatest increase in self-reported illness for 2007 over 2002 (19.4%) with the wealthy segment of the sample reported the least increase (2.7%). The first time that the Jamaica Survey of Living Conditions (JSLC) collected information on self-reported illness and general health status (health status) of Jamaicans was in 2007. Based on that fact, this study will not be able to compare the health status of the sample for the two studied years; however, this will be the basis upon which future studies can compare. The cross-

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tabulation between the two aforementioned variables was a significantly correlated one (χ2 (df = 2) = 39.888, P < 0.001) (Table 15.8). Health care-seeking behaviour A cross tabulation of health care seeking behaviour and aged cohort revealed no statistical relationship between the two variables for 2002 (χ2(df=1) = 0.004, P = 0.947) and for 2007 (χ2(df=1) = 1.308, P = 0.253). Table 15.9 revealed that there is a significant statistical relationship between health careseeking behaviour and health status of the sample (χ2 (df = 2) = 10.539, P = 0.005, cc=0.265). Further examination showed that 57.1% of old-old-to-oldest-old sought medical care, and as health status decreases the percent of sample seeking medical care increases. Of those who reported poor health, 86.7% of them have sought medical care in the 4-week period of the survey. When the aforementioned association was further investigated by aged cohort, the difference was explained by old-old (χ2 (df = 2) = 11.296, P = 0.004, cc=0.305) and not oldestold (χ2 (df = 2) = 0.390, P = 0.823) (Table 15.10). Controlling health care-seeking behaviour and health status by aged cohort revealed that the old-old are more likely to seek more medical care with reduction in their good health status; but this is not the case for the oldest-old. With one-half of the cells in oldest-old category being less than 5 items, the non-statistical association possibly is a Type II Error. Type II Error indicates that there is no statistical significant relationship between variables when there is a probability that an association does exists.

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Multivariate analysis: Predictors of good health status Good health status of old-old-to-oldest-old Jamaicans can be predicted by self-reported illness (Table 15.11). Based on Table 15.11, self-reported illness is a negative predictor of good health status (OR = 0.176, 95% CI = 0.095 - 0.328). Twenty-four percent of the variability in good health status can be explained by self-reported illness. Concurrently, no other variable except self-reported illness was significantly correlated with good health status. Furthermore, 75.9% of the data were correctly classified: 90.5% of good health status and 42.0% of those who has stated otherwise (poor to fair health status). In addition, an old-old-to-oldest-old Jamaican is 0.824 times less likely to reported good health status.

Discussion
Ageing is directly correlated with increased functional disability [18]. This can be concurred with the disproportionate number of elderly who continue to outnumber other age cohorts in visits medical care facilities and number of cases in chronic dysfunctions. Statistics from the Planning Institute of Jamaica and Statistical Institute of Jamaica revealed that elderly Jamaicans disproportionately outnumber other ages in diabetes mellitus, hypertension, arthritis and mortality [10, 16, 17]. The Jamaican Ministry of Health data showed that the prevalence of chronic diseases is greatest for those 65+ years. Is the aforementioned information sufficient enough for public health policy makers, health care practitioners and academics as a reference to a comprehensive understanding of the old-old-to-oldest-old in Jamaica? The answer is a resounding no as this study will show. Bogue [9] showed that functional capacity, demand for medical care and health problems increase with ageing which concurs with Erber’s work [18] and other research [19]. The current study found that 10.3% more old-old-to-oldest-old Jamaicans reported at least one health

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condition in 2007 over 2002 and this was associated with at 1.7% increase health care-seekers. In 2007, 73 out of every 100 old-old-to-oldest-old Jamaicans sought medical care which is the national figure (66 out of every 100 Jamaicans). The research found that significant statistical association existed between medical care and health status of sample. Interestingly in this study though, is the fact that as the old-old’s health status fall to poor 89 out of every 100 of them sought care compared to 53 out of every 100 old-old who had good health. A critical finding of this study is the fact that after an individual reaches 85 years and beyond, there is no difference in seeking health care. Intertwined in this finding is the psychological reluctance of prolonged life at the onset of illness compared to those in the old-old categorization as many of oldest-old believe that they have lived a long time and so they are able to transcend this life. People’s cognitive responses to ordinary and extraordinary situational events in life are associated with different typologies of wellbeing [20]. Positive mood is not limited to active responses by individual, but a study showed that “counting one’s blessings,” “committing acts of kindness”, recognizing and using signature strengths, “remembering oneself at one’s best”, and “working on personal goals” are all positive influences on wellbeing [21,22]. Happiness is not a mood that does not change with time or situation; hence, happy people can experience negative moods [23]. Within the context of the aforementioned, an individual who has lived or is living for 85+ years consider this as a blessing and so they are comfortable with that blessing, which accounts for the psychological reluctance to prolong life if this is accompanied by severity of illness. The World Health Organization opined that the among the challenges of the 21st century will how to prevent and postpone dysfunctions and disability in order to maintain the health, independence and mobility for aged population. The current research found that 42 out of every

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100 old-old-to-oldest old Jamaican reported an illness in 2002 and this increased to 52 out of every 100. The substantiate matter is not merely the increase in dysfunctions; but it is the epidemiological transition in typology of diseases. Health conditions were not only reported, they were substantially diagnosed by a medical practitioner. An alarming finding was the exponential increase in number of diabetic (576%) and cold cases (330.77%) in 2007 over 2002, indicating the challenge of revamping lifestyle at older ages. It should be noted here that the average age for an old-old-to-oldest-old having diabetes mellitus increased from 79.5 years to 90.0 years, and therefore this reinforces the point that psychological reluctance to live with critical changes that diabetes mellitus may cause. The challenge for the old-old-to-oldest in Jamaica is not merely the lifestyle changes that follow diabetes mellitus; but the complication from having more than one illnesses and the issues surrounding the diseases. These issues include blindness, renal failure and micro-vascular

complications. Forty-four out of every 100 persons in the sample had hypertension in 2007, and the fact that diabetes mellitus and hypertension are strongly related, the old-old-to-oldest-old will be experiencing many health problems. A study by Callender [27] found that 50% of individuals with diabetes had a history of hypertension and given that Morrison [28] opined that these are twin problems for the Caribbean, it is more problematic for the people 75+ years. Studies have shown that ageing is directly correlated with increased health conditions, this research found that such a reality dissipates after 75+ years. While this study is not able to provide an explanation for this finding, factors such as sex, marital status, poverty and area of residence are no longer contributions to health disparity which contradicts other studies [29-34]. Poverty, which is critical to health determinant [35,36] and the fact that it explains incapacity to afford food, health care and other necessities, may seem improbable as not being a predictor of

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good health of old-old-to-oldest old Jamaicans. However, it is associated with health conditions for this sample. This means that health status is wider than dysfunction, and how this cohort feels about life is even broader than the challenge of physical incapacity. In spite of this claim, health conditions are a strong predictor of health status for the old-old-to-oldest-old in Jamaica. This concurs with Hambleton and colleagues’ work [13] which found that 33.6% of the total explanatory power (38.2%) of health status of elderly Barbadians was accounted for by current health conditions. Embedded in Hambleton et al. [13] and the current study is the critical role that current health conditions play in determining health status.

Conclusion
This study provides information upon which public health and health practitioners can make more informed decisions about this age group. A fundamental way for this impetus to proceed is the immediate diabetes education in the elderly population in particular those 75+ years. On a panel titled ‘Diabetes Education for the Elderly’ at the 11th Annual international Conference on ‘Diabetes and Ageing’ conference in 2005 at the Jamaica Conference Centre, Merrins [37] called for diabetes care treatment for elderly which indicates that the issue of diabetes education is not new but that it is even more important today within the context of the current findings. With over 570% more diabetic cases found in the old-old-to-oldest elderly in Jamaica, this means that on average 96% more cases are diagnosed each year. This is a massive increase in such cases, and cannot go unabated. The increase in diabetes mellitus could be accounted for by the new persons who become 75 years each year or a higher percentage cases that were formerly undetected become diagnosed. Which ever is the case, a public health promotion thrust is required to test all Jamaicans 75+ within the context of a disease prevention agenda and healthy life expectancy. Hence, the implications of the shift in health conditions will create a

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health disparity between 75+ year adults and the rest of the population. This requires better management of older persons [38], which will also require that people 75+ with good health be tested for diabetes mellitus.

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References
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Planning Institute of Jamaica and Derek Gordon Databank, University of the West Indies [distributors]; 2008. 15. Statistical Institute Of Jamaica. Jamaica Survey of Living Conditions, 2002 [Computer file]. Kingston, Jamaica: Statistical Institute Of Jamaica [producer], 2002. Kingston, Jamaica: Planning Institute of Jamaica and Derek Gordon Databank, University of the West Indies [distributors]; 2003. 16. Statistical Institute of Jamaica (STATIN). Demographic Statistics, 2005. Kingston: STATIN; 2006. 17. World Health Organization, (WHO). Definition of an older or elderly person. Washington DC: 2009. 18. Erber J. Aging and older adulthood. New York: Waldsworth; 2005. 19. Planning Institute of Jamaica, (PIOJ), Statistical Institute of Jamaica, (STATIN). Jamaica Survey of Living Conditions, 1989-2006. Kingston: PIOJ, STATIN;1989-2007. 20. Lyubomirsky S. Why are some people happier than others? The role of cognitive and motivational process in wellbeing. Am Psychologist. 2001;56:239-249. 21. Sheldon K, Lyubomirsky S. How to increase and sustain positive emotion: The effects of expressing gratitude and visualizing best possible selves. J of Positive Psychology. 2006;1:73-82. 22. Abbe A, Tkach C, Lyubomirsky S. 2003. The art of living by dispositionally happy people. J of Happiness Studies. 2003;4:385-404. 23. Diener E, Seligman MEP. 2002, Very happy people. Psychological Sci. 2002;13: 81–84. 24. WHO. Health promotion glossary. Geneva: World Health Organization; 1998. 25. WHO. Primary prevention of mental, neurological and psychosocial disorder. Geneva: WHO; 1998. 26. WHO. The world health report, 1998: Life in the 21st century a vision of all. Geneva: WHO;1998. 27. Callender J. Lifestyle management in the hypertensive diabetic. Cajanus. 2000;33:67-70. 28. Morrison E. Diabetes and hypertension: Twin trouble. Cajanus. 2000;33:61-63. 29.WHO. The Social Determinants of Health. Washington DC: WHO; 2008. 30. Victorino CC, Guathier AH. The social determinants of child health: variations across health outcomes – a population-based cross-sectional analysis. BMC Pediatrics. 2009, 9:53 31. Kelly M, Morgan A, Bonnefog J, Beth J, Bergmer V. The Social Determinants of Health: developing Evidence Base for Political Action, WHO Final Report to the Commission; 2007. 32. Wilkinson R, Marmot M, eds. Social Determinants of Health. The Solid Facts. 2nd ed. Copenhagen Ø: World Health Organization; 2003. 33. Solar O, Irwin A. A Conceptual Framework for Analysis and Action on the Social Determinants of Health. Discussion paper for the Commission on Social Determinants of Health. Geneva: WHO; 2007. 34. Graham H. Social Determinants and their Unequal Distribution Clarifying Policy Understanding The MelBank Quarterly. 2004; 82:101-124. 35. Marmot M. The influence of Income on Health: Views of an Epidemiologist. Does money really matter? Or is it a marker for something else? Health Affairs. 2002; 21: 31-46. 36. Alleyne GAO. Equity and health: Views from the Pan American Sanitary Bureau. In: Pan 416

American Health Organization, (PAHO). Equity and health. Washington DC: PAHO; 2001. p. 311. 37. Herd P, Goesling B, House JS. Socioeconomic Position and Health: The Differential Effects of Education versus Income on the Onset versus Progression of Health Problems. J of Health & Soci Behavior. 2007; 48:223-238 38. Merrins C. Special considerations in providing medical nutrition therapy to the elderly with diabetes. West Indian Med J. 2005; 54:39.

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Table 15.1. Socio-demographic characteristics of sample Variable 2002 Frequency Sex Male Female Marital status Married Never married Divorced Separated Widowed Income Quintile Poorest 20% Poor Middle Wealthy Wealthiest 20% Self-reported illness Yes No Health care-seeking behaviour Yes No Area of residence Rural Semi-urban Urban Educational level Primary or below Secondary Tertiary Health insurance coverage Yes No Age Mean (SD) Public health care expenditure Mean (SD) Private health care expenditure Mean (SD) 453 616 304 255 18 22 442 239 216 195 194 225 441 601 306 136 731 222 116 662 309 24 % 42.4 57.6 29.2 24.5 1.7 2.1 42.5 22.4 20.2 18.2 18.1 21.0 42.3 57.7 69.2 30.8 68.4 20.8 10.9 66.5 31.1 2.4 26.7 73.3 81.37 yrs (±5.38yrs) Ja $368.89.54 (±Ja.$1518.66) Ja. $1856.04 (±Ja.$4347.78) 2007 Frequency 120 162 88 66 6 7 105 56 51 74 58 43 141 132 102 38 83 56 143 % 42.6 57.4 32.4 24.3 2.2 2.6 38.6 19.9 18.1 26.2 20.6 15.2 51.6 48.4 72.9 27.1 50.7 19.9 29.4

48 4.6 998 998 81.29 yrs (±5.6yrs) Ja $341.54 (±Ja.$1165.60) Ja. $1436.23 (±Ja.$2060.42)

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Table 15.2. Self-reported illness by sex of respondents, 2002 and 2007 20021 Self-reported illness Male N (%) Yes No Total 174 (39.3) 269 (60.7) 443 Female N (%) 267 (44.6) 332 (55.4) 599 Male N (%) 60 (51.3) 57 (48.7) 117 Female N (%) 81 (51.9) 75 (48.1) 156 20072

1 χ2 (df = 1) = 2.927, P =0.087 2 χ2 (df = 1) = 0.011, P =0.916

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Table 15.3. Self-reported illness by marital status, 2002 Marital status* Self-reported illness Married N (%) Yes No Total 140 (46.8) 159 (53.2) 299 Never married N (%) 88 (34.8) 165 (65.2) 253 Divorced N (%) 9 (50.0) 9 (50.0) 18 Separated N (%) 10 (45.5) 12 (54.5) 22 Widowed N (%) 190 (43.2) 250 (56.8) 440

* χ2 (df = 4) = 9.027, P =0.060

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Table 15.4. Self-reported illness by marital status, 2007 Marital status* Self-reported illness Married N (%) Yes No Total 55 (62.5) 33 (37.5) 88 Never married N (%) 26 (40.0) 39 (60.0) 65 Divorced N (%) 4 (66.7) 2 (33.3) 6 Separated N (%) 4 (57.1) 3 (42.9) 7 Widowed N (%) 51 (49.0) 53 (51.0) 104

* χ2 (df = 4) = 8.589, P =0.072

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Table 15.5. Self-reported illness by Age cohort, 2002 and 2007 20021 Self-reported illness Old-Old N (%) Yes No Total 333 (42.8) 445 (57.2) 778 Oldest-Old N (%) 108 (40.9) 156 (59.1) 264 Old-Old N (%) 110 (52.9) 98 (47.1) 208 Oldest-Old N (%) 31 (47.7) 34 (52.3) 65 20072

1 χ2 (df = 1) = .289, P =0.591 2 χ2 (df = 1) = .535, P =0.465

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Table 15.6. Mean age of oldest-old with particular health conditions

20021 Health conditions Cold Diarrhoea Asthma Diabetes mellitus Hypertension Arthritis Other Total Mean Age (±SD) 80.00 86.00 0.00 79.50 80.13 79.32 81.64 80.14 (±2.50) (±0.84) (±0.69) (±1.75) (±4.73)

20072

Mean Age (±SD) 77.63 85.00 81.00 90.92 81.21 79.13 83.90 82.75 (±1.77) (±9.66) (±5.20) (±4.84) (±4.95) (±3.54) (±6.82) (±4.50)

F statistic [7,134] = 2.085, P = 0.049

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Table 15.7. Diagnosed Health Conditions by Aged cohort 20021 Diagnosed Health conditions Aged cohort Old-Old % Cold Diarrhoea Asthma Diabetes mellitus Hypertension Arthritis Other 1.5 0.0 0.0 3.0 47.8 35.8 11.9 0.0 Oldest-Old % 0.0 8.3 0.0 0.0 58.3 8.3 25.0 0.0 Aged cohort Old-Old % 7.2 2.7 1.8 11.1 44.1 12.6 11.7 2.7 Oldest-Old % 0.0 3.2 3.2 16.1 45.2 6.5 22.6 3.2 20072

No

1 χ2 (df = 1) = 10.028, P =0.074 2 χ2 (df = 1) = 5.382 P =0.613 424

Table 15.8. Self-reported illness (in %) by health status. Health Status Good Self-reported illness n (%) Yes No Total χ2 (df = 2) = 39.888, P < 0.001, cc=0.357 21 (25.3) 62 (74.7) 83 n (%) 60 (55.0) 49 (45.0) 109 n (%) 60 (74.1) 21 (25.9) 81 Fair Poor

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Table 15.9. Health care-seeking behaviour and health status, 2007 Health Status Good Health care-seeking behaviour n (%) No Yes Total χ2 (df = 2) = 10.539, P = 0.005, cc=0.265 9 (42.9) 12 (57.1) 21 n (%) 21(35.6) 38 (64.4) 59 n (%) 8 (13.3) 52 (86.7) 60 Fair Poor

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Table 15.10. Health care-seeking behaviour by health status controlled for aged cohort Health status

Aged cohort Old-old1 Health CareSeeking Behaviour No

Good

Fair

Bad

Total

7 (46.7)

18 (36.7)

5 (10.9)

30 (27.3)

Yes Total Oldest-old2 Health CareSeeking Behaviour No

8 (53.3) 15

31 (63.3) 49

41 (89.1) 46

80 (72.7) 110

2 (33.3)

3 (30.0)

3 (21.4)

8 (26.7)

Yes Total
1 2

4 (66.7) 6

7 (70.0) 10

11 (78.6) 14

22 (73.3) 30

χ (df = 2) = 11.296, P =0.004, cc=0.305 χ (df = 2) = 0.390, P =0.823

2 2

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Table 15.11. Logistic regression on Good Health status by variables Variable Self-reported illness Age Middle Class Upper class †Poor Coefficient -1.735 -0.041 -0.083 0.391 Std. Error 0.317 0.030 0.414 0.759 Wald statistic 29.950 1.910 0.040 0.264 Odds ratio 0.176 0.960 0.921 1.478 95.0% C.I. 0.095 - 0.328*** 0.905 - 1.017 0.409 - 2.072 0.334 - 6.546

Married Divorced, separated or widowed †Never married

0.297 -0.110

0.393 0.376

0.574 0.086

1.346 0.896

0.624 - 2.907 0.428 - 1.872

Urban area Other town †Rural area Constant

0.347 -0.398 2.979

0.350 0.414 2.456

0.981 0.922 1.471

1.414 0.672 19.667

0.712 - 2.808 0.298 - 1.513 -

χ2 =40.083, p < 0.001 -2 Log likelihood = 283.783 Nagelkerke R2 =0.222 Overall correct classification = 75.9% Correct classification of cases of good self-rated health = 90.5% Correct classification of cases of not good self-reported health = 42.0% †Reference group *P < 0.05, **P < 0.01, ***P < 0.001

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Figure 15.1. Diagnosed health conditions, 2002 and 2007

Figure 15.1 expresses the percentage of people who reported being diagnosed with particular health conditions in 2002 and 2007. Each number denotes a different health condition: cold, 1; diarrhoea, 2; asthma,3; diabetes mellitus, 4; hypertension, 5; arthritis, 6; other (unspecified), 7; and non-diagnosed illness, 8.

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Figure 15.2. Self-reported illness (in %) by Income Quintile, 2002 and 2007

Figure 15.2 expresses the percentage of people who reported an illness by income quintiles for 2002 and 2007. Q1 denotes the poorest 20% to the wealthiest 20% (ie Q5).

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Chapter

16

Happiness, life satisfaction and health status in Jamaica

Paul A. Bourne, Chloe W. Morris, Denise Eldemire-Shearer, & Neva South-Bourne

Introduction: Background The Caribbean has been identified as the most rapidly ageing region of the world. During the 1960 -1995 period, there was a 76.8% increase in the elderly population (United Nations, 2005; Bourne, 2010). The mean growth rate in the elderly population was 5.3%, which was recorded for the period 1995-2000. The Caribbean elderly as a percentage of total population has been projected to reach about 15% by 2020, an almost four-fold increase over the 1950 figure of 4.3% (United Nations, 2005; PAHO, 1997). Is this any different in Jamaica? Jamaica’s elderly population (ages 60+ years) has increased significantly since the mid 1960s (Eldemire, 1997; Bourne, 2010) indicating increased life expectancy. Life expectancy at birth for males between 1879 and 1882 was 37.02 years and for females it was 39.80 years (Bourne, 2010; Statistical Institute of Jamaica, 2010). Between 2002 and 2004 males are expected to live for 71.26 years and females 77.07 years (Appendix I), which is a clear indication of demographic ageing of the Jamaican population. Statistics revealed that over 10% of Jamaicans were older than 60 years in 2009 (Bourne, 2010; Statistical Institute of Jamaica, 2010). An examination of 5-year age cohorts of the elderly population in Jamaica revealed that

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85+ years is the fastest growing from the general elderly population (Figure 16.1). Thus, the society is experiencing an oldest-old population explosion never before seen in its history, and this point to the gains made in public health measures, and improvements in the standard of living of the general populace since the 20th century.

Figure 16.1: Percentage change in elderly population by five year age groups, 1991-2001.

Life expectancy Does the increase in life expectancy means a better quality of life or subjective wellbeing of elderly Jamaicans? A study by Powell, Bourne and Waller (2007) found that the psychosocial wellbeing of Jamaicans was moderately high (mean score = 6.8 out of 10), and offers an explanation for the quality of life of its people. Furthermore, they found that the subjective wellbeing of those in the lower subjective social class had a minimal score (mean score = 5.8 out of 10) compared with those in the upper class (mean score = 6.5 out of 10) and those in the

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middle class (mean score = 6.8 out of 10) (Powell, Bourne and Waller 2007). They continued that Jamaicans (69%) indicated that their current economic situation was at most average, with 19% reporting that it was bad. Nothing was mentioned about the elderly’s population quality of life, but can we assume that a two-fold increase in life expectancy over 1880-1882 means better quality of life? Using the antithesis of illness to measure health (not reporting an illness), many studies have examined health of the Jamaican elderly population (Bourne, 2008a; 2008b; Bourne, 2009a; Bourne, 2010) and another decomposed the mortality rate of the aged population (Bourne, McGrowder and Crawford, 2009). The use of illness to evaluate health is both narrow and negative in scope (Bourne, 2009b; Longest, 2002; Brannon & Feist, 2007), which is the justification of the World Health Organization’s (WHO) broadened conceptualization of health to more than the absence of illness to social, physical and psychological wellbeing (WHO, 1948). Within the broadened conceptualization of health forwarded by the WHO in the preamble to its Constitution in 1946, the use of illness or antithesis of illness is emphasizes the absence of some disease causing pathogens, and not really health (Bourne, 2009b). Thus there is the need to expand the measurement of health from illness or the antithesis of illness to evaluate a broader definition of health and/or wellbeing, particularly among the elderly population because of the composition of this cohort and the importance of understanding their wellbeing for the purpose of planning. This study investigates health, happiness and satisfaction with life for older men in a middle-income developing country, Jamaica. Happiness, life satisfaction, and health status are among some of the subjective indexes used to evaluate health (or wellbeing) of an individual, community or population. Happiness is well established in the scientific literature as a good

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predictor of subjective wellbeing and/or overall life with satisfaction as it covers a number of positive psychological conditions such as marriage, a job, success in life, adaptation to life events, and negative affective conditions such as the lost of life or property, failed examinations, and dissolution of union deteriorate both health and further deepen the negative impact on life and by extension happiness (Diener, 1984; 2000; Easterlin, 2001a; 2001b; 2003; 2004; Stutzer & Frey, 2003; Frey & Stutzer, 2000; 2002; Ng, 1996; 1997). Subjective indexes cover a wider gamut of an individual’s life compared to diagnosed health conditions, morbidity, reproductive health and life expectancy. Yet, the planning and statistical agencies in Jamaica have been collecting national living conditions data including health conditions since 1989 (Planning Institute of Jamaica (PIOJ) and Statistical Institute of Jamaica (STATIN), 1989-2008), and health condition has been used to measure the health of the population, gender of the participants and health within areas of residence. For the first time in 2007 both agencies added health status to health conditions in the yearly national cross-sectional survey that is used to evaluate the population’s living conditions. Happiness therefore, like life satisfaction and health status, provides a better idea of people’s quality of life than does ill health. The use of objective indexes such as diagnosed illness, gross domestic product, life expectancy and mortality are among measures that are said to be limited in scope and justify the use of subjective indexes by some scholars (Diener, 1984; 2000; Easterlin, 2001a; 2001b; Stutzer and Frey, 2003; Frey and Stutzer, 2000; Ng, 1996; 1997; Oswald, 1997). Despite the aforementioned rationale on happiness, no national study has been conducted in Jamaica on happiness, life satisfaction and health status, particularly on older men. Initially, when happiness was put forward by Diener (1984) as a measure of wellbeing, it was rigorously opposed by some scholars as subjective who said it could not be used to measure

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health or wellbeing. Many traditional economists believed that happiness was subjective and that this could not be precisely measured, and this accounted for their reservations about accepting it. They believed that Gross Domestic Product per capita (GDP per capita) or income per capita was an objective measure and that could in fact be precisely quantified. Unlike traditional economists, Diener (1984; 2000), a psychologist, theorized that happiness could in fact be used to measure subjective wellbeing and this was later adopted by economists (Oswald, 1997; Ng, 1996; 1997; Blanchflower and Oswald, 2004; Veenhoven, 1991; 1993; Easterlin, 2001a; 2001b; Stutzer and Frey, 2003; Frey and Stutzer, 2000; DiTella, et al., 2003). Easterlin (2001a, 2001b, 2003, 2004) found a statistical association between happiness and income. He argued that, “The relationship between happiness and income is puzzling”, (Easterlin, 2001a: 465) and that people with higher incomes were happier than those with lower incomes, but that economic growth does not mean happiness. Easterlin used happiness to measure subjective wellbeing, which was found to be highly correlated with income. He went further when he said that, “Those with higher income will then be better able to fulfill their aspirations and, other things equal, will, on average, feel better off…This is the point-of-time positive association between happiness and income”(Easterlin 2001a:472). Like Easterlin, all the aforementioned economists used happiness to evaluate subjective wellbeing as they accepted that happiness is an indicator of people’s judgement of their overall quality of life (Veehnoven, 1991; 1993). Randomly selecting Europeans and Americans from the 1970s to 1990s, Di Tella et al. (2003) did not find this complex relation between income and happiness. They however noted that some variables such as unemployment, unemployment benefits and others are exogenous variables as they are influenced by political decisions and do influence income.

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Diener (2000) argued that wellbeing can be explained outside of welfare theory or a purely objective utility approach, and this was supported by other scholars (Liang, 1984; Diener et al., 1999; Diener and Suh, 1997; Cummins, 1997). Arthaud-day et al.’s (2005) work applied structural modeling and found that subjective wellbeing comprised of (1) cognitive evaluations of one's life (., life satisfaction or happiness); (2) positive affect; and (3) negative affective conditions. Unlike Arthaud-day et al., Diener (2000) proposed that subjective wellbeing can be operationalized by some basic indicators such as emotional components (‘Taking all things together, how happy would you say you are?’) and cognitive components or life satisfaction (‘All things considered, how satisfied are you with your life as a whole nowadays?’). Summers & Heston noted that, “…GDP POP is an inadequate measure of countries' immediate material well-being, even apart from the general practical and conceptual problems of measuring countries' national outputs” (Summer & Heston, 1995:2) From that perspective, the measurement of quality of life is highly economic and excludes psychosocial factors as the emphasis is on objective indexes of wellbeing (Gaspart, 1998) and not in keeping with the breadth of wellbeing offered by the World Health Organization in the preamble to its Constitution (WHO, 1948). Thus, quality of life (wellbeing) extends beyond financial resources (money), although they improve wellbeing or the ‘human lot.’(Easterlin, 1974; 1995; Marmot, 2002). Using data for developing countries, Camfield noted that subjective wellbeing constitutes the existence of positive emotions and the absence of negative ones within a space of general satisfaction with life. Cummins (1997) argued that subjective and objective indexes of material well-being along with the absence of illnesses, efficiency, social closeness, security, place in community, and emotional wellbeing means that life’s satisfaction comprehensively envelopes

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subjective wellbeing. Diener (2000) in an article titled ‘Subjective Well-Being: The Science of Happiness and a Proposal for a National Index’ theorized that the objectification of wellbeing is embodied within satisfaction of life. This explains the rationale for the use of life satisfaction and/or happiness to operationalize wellbeing instead of GDP per capita (or income per capita). Extensive review of the literature turned up just one study in Jamaica that examined life satisfaction (Hutchinson, et al., 2004). In this study, the scholars found that women had a lower overall life satisfaction (72%) than men (76%). Employment status, education, gender, union status, church attendance, self-esteem, and current health status were determinants of life satisfaction. In Di Tella et al.’s work, they found income, employment status, interpersonal trust, health status, marital status, education, sex and inflation, the rate of change of consumer prices in the country, unemployment benefits, and the number of children in households was predictors of happiness. In descending order, they found that marital status, income and employment status had the greatest influence on happiness. Although there is very little or research study in the English speaking Caribbean on happiness of the general populace or on the elderly population, Stutzer & Frey (2003) has identified a few predictors of happiness: income; aspiration; and unemployment. Konow & Earley’s study (1999) revealed that employment status, positive and negative affective conditions, social support and marital status were correlated with happiness. Some of these (., employment status, marital status, living arrangement, age, education, gender) were also recorded as being statistical associated with happiness in Blanchflower & Oswald’s study. Happiness is related to subjective wellbeing which incorporates the negatives and positives of how individuals experience their lives. People in different cultures, regions and cities perceive wellbeing differently. Spirituality and religiosity are important additions to personal

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wellbeing (Wills, 2009). Subjective wellbeing is significantly influenced by personality traits. Life experience is also an important factor. Happiness is the extent to which people favorably evaluate the overall quality of their life as a whole. Higher levels of education, better healthcare and increased income does not automatically increase happiness. Happiness is not a predictor of longevity among the sick but happiness is a predictor of longevity among the healthy. This finding suggests that happiness cannot cure sickness but it is a buffer against becoming sick (Veenhoven, 2008). A comprehensive examination of the happiness and health status literature in the Caribbean and in particular Jamaica found no empirical study that assessed the happiness status of older men. Our research studies happiness of older men (ages 55+ years) in Jamaica. 15.5% of the population reported having had an illness in a 4-week survey period compared to 40.2% of elderly 60+ years. Not examining the subjective wellbeing of men is to eliminate a critical approach in understanding their health behaviour. This paper will fill the gap in the literature by examining happiness, life satisfaction and health status with particular reference to older men in Jamaica. Method Sample The study used primary cross-sectional survey data on men 55+ years from the parish of St. Catherine in 2007. A132-item questionnaire was used to collect the data. Data were collected by way of a self-administered instrument. The instrument was sub-divided into general demographic profile of the sample: past and current health status, health-seeking behaviour, retirement status and social and functional status.

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The Statistical Institute of Jamaica (STATIN) maintains a list of enumeration districts (ED) or census tracts. The parish of St. Catherine is divided into a number of constituencies made up of a number of enumeration districts (ED). The parish was chosen because previous data and surveys (Statistical Institute of Jamaica, 2004; Wilks, 2007; Jackson, et al., 2003) suggest that the parish has the mix of demographic characteristics (urban, rural and agecomposition) similar to the rest of Jamaica. Measures Happiness was measured based on people’s self-report on their happiness. It is a Likert scale question, which ranges from always to rarely happy. Health Status was measured using people’s self-rate of their overall health status, which ranges from excellent to poor. Happiness is measured based on people’s self-report on their happiness (Frey & Stutzer, 2002a, 2002b; Easterlin, 2001; Borghesi & Vercelli, 2007). This operationalization is based on a basic indicator proposed by Diener (2000), including a more emotional component referring to happiness (‘Taking all things together, how happy would you say you are?’). It is a Likert scale question, which ranges from high to low happiness. It was coded into a binary variable, whether or not the individual had moderate-to-high or low happiness: 1=moderate to high happiness, 0 = otherwise. Life satisfaction. Diener (2000) had proposed that happiness includes emotional components and a more cognitive component referring to life satisfaction (‘All things considered, how satisfied are you with your life as a whole nowadays?’), for this paper the researcher separated happiness (emotional) from cognitive (life satisfaction). Life satisfaction is a binary variable, where 1= good-to-excellent self-reported overall satisfaction in life, 0=otherwise.

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Health Status is measured using people’s self-rate of their overall health status (Kahneman, & Riis, 2005), which ranges from excellent to poor health status. The variable used in this study for health status is a binary one, whether or not the person had good-to-excellent or poor health status. It was then coded as a dummy variable, 1=good-to-excellent health status, 0=otherwise. Age group is categorized into three sub-groups. These are (1) ages 55 to 64 years; (2) ages 65 to 74 years; and (3) age 75 years and older (ie 75+ years). Listing of covariates Residence is a binary variable, 1=lives in urban area, 0=lives in rural area. Employment status is a binary variable, where 1=employed, 0=otherwise. Health retirement plan is a binary variable, where 1=having a health retirement coverage, 0=otherwise. Occupation is a binary variable, where 1=current or past occupation which was in the category of professional, 0=otherwise. Marital status is a non-binary variable, where 1=married, 0=otherwise; 1= separated, divorced or widowed, 0=otherwise and single is the reference group. Childhood health status is a binary variable, 1=self-reported poor health status, 0=otherwise. Household head is a binary variable, 1=self-reported head of household, 0=otherwise. Social networking is operationalized based on yes or no to being a member of a social club; civic organization; or community organization. This was dichotomized to be 1 if yes and 0 if otherwise. This variable excludes being a member of a church.

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Results: Socio-demographic Characteristics of Sample The sample was 2,000 men ages 55+ years. Fifty one percent of the sample lived in rural areas; 59.1% had a social network; 55.4% reported good health; 53.9% were retired; 25.6% were actively employed; 58.8% did not own their homes, and 34.3% were single and 44.7% were married elderly. Most of the sample had primary or elementary level education (83.1%); 85.9% reported that they do not regularly exercise; 82.5% reported good health in childhood; and 88.12% were heads of their households (Appendix II). One half of the sample indicated that they spent Ja.$100 (US $1.45) monthly for medical expenditure; 34% of the respondents bought their prescribed medication; 17.1% reported that they have been hospitalized since their sixth birthday and 65.8% reported that they took no medication. Twenty four percent of elderly men indicated that they were rarely happy, 40.5% said sometimes, 31.0% mentioned often and only 4.5% reported always. Furthermore, 17.7% of the sample reported that they were seriously ill as children. Eight percent of the sample reported that they sought medical care whenever they are ill; 25.4% knew the name of the medication that they were taking; 38.5% had a retirement health plan; 28.4% mentioned that good health is ‘physical wellness’, 9.5% said healthy diet, 3.7% claimed ‘psychological wellness’, 0.7% functional ability, and 2.0% reported religious activities. In addition, 82.5% of the sample did not respond to the question on health treatment, 7.8% indicated that they used home remedies (including healers), 2.0% said hospitals and 6.2% mentioned clinics, with 1.6% said private doctors. Sixty seven percent of the sample reported doing some form of physical exercise in the survey period. Twenty-four percent of the Jamaica older men reported that they were rarely happy compared to 5% who indicated that they were always happy.

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Happiness is not significantly correlated with health (Appendix III). A significant statistical association existed between happiness and life satisfaction (Appendix IV). Only 2.4% of sample that indicated rarely satisfied with life was always happy compared to 60% of always satisfied with life that was always happiness. Life satisfaction is not associated with health (Appendix V). Result: Multivariate Analysis Employment status, functional status and one sociodemographic variable (church attendance) were found to be predictors of happiness of older men in Jamaica. Employed older men in Jamaica had the greatest happiness, while retired older men accounted for the least happiness. Older men who attended church had greater happiness than did those who did not attend (Appendix VI); functional status was negatively related to happiness in older men in Jamaica. Limitations to study A single cross-sectional survey cannot be used as the only basis upon which policies should be altered; but it forms a platform with which we can begin to examine the health of older men outside of the traditional objective indexes of health. Another limitation of the study is the fact that individuals could be retired and actively involved, and this was not examined in the survey. The study was unable to examine income’s effect on happiness, as only 25% of the sample was employed, and in hindsight no question was asked on consumption or total expenditure which could have been used to measure income. Another limitation is that participants sometimes gave inaccurate information in their self reports.

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Discussion This study examined the health, life satisfaction and wellbeing of older men. Empirical studies have established that happiness is a good measure of self-rated health (or subjective wellbeing). In keeping with a broader conceptualization of health, happiness is a better measure of health than life expectancy, mortality, morbidity or even self-reported health conditions (Diener, 1984; 2000; Easterlin, 2001a; 2001b; Schimmel, 2009; Stutzer and Frey, 2003; Frey and Stutzer, 2000; Ng, 1996). Using a sample of older men in Jamaica, there is evidence that highlight some disparity in the previous studies on their association among health status, life satisfaction and happiness. These issues will be comprehensively discourse, and their implication examined as such issues will provide some understanding of literature by age cohort. Over the last 2 decades, the Planning Institute of Jamaica and the Statistical Institute of Jamaica have relied on self-reported health conditions, life expectancy, mortality, morbidity and health care-seeking behaviour in assessing the health status of Jamaicans (PIOJ & STATIN, 1989-2007). Happiness and life satisfaction have been well established in the literature as a good measure of subjective wellbeing. But, these have not been examined by the statistical or planning agencies in the nation as alternative measures of subjective wellbeing. The current study found that 24 out of every 100 older men in Jamaica were rarely happy; 5 out of 100 indicated a moderate health status and there was no significant statistical correlation between happiness and health status; however one existed between happiness and life satisfaction. This study highlights that health status and happiness as well as health status and life satisfaction are not good predictors of subjective health, using an older men cohort. However, happiness and life satisfaction are good measures of subjective health as they are strongly related to each other. Study conducted by Wilks et al. (2008) noted that life satisfaction among Jamaicans aged 15-74

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years declined in 2008 over 2000. They found that very dissatisfied Jamaicans increased by 96.2% (in 2008, 5 out of every 100 Jamaicans indicated being very dissatisfied with life generally), imputed therein is the lowering of happiness among the people, particularly the old who are among the vulnerable group in the society. The correlation between happiness and life satisfaction was greater in this study than in Di Tella et al.’s study (Di Tella, et al., 2003). The disparity between both studies did not cease there, as substantially more people in the United States were very happy (33 out of every 100) than in this sample (5 out of 100), and the figure for males was 33 out of 100. More than 100% more older men in this study were rarely happy compared to male Americans (11.7%). The disparity continues as 7.7 times more males in the Europe were very satisfied with life (or always satisfied) compared to elderly males in Jamaica. On the other side of the life satisfaction spectrum (rarely satisfied or not at all satisfied), 6.8 times more elderly males in Jamaica reported being rarely satisfied compared with males in European. An interesting conclusion of the current study, which concurs with the literature, is the correlation between happiness and employment status. The literature showed that unemployed men were less happy than employed people (Blanchflower & Oswald, 2004). This went further, as it found that retired elderly men were less happy than employed men; but even this was greater than for the unemployed. Part of the explanation for this may be embedded in psychological states of men post employment which includes 1) lost social networks, 2) joblessness, 3) reduced income, and 4) lowered levels of self-respect. Happiness, according to Easterlin (2003) is associated with wellbeing, and so is being ill (for example depression, anxiety, dissatisfaction). Easterlin (2003) argued that material resources have the capacity to improve someone’s choices, comfort level, state of happiness and leisure, which militates against

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static wellbeing. The reverse is true, as retirement means not having access to income from employment, and thereby reduces people’s capacity to purchase material and other resources. Outside of those realities, self-respect and social relationships are linked to employment, and a group of scholars found that the impact of unemployment is even greater than the lost income (Wilkelmann & Winkelmann, 1998), re-emphasizing the negative psychological state which accompanies unemployment as well as retirement. This offers some explanation for the negative relation between unemployment and life satisfaction, and unemployment and happiness, as an aspect of elderly’s quality of life is reduced and these are not captured in life expectancy measurement. If retirement comes with other social involvements, the effects of unemployment will mitigate against this, and this may not eliminate the loss of unemployment as it may not offset the degree of socio-economic loss. Two economists studied the “impact of wealth and income on subjective wellbeing and ill-being; they found that employed people had a higher life and financial satisfaction than their unemployed counterparts (Wooden & Headey, 2004). Another study provides further explanations for lower happiness among retired and unemployed persons than employed individuals. The Cornell Study of Retirement found that on average retired people’s income declined to 56 percent of pre-retirement income (Palmore, 1981). Palmore (1981) argued that ‘tax advantage’, ‘housing subsidies’, ‘Medicare’ and ‘income tax’ exemptions offset this. However, for the retired person in Jamaica, there is no such thing as a housing subsidy, and the National Drug for the Elderly programme coverage is minimal and does not offset the income from employment. Men substantially tie their success with their ability to provide, and income and employment are critical to this reality. Using findings from the present work, 3 out of every 4

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older men aged 55+ years old were either retired ore unemployed (1 out of every 4 being unemployed), suggesting the use of past savings, family support, friends and/or welfare assistance as means of survivability. By not paying income tax and receiving social and other types of assistances, this deteriorates the psychological state of men and accounts for their lowered happiness. In addition, the inverse correlation between subjective wellbeing and unemployment extends beyond that relation to unemployment, causing depression, anger, anxiety, loss of self-esteem and disruption in social life. A group of researchers found that even after controlling for fall in income, nnemployment inversely influences wellbeing (Clark, et al., 2006). Thus, this explains the negative correlation between (1) happiness and unemployment, and (2) life satisfaction and unemployment as economic independency is tied to social independency and economic choices. Therefore, unemployed older men must not rely on (1) family support; (2) social institutions (including Non-governmental Organization, NGO, church); (3) saving and these reduce their socioeconomic autonomy. As such, when unemployment is linked with ageing this is likely to result in depression, anxiety, unhappiness and low satisfaction with life as the elderly male is faced with possibility of increased health conditions, social exclusion and lowered income from unemployment to meet the new biological and other challenges. There is little debate within the public arena about the increasing decline of the labour force participation rate of aged (elderly) Jamaicans. In 1980, the labour force participation rate was 46.4% and it was estimated to be 26.6% in 2007 (PIOJ, 1981-2008). This represents a 43% reduction in the number of aged persons ≥ 65 years who were actively involved in the labour force. When the labour force participation rate is separated by gender, the figures reveal a more telling disparity. For females, in 1980, there were 30.4% of women actively involved within the

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labour force, but it is estimated to be 13.8% in 2007, which is a 55% reduction in the number of employed females. With respect to males’ involvement in the labour force, it fell to 41.4% in 2007, from 65.3% in 1980 (PIOJ, 1980-2008). The labour force participation rate for men will fall by 23% compared to that of females. This is within the context of women’s living longer than their male counterparts, and the retirement age for females is 60 years and not 65 years. Therefore, if we are to extrapolate a reduced 5 years for females, the labour force participation rate will increase further by at least a percentage point. With retirement and unemployment at older ages (60 years and older for women and 65 years and older for men), the family, savings and other social networks must replace this lost income. Statistics from the Planning Institute of Jamaica and the Statistical Institute of Jamaica showed that 26.6% of Jamaicans received remittances and that the rate rose by 57% (to 41.8%) (PIOJ, 2008), which emphasizes the role of the family and social support in supplementing the income of many people including the retired and unemployed elderly men. Eldemire (1994) agreed with this finding, when she opined that the loss of financial resources (., income or employment) results in changes in the lifestyle practices of older people as they must readjusted their spending patterns owing to retirement and unemployment. Unemployment or retirement means that those people must now use their past savings or social support to meet current food and other expenditures. Based on some writers, “In Jamaica, just over 60 per cent of people aged over 65 are living in poverty compared with just over 40 per cent for those under 64” which embodies the emotional, social and economic status of older people, particularly men who are culturalized to link manhood to economic dependency (Gorman et al., 2010:7). This means that financial inadequacies that emerged from retirement and unemployment will prevent older Jamaican men from accessing food, nutritional needs, rental cost, socioeconomic expectations of

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the society, the inability to pay utilities and other expenses as well as their general subjective wellbeing. With 3 out of every 4 older Jamaican men being retired or unemployed, the high prevalence of poverty among the elderly (Gorman, et al. 2010) is, therefore, a justification of socioeconomic challenges among this cohort. “There is more poverty among the aged and older persons have lower average incomes than younger adults” (Palmore 1981:16) and the “aged usually does suffer some decline in income as they age, especially upon retirement”. This was recorded in a Cornel Study of Retirement that “estimated that the average retired person’s income declined to 56 percent of pre-retirement income” (Palmore, 1981:16). He argued that ‘tax advantage’, ‘housing subsidies’, ‘Medicare’ and ‘income tax’ exemptions offset this. This is able to afford the aged to maintain a particular accustomed standard of living but the social setting of poor aged was not discounted for in Palmore’s theorizing; and the widespread human suffering that this has on the low educated poor aged. Eldemire (1994) alluded to this finding, when she suggested that loss of financial resources may result in a change in the lifestyle practices of people. From Eldemire’s works, it can be construed that senior citizens (. elderly) are highly likely to see a change in their lifestyle as a result of changes in their financial base, and so family support is critical in these years (Eldemire, 1997; 1996; 1995; 1994; 1987a; 1987b; 2003; 2005). In the current work, 1 in every 4 older Jamaican men indicated being employed, emphasis the challenges of old age. Warnes (1982) encapsulated the importance of resources to the quality of life of elderly in the statement that “…much if not more related to their social isolation or integration and to their physical capacities as to their command of material resources” (Warnes, 1982: 4) because of the likeliness of physical and psychological changes, unemployment and death of peer due to chronological ageing (Centre of Health Service Development, 2001; Katz,

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1970; 1993; 1998; Kuekiquxz & Wallace, 1999; Lawson & Brody, 1969). The challenges of the elderly, particular men are not limited to social exclusion, loss of income, and employment, but health conditions. Findings from studies by the Planning Institute of Jamaica in collaboration with the Statistical Institute of Jamaica show that while the general health status is commendable, chronic illnesses are undoubtedly eroding the quality of life enjoyed by people who are 65 years and older (in Jamaica Survey of Living Conditions – JSLC2000, 58-59; 1997, 45). The JSLC report reveals that prevalence of recurrent (chronic) diseases is highest among individuals 65 years and over (JSLC 2000: 49). The findings show that in 2000, the prevalence of self-reported illness/injury for the aged people 65 years and over was 41.7%, for those 60 to 64 years it was 27.6% compared to 19.8% for children less than five years old. However, the prevalence of self-reported illness/injury for those 50 to 59 years was 18.8%. Some 36.6% of individuals 65 years and over reported injuries/illnesses in 2002 which is a 5.6% reduction in self-reported prevalence of illnesses/injuries over 2000, but the self-reported prevalence of illness/injuries rose by 25.8% to 62.4% in 2004 (JSLC 2004, 2002). It should be noted here that this increase in self-reported cases of injuries/ailments do not represent an increase in incidence of cases as the JSLC for 2004 had that proportion of recurring/chronic cases fell from 49.2% in 2002 to 38.2% in 2004 (JSLC 2004, xvi). According PIOJ & STATIN (2001) in (JSLC 2000) that individuals 60-64 years was 1.5 times more likely to report an injury than children less than five-year, and the figure was even higher for those 64 years and older (2.5 times more). How is the status of elderly within a general setting of higher recurrence of chronic non-communicable diseases and their severity among senior citizens? Within the macho culture of Jamaica, generally, men do not seek preventative care because it is seen as weak. This reality can be deduced from the PIOJ & STATIN’s report 449

(2001:58) that shows that traditional females seek health-care more than males, which allows for a better monitoring and diagnostic assessment of their health conditions as against men. Such a position is learnt from the culture, which states that boys should ‘suppress reaction to pain’ (Chevannes, 2001:37). Chevannes’ work begins the explanation of the figures that are presented in the JSLC 2000 that men are 0.7 times less likely to self-report sicknesses, injuries/ailments than their female counterparts (JSLC 2000:50). With this realty, the elderly man who is unemployed is likely then to experience additional health conditions, and these are made difficult with economic vulnerability. The issue of resource insufficiency affects the ability and capacity of the poor elderly and other older unemployed and retired men from accessing the goods and services available to the rich. This study disagrees with Di Tella et al.’s work which found the least happiness for the unemployed, but agrees that the employed had the greatest level of happiness, indicating that these are constants across America and some European nations as well as in developing states like Jamaica (Di Tella, 2003). Interestingly, advances in medicine and medical technology, particularly in Jamaica, which account for the continued increases in life expectancy - (77.01 yrs for females and 71.26 yrs for males - STATIN, 2006) - if taken at face value will not adequately explain the quality of life of people. In that, while life expectancy is increasing over the past decade, the reality that chronic non-communicable diseases continue to rise since 1997 for people over 60 years indicates a troubling situation for seniors, and justify reduced happiness and satisfaction with life as a result of ageing, and create a vacuum for external assistance from places like the church as well as ‘bad’ habits. According to Kart (1990), religious guidelines aid wellbeing through controlling bad behavioural habits such as smoking, drinking, and poor diets. Researchers found that a positive

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association exists between religion and wellbeing (Kart, 1990; Moody, 2006). Using church attendance to measure religious status of older men, this work supports the literature that people attending church are happier than those who do not. The relationship was even stronger for men than for women, and this association was influenced by denominational affiliation. Graham et al.’s study found that blood pressure for highly religious male heads of households in Evan County was low (Graham, et al., 1978). The findings of this research did not change when controlled for age, obesity, cigarette smoking, and socioeconomic status. A study on the Mormons in Utah revealed that cancer rates were lower (by 80%) for those who adhere to Church doctrine than those with weaker adherence (Gardner & Lyon, 1982), suggesting that religiosity is associated with better quality of life and that low religiosity provides an explanation for more health conditions. Embedded in the aforementioned study is the importance of adherence of religious beliefs on the individual’s health, indicating the negative association between a particular health condition (ie. cancer) and religious practices. The current work found that frequent church attendance was associated with happiness, and that happiness was related to satisfaction with life, but not with health status indicating that happier older men are more satisfied with life. Aged individuals experience changes in sensory processes, perception, motor skills and problem-solving ability (Centre of Health Service Development, 2001; Katz, 1970; 1993; 1998; Kuekiquxz & Wallace, 1999; Lawson & Brody, 1969). Their perception, self-esteem, drives, mental health status, and emotions are frequently altered (Easterlin, 2001; Winkelmann & Winkelmann, 1998; Diener, et al. 1985; Lyumbomirsky, 2001; Leung, et al., 2005; Lyumbomirsky et al., 2005) because of the psychological and physiological changes caused through psychopathological conditions of ageing. We found that low cognitive and functional

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statuses among older men in Jamaica were very low (cognitive functionality, 1.0%; functional status, 1.2%), a statistical association between functional status and happiness and by extension functional status and life satisfaction, suggesting that high physical functionality of this sample speaks to the quality of subjective wellbeing of older men in Jamaica. People’s cognitive responses to ordinary and extraordinary situational events in life are associated with different typologies of wellbeing (Lyumbomirsky, 2001). However, this did not emerged in the current work as no correlation existed between cognitive functionality and happiness or life satisfaction. The literature established that happier people are more optimistic and as such conceptualize life’s experiences in a positive manner. One study revealed that positive moods and emotions are associated with wellbeing (Leung, et al., 2005) as the individual is able to think, feel and act in ways that foster resource building and involvement with particular goal materialization (Lyumbomirsky et al., 2005). This situation is later internalized, causing the individual to be self-confident, from which follows a series of positive attitudes that guide further actions (Sheldon & Lyubomirsky, 2006). Positive mood is not limited to active responses by individuals, but a study showed that “counting one’s blessings,” “committing acts of kindness”, recognizing and using signature strengths, “remembering oneself at one’s best”, and “working on personal goals” all positively influence wellbeing. An interesting finding of this paper is the explanatory power of the micro-econometric happiness equation. The micro-econometric happiness equation of the current study was 32%, which is greater that in Blanchflower & Oswald’s work (Blanchflower & Oswald, 2004). Although Di Tella et al.’s work was not on older men, they found that the majority of men in the United States were pretty happy (56 out of every 100) which was similar for older men in Jamaica (41 out of every 100). Only 12 out of every 100 men in the United States reported being

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‘not too happy’ compared to 24 out of every 100 older men in Jamaica (., ‘rarely happy). The work of Di Tella et al. used data from the 1970’s to the 1990’s and the present study used data for 2007, so the disparity may be wider or narrower in 2007 for both nations. Inspite of the date differences between the current work and that of Di Tella et al. (2003), it can be deduced that happiness and life satisfaction decline with ageing, and thus provide some rationale for the higher percentage of older men in Jamaica who indicated being rarely happy and thereby rarely satisfied with life (or vice versa). The literature empirically establishes that happiness is correlated with health status, but no study found a strong relation between those two variables. Easterlin (1996) found that since World War II in developed nations, the association between those variables is negative and even non-existent. This study disagreed with Easterlin as it found no significant correlation was between happiness and health status, nor life satisfaction and health status. However, in this work, we went further and found a strong positive correlation between happiness and life satisfaction, suggesting that happiness among older men can be used to explain their satisfaction with life, but not self-rated health status which showed no statistical relationship among (1) happiness and self-rated health and (2) life satisfaction and self-rated health status. The current study provides some critical findings in the understanding of older men in Jamaica, particular self-rated health, life satisfaction and happiness. Again, happiness is not statistically correlated with health status as well as life satisfaction and health status, while life satisfaction and happiness are good measures of subjective health (., wellbeing), which provides some disparity between the literature and a present work, particularly age cohort and locality. Interesting therefore is that not all three subjective indexes (life satisfaction, happiness and health status) are good measures of each other. Embedded in the current work is the fact that the

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findings in one geographically defined region cannot be wholesale used to evaluate those in another region. This is highlighted in the current work, and offers some justification for researcher in different regions and among particular sociodemographic characteristics as while the literature showed that aforementioned subjective indexes were correlation this was not the case among older men. As such, while some similarities emerged between the current work and previously done empirical researches, national planning needs to understand those issues outside of their borders, but must understand the complexities and issues with its borders for effectively planning for the people, and any socioeconomic disparities in the population and subpopulations. Conclusion Happiness is strongly related to life satisfaction but not to health status, and life satisfaction is not statistically associated with health status. This suggests that older men make a distinction between happiness as well as life satisfaction and health status. Satisfaction with life and happiness are good proxies for each other, but neither life satisfaction nor happiness are associated with health status. The present study highlights a differential in the three identified variables as older Jamaicans generally view health as the antithesis of illness and so happiness and life satisfaction is a more holistic measure than self-rated health status. Thus, happiness or life satisfaction cannot be used as an independent variable in each other’s models. Health is a narrower measure for quality of life than life satisfaction or happiness. In spite of the broad definition of health as was forwarded by WHO in the late 1940s, health for older men in Jamaica is still narrowly conceptualized and cannot be used to measure quality of life (or subjective wellbeing) like happiness or life satisfaction. There is also the issue of gender, where the literature suggests that fewer women are part of the labor force than men. This situation is due to the glass ceiling in society which denies

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Jamaican women their rights and opportunities. The role of the glass and grey ceilings on the wellbeing of older Jamaican women should be researched. This is another double burden in addition to the well known double burden of professional work and housework that constrains the professional and economic success of women and hence their wellbeing. The findings are far reaching and can be used to influence patient care outcome as well as other policy intervention programmes.

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Wills, E. (2009). Spirituality and subjective wellbeing: Evidence for a new domain in the personal wellbeing index. Journal of Happiness Studies 10: 49-69. Wilks, R., Younger, N., Tulloch-Reid, M., McFarlane, S., Francis, D. (2008). Jamaica health and lifestyle survey 2007-8. Kingston: Tropical Medicine Research Institute, University of the West Indies, Mona. Winkelmann, L., & Winkelmann, R. (1998). Why are the unemployed so unhappy? Evidence from panel data. Economics 65:1-15. Wooden, M., & Headey, B. (2004). The effects of wealth and income on subjective well-being and ill-being. Australia: Melbourne Institute of Applied Economic and Social Research.

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Additional referencing Reference Brannon, L. and J. Feist. 2004. Health psychology. An introduction to behavior and health, 5th ed. Los Angeles: Wadsworth. Buzina, K. 1999. Drug therapy in the elderly. Cajanus 32:194-200. Callender, J. 2000. Lifestyle management in the hypertensive diabetic. Cajanus, 33:67-70. Caribbean Food and Nutrition Institute. 1999a. Health of the elderly. Cajanus 32:217-240. Eldemire, D. 1995. A situational analysis of the Jamaican elderly, 1992. Kingston: Planning Institute of Jamaica. Erber, J. 2005. Learning. Aging and older adulthood. New York: Waldsworth, Thomson

International Labour Organization. 2000. Ageing in Asia: The growting need for social protection. http://www.ilo.org/public/english/region/asro/bangkok/paper/ageing.htm (accessed May 3, 2007). Lawson, S. C. 1996. Culture and Aging: The case of Jamaican Elderly persons. Paper presented at the Conference on Caribbean Culture, The University of the West Indies, Mona Campus, Jamaica, March 4-6, 1996. Lyubomirsky, S. 2001. Why are some people happier than others? The role of cognitive and motivational process in wellbeing. American Psychologist 56:239-249. http://www.faculty.ucr.edu/~sonja/papers/L2001.pdf (accessed July 22, 2006). Lyubomirsky, S., L. King, and E. Diener. 2005. The benefits of frequent positive affect: Does happiness lead to success? Psychological Bulletin, 6, 803-855. Morrison, E. 2000. Diabetes and hypertension: Twin trouble. Cajanus 33:61-63. Planning Institute of Jamaica. 2007. Economic and Social Survey Jamaica, 2006. Kingston, Jamaica: PIOJ. Statistical Institute of Jamaica (STATIN). 2006. Demographic Statistics, 2005. Kingston, Jamaica: STATIN. ____________. 2001. Population Census 2001, Jamaica. Volume 1: Country Report. Kingston, Jamaica: STATIN. ____________. 2004. Population Census 2000. Jamaica, vol. 4, Part B, Book 1. Housing. Kingston: STATIN. ____________. 1972 - 2006. Demographic Statistics, 1972-2005. Kingston, Jamaica: STATIN. ____________.1973-1989. Statistical Yearbook of Jamaica, 1973-1989. Kingston, Jamaica: STATIN. Steingo, B. 2000. Neurological consequences of diabetes and hypertension. Cajanus 33:71-83. Rowland, D. T. 2003. Demographic methods and concepts. Oxford: Oxford University Press. United Nations. 2007a. Advanced data extract – years selection. Department of Economic and Social Affairs, Population Division. New York: UN http://millenniumindicators.un.org/unsd/cdb/cdb_advanced_data_extract_yr.asp?HSrID=136 83&HCrID=388. ________. 2007b. ECLAC, Statistical yearbook for Latin America and the Caribbean, 2006. Santiago, Chile: UN. ________. 2006. Statistical yearbook, 50th issue. Department of Economic and Social Affairs, Population Division. New York: UN 461

________. 2005c. World population prospect: The 2004 revision. Department of Economic and Social Affairs, Population Division. New York: UN. Wise, D. A. 1997. Retirement against the demographic trend: More older people living longer, working less, and saving less. Demography 34:17-30. World Health Organization. 1998a. Health promotion glossary. Geneva: World Health Organization. __________. 1998b. Primary prevention of mental, neurological and psychosocial disorder. Geneva: WHO. __________. 1998c. The world health report, 1998: Life in the 21st century a vision of all. Geneva: WHO.

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Appendix I: Life Expectancy at Birth of Jamaicans by Sex: 1880-2004 (in yrs) Average Expected Years of Life at Birth Period: 1880-1882 1890-1892 1910-1912 1920-1922 1945-1947 1950-1952 1959-1961 1969-1970 1979-1981 1989-1991 1999-2001 2002-2004 Male 37.02 36.74 39.04 35.89 51.25 55.73 62.65 66.70 69.03 69.97 70.94 71.26 Female 39.80 38.30 41.41 38.20 54.58 58.89 66.63 70.20 72.37 72.64 75.58 77.07

Sources: Demographic Statistics (1972-2006)

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Appendix II: Socio-demographic Characteristics of Sample Variable Cognitive Functionality Low Moderate High Functional Status High dependence Moderate dependence Low dependence Age group 55- 64 years 65 – 74 years 75 years and older House Ownership Yes No Employment Status Employed Unemployed Retired Happiness Rarely Sometimes Most times Always Self-rated Health Status Excellent Good Fair Social Networking Yes No Regular Exercise Yes No Childhood Health status Good Poor Area of residence Urban Rural

Frequency 19 99 1882 24 184 1792 851 712 437 824 1176 511 412 1077 480 810 620 90 357 1038 480 817 1183 282 1718 1650 350 981 1019

Percent 1.0 4.9 94.1 1.2 9.2 89.6 42.5 35.6 21.9 41.2 58.8 25.5 20.6 53.9 24.0 40.5 31.0 4.5 19.0 55.4 25.6 59.1 40.9 14.1 85.9 82.5 17.5 49.0 51.0

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Appendix III. Happiness and Health Status Happiness Excellent Rarely Sometimes Most times Always Total
χ2 (df=6) = 3.333, P = 0.766

Health status Good Fair (Moderate) n (%) 261 (25.1) 424 (40.8) 313 (30.2) 40 (3.9) 1038 n (%) 107 (22.3) 202 (42.1) 148 (30.8) 23 (4.8) 480

Total n (%) 454 (24.2) 763 (40.7) 578 (30.8) 80 (4.3) 1875

n (%) 86 (24.1) 137 (38.4) 117 (32.8) 17 (4.7) 357

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Appendix IV. Happiness and life satisfaction Life Satisfaction Happiness Rarely Rarely 348 (52.9) Sometimes 82 (12.2) Most times 40 (6.7) Always 10 (14.3) Total 480 (24.0)

Sometimes

172 (26.2)

466 (69.1)

160 (26.7)

12 (17.1)

810 (40.5)

Most times

122 (18.5)

116 (17.2)

376 (62.9)

6 (8.6)

620 (31.0)

Always Total

16 (2.4)

10 (1.5)

22 (3.7)

42 (60.0)

90 (4.5)

658

674

598

70

2000

χ2 (df = 9) = 1334.448, P = 0.001, contingency coefficient = 0.833

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Appendix V. Health status and life satisfaction Life Satisfaction Health status Excellent Rarely 113 (18.4) Sometimes 112 (17.5) Most times 121 (21.7) Always 11 (17.7) Total 357 (19.0)

Good

346 (56.3)

358 (55.8)

299 (53.7)

35 (56.5)

1038 (55.4)

Fair Total
χ2 (df = 6) = 4.07, P = 0.667

156 (25.4) 615

171 (26.7) 641

137 (24.6) 557

16 (25.8) 62

480 (25.6) 1875

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Appendix VI: Happiness Equation for Older Men in Jamaica (Ordered Probit Regression) Dependent Happiness variable: Reported CI (95%) 0.029 - 0.300 0.091 - 0.335 -0.060 - -0.010 -0.232 - 0.241 -0.193 - 0.032 -0.259 - 0.053 -0.114 - 0.153 -0.114 - 0.138 -0.160 - 0.122 -0.244 - 0.092 -0.264 - 0.273 -0.093 - 0.303 0.046 - 0.338 -0.007 - 0.315 -0.136 - 0.070 -0.141 - 0.097 -0.148 - 0.109 -1.016 - -0.422

P Coefficient Z Unemployed 0.164 2.386 0.017 Employed 0.213 3.411 0.001 Functional status Index -0.035 -2.779 0.005 Logged Cognitive functioning Index 0.005 0.037 0.970 Dummy Home Dwelling -0.080 -1.404 0.160 Dummy Brother Alive -0.103 -1.296 0.195 Dummy Sister Alive 0.019 0.283 0.777 Dummy Exercise 0.012 0.190 0.850 Dummy Mother Alive -0.019 -0.266 0.790 Dummy Father Alive -0.076 -0.888 0.374 Dummy Have Children 0.005 0.035 0.972 Dummy Education 0.105 1.037 0.300 Church Attendance 0.192 2.574 0.010 Social Support 0.154 1.871 0.061 Dummy Urban Area -0.033 -0.632 0.528 Childhood Health Status -0.022 -0.365 0.715 Current Health Status -0.019 -0.296 0.767 Intercept -0.719 -2.422 0.015 Pearson Goodness of fit Test - Chi-square = 2,361.773, P < 0.001 n = 1,873 Pseudo R2 = 0.320 Log likelihood = 755.268

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Contributors
Paul A. Bourne is Director, Socio-Medical Research Institute, Kingston, Jamaica Chloe W. Morris is Lecturer, Department of Community Health and Psychiatry, Faculty of Medial Sciences, University of the West Indies, Mona, Jamaica Denise Eldemire-Shearer is Professor of Public Health and Head of Department, Department of Community Health and Psychiatry, Faculty of Medial Sciences, University of the West Indies, Mona, Jamaica Neva South-Bourne is Research Assistant, Socio-Medical Research Institute, Kingston, Jamaica

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Chapter

17

Dichotomising poor self-reported health status: Using secondary crosssectional survey data for Jamaica

Introduction
Logistic regression has been widely used by Caribbean and/or Latin American scholars to examine parameters and weights of determinants of self-reported health status [1-7] or life satisfaction [8]. This is a global practice [9-14]. Embedded in the use of logistic regression in the study of self-reported (rated) health is the dichotomisation of health status. Self-rated health status is a Likert scale variable ranging from very poor to very good health status. This denotes that the dichotomisation of self-reported health must address where moderate health status should be placed. The dichotomisation of self-reported health status brings into focus the issue of a cut-off and the validity of one’s choice. By categorising an ordinal measure (self-reported health) into a dichotomous one, this means that some of the original data will be lost in the process. Another important issue which is unresolved in the choice of a cut-off is the subjective with which Caribbean scholars have continued to make their decision. Their decision as to what constitutes bad or good (including excellent) health is not purely subjective, as this practice is global one. The decision of a cut-off cannot be subject to international norm if there is no rationale for this approach. Caribbean scholars cannot merely follow tradition in their choice of conceptualisation

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and operationalisation of a measure, as this is not a scientific enough rationale for the use of a particular measure. Some scholars have opined that self-reported health status should remain a Likert scale measure or in its continuous form as against the dichotomisation of the measure [15-17]. The work of Finnas et al. showed that the five-point Likert scale variable of self-reported health status can be dichotomised. However, there are some methodological issues that must be considered [18]. Finnas and colleagues’ study revealed that the cut-off point of bad versus good self-reported health and the decision as to where moderate self-reported health status be placed does not depend on age. However, when the categorisation of poor self-reported health excludes moderate self-reported health, the covariate of marital status and educational level were found to be highly age-dependent. Within the context of the aforementioned findings, Caribbean scholars need to examine these issues within the available health data in order to be able to empirically make a choice of 1) dichotomisation or 2) non-dichotomisation of self-reported health status. The discourse on whether or not to dichotomise self-reported health status is unresolved., Therefore, dichotomising the measure simply because it has been done so by non-Caribbean scholars in developed nations is not a sufficient rationale for following suit in Latin America and the Caribbean. Latin America and the Caribbean are developing nations whose socio-economic situations are different from those in First World Countries, emphasising the justification of why Latin America and Caribbean scholars should examine self-reported health data in order to concretise their choice of dichotomisation or not. Jamaica, which is a part of Latin America and the Caribbean, has been collecting selfreported health data since 1988 [19], and these data have been used repeatedly by scholars to aid public health programmes. An extensive review of the literature did not find a single study that

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has examined the validity of dichotomisation of self-reported health status. The same was also found for the wider Caribbean, suggesting that scholars have been keeping with the tradition and the practice of using the scholarly information from the developed nations when it comes to dichotomised self-reported health status. The current study fills this gap in the literature, and will be used to guide public health practitioners and other users of self-reported health data on Jamaicans. The objectives of the study are: 1) evaluate which cut-off point should be used for self-reported health status; 2) assess whether dichotomisation of self-reported data should be practiced; 3) ascertain any disparity in dichotomisation by some covariates (., marital status, age cohort, social class); and 4) examine the odds of reporting poor or moderate-to-very poor selfreported health status if one has an illness.

Materials and Methods
Sample This study used secondary cross-sectional survey data, which was collected between May and August, 2007 [20]. The Jamaica Survey of Living Conditions (JSLC), which is used for this study, is a joint research conducted by the Planning Institute of Jamaica (PIOJ) and the Statistical Institute of Jamaica (STATIN) [19]. The JSLC is an annual survey that began in 1988. It is a standard exercise; the JSLC’s sample is a proportion of the Labour Force Survey (LFS). In 2007, it was one-third of the LFS. For 2007, the JSLC’s sample was 6,783 respondents. The current study extracted 1,583 respondents from the larger sample as the focus was on participants aged 46+ years. The survey was drawn using stratified random sampling. This design was a two-stage stratified random sampling design where there was a Primary Sampling Unit (PSU) and a selection of dwellings from the primary units. The PSU is an Enumeration District (ED), which constitutes a minimum

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of 100 residences in rural areas and 150 in urban areas. An ED is an independent geographic unit that shares a common boundary. This means that the country was grouped into strata of equal size based on dwellings (EDs). Based on the PSUs, a listing of all the dwellings was made, and this became the sampling frame from which a Master Sample of dwellings was compiled, which in turn provided the sampling frame for the labour force. A total of 620 households were interviewed from urban areas, 439 from semi-urban areas and 935 from rural areas, which constituted 6,783 respondents. The sample was weighted to reflect the population of the nation. The non-response rate for the survey for 2007 was 27.7%. Data collection The JSLC is a modification of the World Bank’s Living Standards Measurement Study household survey [21]. Face-to-face interviews over the aforementioned period were used to collect the data. A structured questionnaire was used and already trained interviewers were then trained again specifically for this task. The questions covered demographic characteristics, household consumption, health status, health care-seeking behaviour, illnesses, education, housing, social welfare and related programmes, and inventory of durable goods. Statistical analyses Data were stored, retrieved and analyzed using SPSS-PC for Windows version 16.0. Descriptive statistics were used to provide background information on the sample. Cross tabulations were done to examine non-metric dependent and independent variables, which provided the percentages. Percentages were computed for dichotomous health statuses (., very poor or poor health status, and the other very poor to moderate health status); these were employed for calculating the odds ratio in each dichotomisation of self-reported health status.

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Among men aged 46-54 years, 37.7% of those who reported an illness rated their health status as very poor or poor, as compared to 7.3% of those who did not indicate an illness. Hence, the odds ratio of very poor-to-poor health status was 7.7 [(37.7/62.3)/(7.3/92.7)] indicating that men who reported an illness also have 8 times as high odds of reporting very poor or poor health status than those who did not report a dysfunction. In age cohort 46-54 years, the percentage of men who reported very poor, poor or moderate health status was 81.4% compared to 39.9% of those who did not report an illness. Hence, the odds ratio of very poor, poor or moderate health status versus non-very poor to moderate health status was 9.6 [(81.4/18.6)/ (31.2/68.8)]. The current study expanded on the work of Finnas et al. [18], which examined some of the methodological challenges in self-reported data in Finland. This paper is an expansion of Finnas et al.’s study in a number of respects, such as: 1) their work used age cohort 35-64 years while this study used 45-85+ years; 2) self-reported illness was included among the covariates in the examination of self-reported (rated) health status; and 3) social class and access (or lack of access) to material resources play a critical role in directly and indirectly influencing health, and so this was added to this paper. Although higher education plays a vital role in health status, 2% of the sample had tertiary level education and of this, 0.2% was older than 45 years. Most of the sample had at most primary level education (87.3%), which means that the role of tertiary education would contribute marginally to this sample. Hence, the researcher excluded it from the covariate analysis of self-reported health status. Measurement of variables Self-reported illness status is a dummy variable, where 1 = reporting an ailment or dysfunction or illness in the last 4 weeks, which was the survey period, 0 = no self-reported ailments, injuries or 474

illnesses [11, 12, 25]. While self-reported ill-health is not an ideal indicator of actual health conditions, because people may underreport, it is still an accurate approximation of ill-health and mortality [26, 27]. Self-reported health status (or health status) was measured by the question: Generally, how would you describe your health currently? The options were: very good, good, moderate (or fair), poor, and very poor. Age group was classified as children (aged less than 15 years), youth (aged 15 through 25 years), and other age cohorts ranging in 5 year intervals from 26-30 years, et cetera. Medical care-seeking behaviour was taken from the question: Has a health care practitioner, healer, or pharmacist been visited in the last 4 weeks? The two options were yes or no. Medical care-seeking behaviour, therefore, was coded as a binary measure where 1=yes and 0= otherwise. Social class is measured using income quintile where it ranges from poorest 20% to wealthiest 20%.

The distribution of the different age cohorts for each sex based on self-reported health status is given in Figures 17.1.a and 17.1.b. Figures 17.a and 17.1.b will be used to argue the case for a cut-off point for the dichotomisation of self-reported health status in Jamaica.

It is well established in biomedical literature that there is a strong negative correlation between health and age; the current study using self-reported health status by different age cohort controlled for sexes revealed that good health decreases as the individual ages and that more women beyond 80 years old reported very good health status compared to men in the same age cohorts. Health status, therefore, can be simply explained by age cohorts, and the aforementioned findings show that sex must be taken into consideration among the covariates in order to comprehend the effects of particular demographic variables on the statistical interpretations of

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health data. The other covariates must include education level, marital status, area of residence, and social class.

The issue of dichotomising self-reported health status continues to be debated in Jamaica as researchers continue to grapple with whether to use very poor-to-poor health status versus moderate-to-very poor health status. The issue of using moderate health in poor or good health status is critical as this will aid researchers in understanding whether there should be a cut-off point and where it should be, as this is the crux of the interpretation of the logistic regression model. Based on Figure 17.1, the very poor-to-poor health status is marginal at ages below 46 years, and so for the purpose of dichotomisation, ages 46 years and older will be used.

Results
Demographic characteristics Of the sample (6783), 48.7% was male; 51.3% female; 69.2% never married; 14.9% reported having an illness in the survey period (4-week); 49.0% dwelled in rural areas; 82.2% reported at least good health and 4.8% reported at least poor health status (Table 17.1). Concomitantly, 61.8% indicated no formal education; 2.0% reported tertiary level education; 20.4% was classified as in the wealthiest 20% and 19.7% was in the poorest 20%. Continuing, the mean age of the sample was 29.9 years (SD = 21.8 years) with 25 percent of the sample being 12 years old; 50 percent being 26 years old and 75 percent being 44 years old; 2.1% of the sample was at least 81 years old. Furthermore, 31% of the sample was less than 15 years old and 18.9% youth.

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Multivariate analyses Interpretation of the odds ratios Comparatively, for ages 46-54 years, the odds ratio for reporting an illness when an individual is a male who self-reported that he had very poor-to-poor health status was 7.7 times compared to a male who did not report an illness. For women of the same age cohort, those who reported an illness who had reported a health status of very poor-to-poor was 3.3 times more likely to report an illness compared to a female of the same age cohort who did not report a dysfunction. The findings revealed that the odds ratio of an 85+-year-old male reporting an illness when he had indicated very poor-to-poor health status was 7.9 times more than for one who had not indicated a dysfunction. However, the odds ratio of reporting an illness declined for Jamaican males (Table 17.2). On the other hand, the odds of a female of the same age who reported an illness indicating that she had very poor-to-poor health status was greater at 85+ years than a 4654-year-old female (Table 17.3). Generally, using the odds ratio, males benefited more by being married (Table 17.3) than females (Table 17.3). Concomitantly, the variance from adding moderate-to-poor or very poor health status marginally change the odds ratios over very poor-to-poor health status to very moderate-to-very poor self-reported health status. This was the same across area of residence for the sexes. A substantial disparity in the odds ratios occurred in social standing for males, while it was relatively the same for females. Table 17.3 revealed that by adding moderate self-reported health status to very poor or poor self-reported health status for males, the odds ratios at older ages (75+ years) increased exponentially over very poor-to-poor self-reported health status. Using odds ratios, the cut-off point for poor health status (excluding moderate health) increased over the age cohorts. However, when the cut-off point included moderate health status,

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the odds ratios from ages 46 years to 84 years showed that as respondents’ age within this age cohort, their likeliness of reporting poor health increased; this declined for ages beyond 85+ years. Concurrently, the odds ratios are exponentially higher for the latter dichotomisation than the former (Table 17.4).

Discussion
The findings of the current study show that the choice of cut-off for the dichotomisation of selfreported health status marginally matters for age, marital status, and area of residence. These findings concur with Finnas et al.’s work [18]. However, social class matters for males. The odds ratios for males at the different social classes, when moderate heath status is added to poor health status, changed substantially. This suggests that the dichotomisation of self-reporting for males will not shift and will produce a different result from if only poor or very poor were the cut-offs for self-reported health status. The findings of the study showed that the poor or poorest 20% of males benefitted exponentially when moderate self-reported health status is added to the cut-off point in dichotomising poor health status (including very poor). Another important finding of this study, which was not examined by Finnas et al., is the validity of using self-reported illness to measure the health status of people. Even though the likelihood of a person with an illness reporting very poor-to-poor health status is greater than one, it should be noted that that likelihood falls at older ages for males and increases at older ages for females. For men, when the cut-off point includes moderate health status, the impact of assessing selfreported illness with poor or very poor health status is higher than if the cut-off was only poor or very poor health status. Embedded in this finding is the vast difference that is created by merely changing the cut-off point from poor health status to moderate-to-very poor health status for males. While this disparity does not emerge for females, health researchers who use sex as a

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covariate must be aware of this reality when dichotomising self-reported health status. The cutoff point for dichotomising self-reported health does not matter if one is examining the health status of only females, as the marginal difference in odds ratio is insignificant and would not create a classification disparity in interpreting the final results. However, the same cannot be said about males, particularly those of older ages. Therefore, with regards to using self-reported health status, combining people from broad age groups should not be done, as this will not capture the challenges identified in health data on males in Jamaica. Studies have shown that health deteriorates with age [22-30], indicating the critical role that age plays in the understanding health of people. Therefore, in an examination of poor health status, cautioned must be used by the researcher(s), as people are less likely to report very poor-to-poor health at ages 15-30 years. On examination of self-reported health status for Jamaicans, the researcher became aware of this fact and so the study of dichotomisation of poor health did not use that age cohort. It is this rationale, and why the researcher concurred with Finnas et al., that it was decided that these should be used as covariates. Within the context of the current study, which revealed that small percentages of particular age cohorts are likely to report very poor-topoor health status, the researcher chose age cohorts that are more likely to report very poor-topoor health status as this was critical to study. Unlike Finnas et al.’s work, which cuts off at age 64 years, this study extended as far as to study respondents up to 85+ years. In 2007, 3.8% of Jamaicans were 75+ years (101,272); 1% were older than 84 years (26,821), and given that people at these ages are more likely to report poor or very poor health, the researcher believes that stopping the study at age 64 would have excluded a critical proportion of those who are likely to be reporting poor health status.

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Among the social determinants of health are social class and area of residence [1-6, 3133]. People are not only defined by their ages, but by where they live and the social class in which they belong. The current study revealed that rural Jamaican women indicated the greatest percentage of very poor-to-poor health status, while this was not the case for men. However, the inclusion of moderate health status to poor or very poor health status across the age cohorts by area of residence revealed marginal differences as was the case without the inclusion of moderate health status. Among men of 85+ years, the odds ratio of reporting very poor-to-poor health approximately doubled over the previous age cohort (75-84 years) and this was marginally the same when moderate health was included in the dichotomisation of very poor-to-poor health. For women, this was not the case as the odds ratios were mostly the same for the two dichotomisations. Health literature has shown that the poor had the lowest health status [34]. Among men, the effect of social class on health showed no consistent pattern and this was the same for women. However, when moderate health status is included in the cut-off for very poor-to-poor health status, significant changes were observed over the age cohorts. For men, exponential increases occurred with the inclusion of moderate health status to the cut-off point, while this was not the case for women. The current study revealed that the dichotomisation of self-reported health status fundamentally increased the odds ratio, suggesting that the moderate-to-very poor exponentially takes in more men based on how self-reported health status is dichotomised in Jamaica at older ages (75+ years). Embedded in the finding is the disparity between the percentages of sexes who reported moderate health at older ages for men more than women. This study included self-reported illnesses, unlike Finnas et al.’s work, and the findings indicated that cut-off point for dichotomisation of health status was somewhat changed for women, but

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exponentially changed for men. The findings revealed that women ages 85+ years—when selfreported health status was dichotomised using very poor-to-poor health—had the highest odds of reporting poor health status. When poor health status was expanded to include moderate health status, the younger ages recorded greater odds of indicating moderate-to-very poor health status. This indicates that at longer ages using the latter dichotomisation approach the odds were agedependent. Men of 85+ years recorded the least odds ratio of very poor-to-poor and moderate-tovery poor health status. There was no clear pattern of age-dependence of self-reported illness for men. Embedded in the findings is the greater likelihood of men to report moderate health than poor health at higher ages (85+ years). This suggests that they are under-reporting their true very poor-to-poor health status at higher ages. It follows that the narrower categorisation of age was able to capture this which was lost in a wider categorisation. Marital status as a covariate indicated that marriage benefits Jamaicans men more than it does women. Among men, the odds of reporting very poor-to-poor status are less than for those who were unmarried, across the age cohorts. Interestingly, beyond 84 years, the odds ratio of very poor-to-poor health status of men declines, suggesting that the benefits of marriage at this age increases compared to earlier ages. When the cut-off point included moderate health status for men, the odds were relatively the same except for men above age 75. The odds ratios of reporting poor health (including moderate health status) for those of 75+ years fell substantially, which means that health status for men over 75+ years increased with marriage. Among women, the odds ratio for those under 55 years who were married was the same as for their unmarried counterparts. It was found that marriage becomes beneficial for women when they are older than 75+ years, compared to unmarried women of the same age. When the dichotomisation of poor health included moderate health, marginal disparities in odds ratios were found among women in

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different areas of residence compared to when poor health status excluded moderate health. Embedded in this finding is the fact that poor health is weakly age-dependent, as there were not clear patterns for the sexes. However, owing to narrowing age groups, this is a new finding which has emerged in health research literature for Jamaica—that marriage substantially benefits women at older ages (75+ years) than their younger counterparts. One of the critical findings of this study is that a narrower definition of poor health status (excluding moderate health status) had odds ratios that were closer across the age groups, suggesting that it would be better to exclude moderate health status from very poor-to-poor health status on dichotomising health status. However, if researchers decide to include moderate as a part of the dichotomisation of poor health status, they should be aware of some of the methodological implications of their choice, and how this will impact on the interpretation, in particular for men, within the different social classes.

Conclusion
In summary, the odds ratios vary substantially for men in different social classes as well as for self-reported illness based on the dichotomisation cut-off point for poor health. Among women, there was no clear age dependency based on the cut-off point of poor health; the vast disparity that was present for men was not found for women in the different social classes. Like the study conducted by Finnas et al., this paper agrees that the choice of cut-off point in dichotomising poor health status cannot be made primarily on variables such as age, because sex and social class must also play a factor in this choice, as well as the nature of the study. Concurrently, this study differs from Finnas et al.’s work in that with a narrower classification of poor health, the effect of marital status and area of residence were not found to be highly age-dependent. The current study found that dichotomising poor health status is acceptable assuming that poor health

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excludes moderate health status, and that it should remain as is and ordinal logistic be used instead of binary logistic regression.

Conflict of interest
There is no conflict of interest to report.

Disclaimer
The researcher would like to note that while this study used secondary data from the Jamaica Survey of Living Conditions, 2007, none of the errors that are within this paper should be ascribed to the Planning Institute of Jamaica or the Statistical Institute of Jamaica as they are not theirs, but are instead owing to the researcher.

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References 1. Bourne PA. A theoretical framework of good health status of Jamaicans: Using econometric
analysis to model good health status over the life course. North Am J of Med Sci 2009; 1: 86-95. 2. Bourne PA. Good Health Status of Older and Oldest Elderly in Jamaica: Are there differences between rural and urban areas? Open Geriatric Medicine J 2009; 2:18-27. 3. Bourne, Paul A. A Comparative Analysis of Health Status of men 60 + years and men 73 + years in Jamaica: A Multivariate Analysis. Asian Journal of Gerontology and Geriatrics. (in print). 4. Bourne PA, Rhule J. Good Health Status of Rural Women in the Reproductive Ages. Int J of Collaborative Research on Internal Medicine & Public Health 1:132-155. 5. Bourne PA, McGrowder DA. Rural health in Jamaica: Examining and refining the predictive factors of good health status of rural residents. Journal of Rural and Remote Health 2009; 9:1116. 6. Hambleton IR, Clarke K, Broome HL, Fraser HS, Brathwaite F, Hennis AJ. 2005. Historical and current predictors of self-reported health status among elderly persons in Barbados. Rev Pan Salud Public 2005; 17: 342-352. 7. Reyes-Ortiz CA, Pelaez M, Koenig HG, Mulligan T. Religiosity and self-rated health among Latin American and Caribbean elders. Int J Psychiatry Med 2007; 37:425-43. 8. Hutchinson G, Simeon DT, Bain BC, Wyatt GE, Tucker MB, LeFranc E. Social and Health determinants of well-being and life satisfaction in Jamaica. International Journal of Social Psychiatry 2004; 50:43-53. 9. Idler EL, Benjamin Y. Self-rated health and mortality: A Review of Twenty-seven Community Studies. Journal of Health and Social Behavior 1997; 38: 21-37. 10. Idler EL, Kasl S. Self-ratings of health: Do they also predict change in functional ability? J of Gerontology 1995; 50B: S344-S353. 11. Stronks K, Van De Mheen H, Van Den Bos, J Mackenback JP. The interrelationship between income, health and employment status. Int J of Epidemiol 1997; 26:592-600. 12. Molarius A, Berglund K, Eriksson C, et al. Socioeconomic conditions, lifestyle factors, and self-rated health among men and women in Sweden. Eur J Public Health 2007; 17:125-33. 13. Helasoja V, Lahelma E, Prattala R, Kasmel A, Klumbiene J, Pudule I. The sociodemographic patterning of health in Estonia, Latvia, Lituania and Finland. Eur J Public Health 2006; 16:8-20. 14. Leinsalu M. Social variation in self-rated health in Estonia: A cross-sectional study. Soc Sci Med 2002; 55:847-61. 15. Mackenbach JP, van de Bos J, Joung IM, van de Mheen H, Stronks K. The determinants of excellent health: different from the determinants of ill-health. Int J Epidemiol 1994; 23:1273-81. 16. Manderbacka K, Lahelma E, Martikainsen P. Examining the continuity of self-rated health. Int J Epidemiol 1998; 27:208-13. 17. Manor O, Matthews S, Power C. Dichotomous or categorical response: Analysing selfreported health and lifetime social class. Int J Epidemiol 2000; 29:149-57. 18. Finnas F, Nyqvist F, Saarela J. Some methodological remarks on self-rated health. The Open Public Health Journal 2008; 1: 32-39. 19. Planning Institute of Jamaica, (PIOJ) & Statistical Institute of Jamaica, (STATIN): Jamaica Survey of Living Conditions, 1988-2007. Kingston: PIOJ & STATIN; 1989-2008. 20. Statistical Institute Of Jamaica. Jamaica Survey of Living Conditions, 2007 [Computer file]. Kingston, Jamaica: Statistical Institute Of Jamaica [producer], 2007. Kingston, Jamaica: 484

Planning Institute of Jamaica and Derek Gordon Databank, University of the West Indies [distributors]; 2008. 21. World Bank, Development Research Group, Poverty and Human Resources. Jamaica Survey of Living Conditions, 1988-2000. Basic information. Washington: The World Bank; 2002. (September 2, 2009, at http://siteresources.worldbank.org/INTLSMS/Resources/33589861181743055198/3877319-1190214215722/binfo2000.pdf). 22. Reijneveld SA, Gunning-Schepers LJ. Age, health and measurement of the socio-economic status of individuals. Eur J Public Health 1995; 5:187-92. 23. Shooshtari S, Menec V, Tate R. Comparing predictors of positive and negative self-rated health between younger (25-54) and older (55+) Canadian adults: a longitudinal study of wellbeing. Res Aging 2007; 29:512-54. 24. Bogue DJ: Essays in human ecology, 4. The ecological impact of population aging. Chicago: Social Development Center; 1999. 25. Yashin AI, Iachine IA. How frailty models can be used for evaluating longevity limits: Taking advantage of an interdisciplinary approach. Demography 1997; 34:17-30. 26. Medawar PB. Old age and natural death. Mod. Q. 1946; 2:30-49. In: Medawar PB. ed. The Uniqueness of the Individual. New York: Basic Books; 1958: 17-43. 27. Carnes BA, Olshansky SJ. Evolutionary perspectives on human senescence. Population Development Review 1993; 19: 793-806. 28. Carnes BA, Olshansky S J, Gavrilov L A, Gavrilova NS, Grahn D. Human longevity: Nature vs. nurture – fact or fiction. Persp. Biol. Med. 1999; 42:422-441. 29. Charlesworth B: Evolution in Age-structured Populations. 2nd ed. Cambridge: Cambridge University Press; 1994. 30. Gavrilov LA, Gavrilova NS: The biology of ¸life Span: A Quantitative Approach. New York: Harwood Academic Publisher; 1991. 31. Shields M, Shooshtari S. Determinants of self-perceived health. Health Rep 2001; 13:35-52. 32. Grossman M: The demand for health – A theoretical and empirical investigation. New York: National Bureau of Economic Research; 1972. 33. Smith JP, Kington R. Demographic and Economic Correlates of Health in Old Age. Demography 1997; 34:159-70. 34. Marmot M. The influence of income on health: Views of an Epidemiologist. Does money really matter? Or is it a marker for something else? Health Affairs 2002; 21:31-46.

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Table 17.1. Socio-demographic characteristic of sample, n = 6,783 n Sexes Male Female Marital status Married Never married Divorced Separated Widowed Self-reported illness Yes No Self-reported health status Very good Good Moderate Poor Very poor Area of residence Urban Semi-urban Rural Income quintile Poorest 20% Poor Middle Wealthy Wealthiest 20% Education attainment (level) No formal Basic Primary or preparatory Secondary Tertiary 3303 3479 1056 3136 77 41 224 980 5609 2430 2967 848 270 50 2002 1458 3322 1343 1354 1351 1352 1382 4071 783 898 709 131 % 48.7 51.3 23.3 69.2 1.7 0.9 4.9 14.9 85.1 37.0 45.2 12.9 4.1 0.8 29.5 21.5 49.0 19.8 20.0 19.9 19.9 20.4 61.8 11.9 13.6 10.8 2.0

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Table 17.2. Very poor or poor and moderated-to-very poor self-reported health status of sexes (in %) Very poor-to-poor Moderate-to-very poor 4655657585+yrs 4655657585+yrs 54yrs 64yrs 74yrs 84yrs 54yrs 64yrs 74yrs 84yrs Men Self-reported illness Yes 37.7 40.0 50.7 46.7 41.7 81.4 87.5 92.5 93.3 91.7 No 7.3 10.4 13.6 21.4 27.3 31.2 39.9 42.4 64.3 72.7 Area of residence Urban 12.1 14.5 21.9 22.0 25.0 49.2 60.9 50.0 55.6 62.5 Semi-urban 18.3 27.0 38.2 50.0 60.0 46.2 65.1 79.4 96.0 90.0 Rural 20.2 24.7 35.3 35.7 30.0 48.3 56.8 70.6 92.9 70.0 Marital status Married 16.8 19.5 31.3 30.0 25.0 48.8 56.4 64.2 60.0 62.5 Not 18.3 25.9 33.8 33.3 35.7 57.2 62.9 72.3 88.9 92.9 Social class Poorest20% 19.6 22.4 28.1 33.3 25 54.6 59.7 65.6 100 100 Poor Middle Wealthy Wealthiest20% Total n 20.7 18.0 18.6 12.0 266 29.4 24.2 22.0 16.4 207 42.9 30.3 33.3 20.1 156 50.0 33.3 30.0 20.0 50.0 57.1 25.0 18.4 97 23 Women 41.7 18.5 25.0 28.6 32.1 0 30.0 33.3 28.6 31.3 50.0 20.0 119 47.4 17.4 25.0 28.6 34.8 0 31.7 28.6 27.3 38.5 50.0 22.2 43 46.7 47.0 52.0 40.7 266 58.8 61.3 62.7 54.5 207 81.0 66.7 73.3 50.0 156 100.0 71.4 87.5 25.0 97 100.0 83.3 85.7 33.3 23

Self-reported illness Yes 29.1 No 11.1 Area of residence Urban 9.7 Semi-urban 14.2 Rural 26.8 Marital status Married 18.6 Not 19.0 Social class Poorest20% 28.7 Poor 19.0 Middle 19.0 Wealthy 18.6 Wealthiest20% 9.8 Total n 284

35.1 13.6 11.9 14.5 33.9 22.7 23.1 33.8 23.7 21.7 22.8 14.5 216

37.1 15.3 16.1 17.2 36.9 32.3 25.2 43.8 22.9 26.1 25.8 12.9 172

77.2 44.3 53.0 52.2 64.5 58.8 58.2 65.7 64.0 57.1 61.9 46.2 284

81.8 51.8 60.6 62.3 69.6 69.3 64.3 70.4 74.6 62.7 68.4 53.9 216

79.8 60.0 59.7 72.4 77.4 80.6 68.5 75.0 77.1 69.6 71.0 58.1 172

79.2 59.3 56.3 71.4 75.0 0.0 70.0 77.8 71.4 62.5 80.0 60.0 119

73.7 52.2 41.7 71.4 69.6 0.0 63.3 71.4 63.6 56.8 80.0 55.6 43

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Table 17.3. Odds ratios for very poor or poor and moderate-to-very poor self-reported health of sexes by particular variables Very poor-to-poor Moderate-to-very poor 4655657585+yrs 4655657585+yrs 54yrs 64yrs 74yrs 84yrs 54yrs 64yrs 74yrs 84yrs Men Self-reported illness Yes 7.7 5.7 6.5 3.2 1.9 9.6 10.5 16.8 7.7 4.1 No 1 1 1 1 1 1 1 1 1 1 Area of residence Urban 0.5 0.5 0.5 0.5 0.8 1.0 1.2 0.4 0.1 0.7 Semi-urban 0.9 1.1 1.1 1.8 3.5 0.9 1.4 1.6 1.8 3.9 Rural 1 1 1 1 1 1 1 1 1 1 Marital status Married 0.9 0.7 0.9 0.9 0.6 0.7 0.8 0.7 0.2 0.1 Not 1 1 1 1 1 1 1 1 1 1 Social class Poorest20% 1.8 1.5 1.6 1.5 1.5 1.8 1.2 1.9 large large Poor 1.9 2.1 3.0 3.0 2.2 1.3 1.2 4.3 large large Middle 1.6 1.6 1.7 1.3 1.1 1.3 1.3 2.0 7.5 10.0 Wealthy 1.7 1.4 2.0 3.0 5.9 1.6 1.4 2.7 21.0 12.0 Wealthiest20% 1 1 1 1 1 1 1 1 1 1 Total n 266 207 156 97 23 266 207 156 97 23 Women Self-reported illness Yes 3.3 3.4 3.3 3.2 4.3 4.3 4.2 2.6 2.6 2.6 No 1 1 1 1 1 1 1 1 1 1 Area of residence Urban 0.3 0.3 0.3 0.7 0.6 0.6 0.7 0.4 0.4 0.3 Semi-urban 0.5 0.3 0.4 0.8 0.8 0.6 0.7 0.8 0.8 1.0 Rural 1 1 1 1 1 1 1 1 1 1 Marital status Married 1.0 1.0 1.4 0.0 0.0 1.0 1.3 1.9 0.0 0.0 Not 1 1 1 1 1 1 1 1 1 1 Social class Poorest20% 3.7 3.0 5.3 2.0 1.4 2.2 2.0 2.2 2.3 2.0 Poor 2.2 1.8 2.0 1.6 1.3 2.1 2.5 2.4 1.1 1.4 Middle 2.2 1.6 2.4 1.8 2.2 1.5 1.4 1.7 1.1 1.0 Wealthy 2.1 1.7 2.3 4.0 3.5 1.9 1.9 1.8 2.7 3.2 Wealthiest20% 1 1 1 1 1 1 1 1 1 1 Total n 284 216 172 119 43 284 216 172 119 43

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Table 17.4. Odds ratios of poor health status by age cohorts Poor Health status 46-54yrs 55-64yrs Age cohorts 65-74yrs 75-84yrs 85+yrs

Very poor-to-poor health Yes No 0.004 1 0.020 1 0.046 1 0.167 1 0.228 1

Moderate-to-very poor health Yes No Total n 0.091 1 550 0.529 1 423 1.861 1 328 5.444 1 216 5.048 1 66

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Chapter

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Retesting and refining theories on the association between illness, chronic illness and poverty: Are there other disparities?

Poverty is well established as being associated with illness and chronic illness. Studies which have examined this phenomenon have done so using objective indices such as life expectancy, infant mortality and general morality. This study (1) examined subjective indices such as selfreported illness and self-reported health, (2) re-tested the theories that chronic illnesses are more likely to be greater in number among the poor and that illnesses are positively correlated with poverty, and (3) evaluated other social characteristics that account for the poverty-illness theory. Those in the two wealthy social hierarchies were 18% less likely to report chronic illnesses compared to those in the two poor social hierarchies. Males were 69% less likely to report chronic illness compared to females as well as 56% less likely to indicate an illness. When the chronic illnesses were disaggregated by sex of respondents, the prevalence rate of females with hypertension was 2.2 times more than hypertensive males; 3.2 times more than male arthritic patients, and 3.0 times more than male diabetics. Forty-five percent of those with chronic illnesses were married. While poverty has declined in Jamaica since the 1990s, the health disparity between the poor and the upper social hierarchy continues to this day. The information provided in this research has far-reaching implications, and may be used to guide policies, frame interventions and provide a focus for future research in Jamaica.

Introduction
Empirically there are many studies which have found and established a statistical association between poverty and illness [1-8]. Some research has shown that those in the lower socioeconomic status are less healthy than those in the wealthy socioeconomic groups [9, 10]. A study by Van Agt et al. [8] found that poverty was greater among chronically ill people than the non-chronically ill, and the WHO [4] concurred with Van Agt et al. [8] when it opined that 80%

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of chronic illnesses were in low and middle income countries. Poverty is not only associated with illness and ill-health, but also higher rates of mortality. According to the WHO [4], 60% of global mortality is caused by chronic illness, and this should be understood within the context that four-fifths of chronic dysfunctions are in low-to-middle income countries. The rationales given for the poverty and illness theory are (1) money (insufficient financial resources); (2) medical expenditure; and (3) other types of socio-political incapacity [3, 8, 11]. Sen [11] encapsulated this well when he opined that high levels of unemployment in the economy are associated with higher levels of capabilities, pointing to money and other incapacities of those who are likely to be unemployed in the society. The poor are therefore more likely to be unemployed, to be ill, to suffer from more chronic illnesses, to have insufficient money, low levels of educational attainment, to experience a greater percentage of infant and other mortality and to live in an inadequate physical environment, compared to those in the wealthy social hierarchies. Using objective indices such as infant mortality and life expectancy to measure the health of a population, studies in Latin America and the Caribbean concur with the aforementioned research. Cass et al. [12] found that infant mortality in Peru for those in the poorest quintile (. poorest 20%) was almost 5 times more than that for those in the wealthiest quintile (. wealthiest 20%). Another study revealed that out-of-pocket medical expenditure accounts for some people becoming poor and that a greater percentage of these people do not have health insurance coverage [2]. One study highlighted the fact that life expectancy between the poorest 20% and the wealthiest 20% was 6.3 years and this was 14.3 years for disability-free life expectancy [13]. The relationship between poverty and illness is longstanding, and the Director of the Pan American Health Organization in 2001 wrote that it is still evident in contemporary societies

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[14]. He however went further to state that poverty affects mental as well as physical health, and concurs with the literature that those in the lower socioeconomic status have greater levels of illnesses (psychopathology). It has been clearly understood and well-established for centuries that poverty is associated with illness, and that it affects those individuals by constricting their capacity, which further affects their health. The poor have less access to money and other resources than the wealthy, and are also deprived of a good health outcome in the future. A study by Mayer et al. [15] provided evidence that there is a strong relationship between health and future economic growth, suggesting that current poverty contracts future health and economic prosperity. Mayer et al.’s work provides pertinent insight into the retardation of poverty, but also gives an understanding of how poverty affects health, production, productivity and how it poses a present and future problem for public health policy makers. How is this of concern to public health policy makers in Jamaica? A recent study conducted by Bourne [16] found that (1) moderate and direct correlation between the prevalence of poverty (in %) and unemployment (R2 = 0.48); (2) direct association existed between not seeking medical care (in %) and prevalence of poverty (in %) – R2 = 0.58; (3) a strong statistical relationship between prevalence of poverty and mortality – R2 = 0.51; and (4) a non-linear relationship between not seeking medical care and illness. From Bourne’s findings, the challenges for public health specialists as well as policy makers are a reality in Jamaica, as in other nations. If poverty is associated with unemployment and not seeking medical care, and not seeking medical care is related to illness, it appears to be a non-issue to re-test the established theory of poverty and illness and poverty and chronic illness in Jamaica, but this is not the case as there is self-reported illness may not give the same result as diagnosed illnesses.

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None of the aforementioned studies that have examined poverty and illness have used self-reported data to test the poverty and illness, and poverty and chronic illness phenomena. The aims of the current study are to investigate (1) poverty and self-reported illness, (2) poverty and self-reported chronic illness, and (3) other socio-demographic characteristics, in order to provide an understanding of existing disparities as well as to concur with, or refute, current theories.

Methods
Study population The current study used a secondary cross-sectional dataset from the Jamaica Survey of Living Conditions (JSLC). The JSLC was provided by the Planning Institute of Jamaica (PIOJ) and the Statistical Institute of Jamaica (STATIN) for analysis [17-19]. These two organizations are responsible for planning, data collection and formulating policy guidelines for Jamaica. The cross-sectional survey was conducted between May and August 2002 in the 14 parishes across Jamaica and included 25,018 people of all ages [20]. The JSLC used stratified random probability sampling technique to draw the original sample of respondents, with a non-response rate of 26.2%. The sample was weighted to reflect the population. Study instrument The JSLC used an administered questionnaire where respondents were asked to recall detailed information on particular activities. The questionnaire was modelled on the World Bank’s Living Standards Measurement Study (LSMS) household survey. The questionnaire covered demographic variables, health, education, daily expenses, non-food consumption expenditure and other variables. Interviewers were trained to collect the data from household members.

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Statistical methods Descriptive statistics were used to provide socio-demographic characteristics of the sample. Chisquare analyses were used to examine the association between non-metric variables. Analysis of variance was used to test the statistical significance of a metric and non-dichotomous variable. Logistic regression analyses examined 1) the relationship between good health status and some socio-demographic, economic and biological variables; as well as 2) a correlation between medical care-seeking behaviour and some socio-demographic, economic and biological variables. The statistical package SPSS 16.0 was used for the analysis. A p-value less than 5% (2-tailed) was used to indicate statistical significance. The correlation matrix was examined in order to ascertain if autocorrelation and/or multicollinearity existed between variables. Based on Cohen and Holliday [21] correlation can be low (weak) - from 0 to 0.39; moderate – 0.4-0.69, and strong – 0.7-1.0. Any variable that had at least moderate (r > 0.6) was re-examined in order to address multicollinearity and/or autocorrelation between or among the independent variables [22-28]. Another approach in addressing collinearity (r > 0.6) was to independently enter variables in the model to determine which one should be retained during the final model construction. The method of retaining or excluding a variable from the model was based on the variables’ contribution to the predictive power of the model and its goodness of fit. Wald statistics were used to determine the magnitude (or contribution) of each statistically significant variable in comparison with the others, and the Odds Ratio (OR) for the interpreting of each significant variable. Measures Self-reported illness status is a dummy variable, where 1 = reporting an ailment or dysfunction or illness in the last 4 weeks, which was the survey period; 0 if there were no self-reported ailments,

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injuries or illnesses [29-31]. While self-reported ill-health is not an ideal indicator of actual health conditions because people may under-report, it is still an accurate proxy of ill-health and mortality [32, 33]. Health status is a binary measure where 1=good to excellent health; 0= otherwise which is determined from “Generally, how do you feel about your health?” Answers for this question are on a Likert scale, ranging from excellent to poor. Medical care-seeking behaviour was taken from the question “Has a health care practitioner, healer, or pharmacist been visited in the last 4 weeks?” with there being two options: Yes or No. Medical care-seeking behaviour therefore was coded as a binary measure where 1=Yes and 0= otherwise. Crowding is the total number of individuals in the household divided by the number of rooms (excluding kitchen, verandah and bathroom).

Sex: This is a binary variable where 1= male and 0 = otherwise. Age is a continuous variable which is the number of years alive since birth (using last birthday).

where ki represents the frequency with which an individual witnessed or experienced a crime, where i denotes 0, 1 and 2, in which 0 indicates not witnessing or experiencing a crime, 1 means witnessing 1 to 2, and 2 symbolizes seeing 3 or more crimes. Tj denotes the degree of the different typologies of crime witnessed or experienced by an individual (where j = 1…4, which 1 = valuables stolen, 2 = attacked with or without a weapon, 3 = threatened with a gun, and 4 = sexually assaulted or raped. The summation of the frequency of crime by the degree of the incident ranges from 0 to a maximum of 51.

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Result
The sample was 25,018 respondents: males, 49.3%; rural residents, 61%; semi-urban residents, 25.6%; married, 16.2%; never married, 67.3%; divorced, 0.8%; separated, 1.2%; widowed, 5.6%; self-reported illness, 12.5%; self-reported injury, 1.2%; health care seekers in the last 4-week period, 63.9%; level of education primary or below, 20.9; secondary level education, 73.1%, and the mean age of the sample was 28.8 years (SD = 22.0 years). The mean number of people per room was 2.0 (SD = 1.4), and the mean number of crimes experienced (including family members) was 2.1 (SD = 8.0). Table 18.1 presents information on demographic characteristics of the sample by area of residence for 2002. There was a significant statistical association between social hierarchy and area of residence – χ2 = 1739.98, P < 0.0001. Poverty (poorest 20%) was substantially a rural phenomenon (74.9%) compared to semi-urban poverty (17.2%) and urban poverty (7.9%) - χ2 = 1739.98, P < 0.0001. Almost 14% of rural residents reported having an illness in the last 4 weeks compared to semi-urban residents (10.9%) and urban residents (10.9%) - χ2 = 36.861, P < 0.0001. However, for 2002, no significant statistical relationship existed between self-reported diagnosed health conditions and area of residents - χ2 = 12.62, P = 0.397. The mean age of the sample was 28.8 years (± 22.0 years), with there being a statistical difference between the mean ages of respondents based on their area of residence – F-statistic [2, 24991] = 7.28, P < 0.0001: the mean age of rural residents was 29.1 years (± 22.6 years); that of semi-urban residents was 27.9 years (± 21.0) and the mean age of urban dwellers was 29.1 years (± 21.0 years). Concurringly, the mean number of visits to health care practitioners in the last 4week period was 1.7 (± 1.4). There was a significant statistical difference between the mean number of visits to health care practitioners and area of residence (F-statistic = 5.48, P = 0.004:

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the mean number of visits by rural residents was 1.6 (± 1.2) compared and 2.0 (± 2.5) for urban dwellers, but non between rural and semi-urban dwellers (1.6 ± 1.2). However, there was no significant difference between mean medical expenditure and area of residence (mean public health care expenditure was USD 9.05 ± USD 25.65 – F-statistic [2, 1126] = 0.577, P = 0.562; and mean private health care expenditure was USD 24.40 ± USD 37.13 – F-statistic [2,935] = 0.577, P = 0.220). There was a significant statistical difference between crime and victimization and area of residence - F-statistic [2, 24958] =28.604, P < 0.0001. The mean number of crimes and incidents of victimization experienced by people in rural residents was 1.8 ± 7.7 compared to semi-urban residents, 2.3 ± 8.0; and urban dwellers, 2.9 ± 9.3. Table 18.2 examines visits to health care facilities, health insurance coverage, educational level and crime by social hierarchy. When self-reported illness and social hierarchy was disaggregated by area of residence, the significant statistical relationship was explained by rural areas (χ2 = 30.92, P < 0.0001) and not semi-urban (χ2 = 8.84, P = 0.065) and urban areas (χ2 = 1.74, P = 0.789). Table 18.3 presents information on self-reported injury, normally go if ill/injured, why didn’t seek care for current illness, length of illness and number of visits to health practitioner by social hierarchy. A statistical relationship existed between each of the variables (P < 0.0001). A statistical difference existed between the mean length of the illness among the social hierarchy – F statistic = 2.536, P = 0.038. This difference was accounted for by the poorest 20% and the wealthy (P = 0.049) and the poorest 20% and the wealthiest 20% (P = 0.049). Likewise the statistical difference between the mean number of visits made to medical practitioner(s) and

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social hierarchy were accounted for by the poorest 20% and wealthy (P = 0.011) and the poorest 20% and wealthiest 20%. The prevalence of chronic illness was 104 out of every 10,000 respondents. On disaggregating the overall prevalence of chronic illness into the different typology of conditions it was found that 5 out of every 10,000 respondents had diabetes mellitus; 50 out of every 10,000 had hypertension; 28 per 10,000 had arthritis; and other chronic illnesses (unspecified) accounted for 21 per 10,000. Chronic illness was more a female phenomenon than for males- χ2 = 6.56, P = 0.013. The prevalence rate of females with chronic illness was 144 per 10,000 compared to 62 per 10,000 for males. Furthermore, the prevalence rates of those with particular chronic illnesses by sex was as follows: diabetes mellitus 2 per 10,000 for males and 7 per 10,000 for females; hypertension 32 per 10,000 for males and 69 per 10,000 for females; arthritis 13 per 10,000 for males and 42 per 10,000 for females and other chronic conditions, 15 per 10,000 for males and 27 per 10,000 for females. Seventy-two percent of those who indicated that they had a chronic illness sought medical care in the last 4-week period, compared to 78.9% not suffering from a chronic illness who sought medical attention - χ2 = 0.030, P = 0.562. Likewise no statistical association existed between health insurance coverage and chronic illness - χ2 = 0.048, P = 0.649. Concurringly, there was a significant statistical association between marital status and individuals with chronic illness - χ2 = 12.708, P = 0.013. Of those who indicated that they had chronic illness, 44.9% were married; 29.1% were never married; 0.4% divorced; 1.2% separated and 24.4% widowed.

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Multivariate analyses Table 18.4 provides information on particular variables and their correlation (or not) with selfreported illness. Of the 17 variables identified from the literature and available for this study, 5 emerged as being statistically significant correlates of self-reported illness of Jamaicans (. social hierarchy, medical expenditure, sex, age and income) - Model χ2 (17) =56.45, P < 0.001. The statistically significant correlates accounted for 14.8% of the variability in self-reported illness.

Table 18.5 examines social hierarchy and sex and their influence (or not) on self-reported chronic illness. One sex emerged as being a statistically significant correlate of self-reported chronic illness in Jamaica - Model χ2 (3) =6.42, P < 0.001.

Discussion
The current study revealed that 13 out of every 100 Jamaicans reported an illness in the 4-week surveyed period. Concurringly, those in the two wealthy social hierarchies were 18% less likely to report chronic illnesses compared to those in the two poor social hierarchies, and the former group was 64% less likely to report an illness compared to the latter group. Males were 69% less likely to report chronic illness compared to females, as well as 56% less likely to indicate an illness. The prevalence rate of those with chronic illness was 104 per 10,000 respondents – diabetes, 5 per 10,000; hypertension, 50 per 10,000; arthritis, 28 per 10,000 and other chronic conditions, 21 per 10,000. When the chronic illnesses were disaggregated by sex of respondents, the prevalence rate of females with hypertension was 2.2 times more than hypertensive males; 3.2 times more than male arthritic patients, and 3.0 times more than male diabetics. Poverty was substantially a rural phenomenon (75%), and almost 14% of rural residents indicated an illness compared to semi-urban (11%) and urban dwellers (11%). The disparity did not cease there as

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rural residents had the least percentage of people with tertiary level education, and the least per capita consumption, which was 57.4% of consumption per capita of urban residents and 69.0% of that consumption per capita of semi-urban people. On the contrary, those in the poorest 20% self-reported fewer injuries (owing to work and care accidents, poisoning, and burns) than those in the wealthiest 20%. For centuries, using objective indices such as life expectancy, infant mortality and general mortality, it has been well established that poverty is associated with illness, and those with more chronic illnesses are more likely to be poor. The current study, using self-reported illnesses, has concurred with the literature that the poor report more illnesses and are more likely to have more chronic illness than those in the upper class. This study, however, found that there is no significant statistical correlation between self-reported illness or chronic illness of those in the poor social hierarchies and those in the middle class. The current research does not concur with the literature that married people are healthier than other marital cohorts [34-38] as the findings showed no statistical association between marital status and self-reported illness. However, the findings revealed that almost 45% of those with chronic illnesses were married compared to those who were never married, widowed, separated or divorced. Lillard and Panis [39] contradicted many of the traditional findings, for instance that married people are healthier and report less health conditions than non-married people. They found that healthier men are less likely to be married; and secondly, that healthier married men enter into unions later in life and that they do postpone remarriage. Conversely, Lillard and Panis [39] revealed that it is unhealthy men who enter marriage at an early age, which suggests that these men do so because of health reasons [39]. This then would support the current research of married people indicating more chronic illnesses than non-married people. Concurringly, married

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people do not report more illnesses, but do report more chronic illnesses than non-married people in this study. An interesting finding that emerged from this study is the low statistical relationship between self-reported illness and self-reported injury (. contingency coefficient = 0.11). Furthermore 4.4% of those who indicated that they were ill had an injury in the last 4 weeks, and of those who had an injury, 46.2% claimed they were ill. This denotes that few people considered illness and injury and vice versa. Illnesses therefore is in keeping with acute and chronic health conditions, and less so with injuries caused by accidents, burns, poisoning and other such events. Marmot [3] asked the question “Does money matter for health? If so, why?” It is the lack of money (. insufficient money) that accounts for the inability of the poor to access (1) higher level education; (2) greater and better, or the best, health care treatment; (3) a better physical milieu; (4) lower levels of infant mortality; (5) better material conditions; (6) clean water and nutrition; and (7) social position. It follows that poverty incapacitates the individual and this extends into the future if he/she is not assisted by external sources. Does money really make a difference in Jamaica? The answer is a resounding yes. Those in the poorest 20% spent on average almost 3 times less than those in the wealthiest 20%, and the second poor spent 2 times less than those in the wealthiest 20% on medical expenditure. Concurringly, 76 out of every 100 of those in the poorest 20% normally utilize public health facilities (including hospitals) compared to 28 out of every 100 of those in the wealthiest 20%. Poverty therefore retards people’s health care choices, expenditure on medication, and by extension healthy life expectancy. The current study found that 35 out of every 100 respondents in the poorest 20% indicated that the reason why they have not visited a health care practitioner

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was owing to insufficient funds, compared to 9 out of every 100 of those in the wealthiest 20%. Furthermore, findings from the present research showed that people who spend more on medical expenditure are 39% less likely to report an illness, suggesting that the poor are more likely to be living with their health conditions without seeking medical care, compared to the wealthy. This matter of insufficient financial resources hampers the healthy life expectancy of the poor, as well as explaining the greater infant and general mortality among them than those in the upper class. According to Grossman [40], Smith and Kington [41], there is a positive statistical association between income and health, and income and demand for health, which further unfolds the complexity of poverty and health. Corbett [42] argued that Edwin Chadwick, in the 1840s, believed “that the primary cause of pauperism and misery was not poverty or rampant capitalism, but filth.” This study is not arguing that the main cause of pauperism is ill-health, but it does substantiate an association between poverty and illness and poverty and chronic illness. This finding is contrary to the belief of Edwin Chadwick; insufficient money does account for some amount of illness, and illness can lead to poverty and future constraints on capabilities, limiting opportunities for the creation of a better life for themselves. If those in the poorest 20% group experienced illnesses and visited medical practitioners more than those in the upper class, it follows that poverty explains (1) most of the prevalence of illness, (2) the severity of the illness, and (3) more chronic illnesses. Money therefore does matter in health, and offers an explanation of how chronic illness can result in poverty, and how pauperism leads to increased morbidity and premature mortality. An understanding of poverty in Jamaica as well as a comprehensive knowledge of the relationship between poverty and illness as well as the other health inequalities, will aid physicians in understanding the reasons for the disproportionately greater number of poor visiting them and having particular chronic illnesses.

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Health is also a social phenomenon, and so physicians need training in the roles of social determinants and their influence on health, as these are outside of the clinical laboratory, but provide an understanding of those on the social margins of the health care system. Given that illness is influenced by exposure to pathogens, the socio-physical milieu of the poor, coupled with their incapacitation because of money, provides some insights into their plight. It is critical to understand this group and where they live, as Kiefer said, and to see poverty “not as a simple economic condition, but as a state of demoralization, where people lack all or most of the minimum ingredients we accept as the basis of a decent life” [43] and we can also add the justifications of their encounter with illness and particular health conditions such as tuberculosis, HIV/AIDS, diarrhoea, respiratory tract infections, arthritis and malaria. Another issue is nutritional deficiency, as some people hold the belief that so long as they have something to eat, or a ‘full tummy’, it is enough to prevent illness. The image of a ‘full tummy’ is embedded in those in the lower socioeconomic class and not the upper class. It follows therefore that households in lower socioeconomic group find it difficult to address material, food and opportunity deprivation within the context of a social setting to pay special attention to the nutritional value in food intake. Households in low-income groups are substantially found in rural areas in Jamaica where a ‘full tummy’ is important and not the nutritional intake of the food groups. According to Foster [44] “…a better-off individual who is generally healthy may be more readily able to identify when he or she is ill than a poor individual with low caloric intake.” Within Foster’s perspective lies the underlying fact that reported illnesses among those in the lower socioeconomic group may be understated figures, as their image of ill-health is hampered by nutritional deficiency. Diet and nutrition are important ingredients in good health [45], but do residents of low-income rural areas as well as low-income

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urban areas know that a deficient intake of calcium, iron, magnesium, zinc, folate, vitamin A, vitamin B 6 and vitamin C is responsible for some of their illnesses? And another aspect to this discussion is their image of health, illness and the role that these play in influencing the collected survey data on health, health conditions and health outcome from those in the lower socioeconomic group.

Conclusion
For centuries researchers have been using objective indices such as life expectancy, infant mortality and the general mortality of a population or sub-population to measure health, and these have been used to establish a statistical association with poverty. Other scholars and institutions have found a significant statistical relationship between diagnosed illness and poverty, but this research has established that self-reported illness and self-reported diagnosed health conditions can be used instead of the objective indices of the past. While those people in poor social hierarchies were more likely to report more illnesses and self-reported chronic illnesses than those in the wealthy group, there is no difference between those in the poor group and the middle class. Those with chronic illnesses are not only more likely to be poor, they are married, females, rural residents, less educated at the tertiary level, more likely to visit public hospitals, most likely to have hypertension, and there is less probability that they will utilize health care facilities than the upper class. In summary, subjective indices such as self-reported illness or selfreported diagnosed health conditions can be used to measure health as the traditional infant mortality, general mortality and life expectancy. Poverty indeed still continues to influence illhealth, and those with chronic illnesses are more likely to be poor than in the upper class, but

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other demographic characteristics provide more information on the poor and those with chronic illnesses. In summary, much investment has been made in health and this clearly has not reduced the inequalities and disparities between and among the different social groups in Jamaica. It means that merely mobilizing greater domestic resources for health will not address the inequalities, as using national health aggregates do not provide a detailed understanding of the disparities between and among groups. While poverty has declined in Jamaica since the 1990s, the health disparity between the poor and the upper social hierarchy has continued to this day. The information provided in this research has far-reaching implications, and can be used to guide policies, frame interventions and provide a focus for future research in Jamaica.

The way forward
Subjective indices such as self-reported illness and self-reported chronic illness can be used to measure ill-health and replace infant and general mortality in the study of health. The use of national statistics does not provide a comprehensive understanding of the health disparity and inequalities between and among the social groups in a society. In order to address some of the health inequalities and disparities in society, programmes are needed that will address issues in rural areas, gender, income inequalities, and the health disparities between public and private health care services offered to the public. Another area which must be addressed is that of the nutritional deficiencies between and among the social hierarchies and area of residences. A national dietary survey is needed in order to provide evidence for policy intervention as well as the role of identified social problems and their influence on mental health. Concurringly, future research is needed to examine the harmful effects of mental health on the accumulation of people’s negative life events, and their effects on the crime problem in the Caribbean. Another

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issue which must be investigated is the quality of care offered to the poor from the perspective of the individual (. a survey research). This would provide pertinent information as to whether those people who are poor perceived themselves to be receiving the worst health, and to devise a method that will objectively assess, service and deliver to the social group in order to address this, if it is contributing to the lower health outcomes. Researchers need to treat poverty as an illness and not a cause of illness, which would allow for a new shift in the study of poverty, and this thereby could provide more answers to health practitioners and policy makers.

Conflict of interest
The author has no conflict of interest to report.

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37. Ross CE, Mirowsky J. 1999. Refining the association between education and health: The effects of quantity, credential, and selectivity. Demography 1999; 36:445-460. 38. Gore WR. Sex, marital status, and mortality. American Journal of Sociology 1973; 79:4567. 39. Lillard LA, Panis CWA. 1996. Marital status and mortality: The role of health. Demography 1996; 33:313-327. 40. Grossman M. The demand for health - a theoretical and empirical investigation. New York: National Bureau of Economic Research, 1972. 41. Smith JP, Kington R. Demographic and Economic Correlates of Health in Old Age. Demography 1997; 34:159-70. 42. Corbett S. Health and Social Justice in the Age of Chadwick Britain 1800–1854. Public Health Promotion Int 1999; 14 (4): 381-382. 43. Kiefer CW. Health work with the poor: A practical guide. New Brunswick, NJ: Rutgers University Press; 2000: p. 78. 44. Foster AD. Poverty and illness in low-income rural areas. The Am Economic Review 1994;84(2):216-220. 45. Khetarpal A, Kochar G. Health and well-being of rural women. The Internet Journal of Nutrition and Wellness 2007;3(1)

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Table 18.1: Demographic characteristic of sample, 2002 2002 Area of residence Semi-urban Urban n (%) n (%) 3062(47.9) 3337(52.1) 1115(26.9) 2758(66.5) 41(1.0) 49(1.2) 187(4.5) 1543(46.0) 1814(54.0) < 0.0001 2460(25.5) 6436(66.6) 56(0.6) 104(1.1) 610(6.3) 475(21.0) 1619(71.6) 26(1.2) 32(1.4) 108(4.8) 0.397 1(0.5) 4(2.1) 6(3.1) 10(5.2) 82(42.9) 48(25.1) 40(20.9) 1302(63.8) 740(36.2) 1987(13.5) 12713(86.5) 1036(7.0) 13714(93.0) 3724(24.4) 3574(23.4) 3169(20.8) 2774(18.2) 2017(13.2) 1181±1340 0(0.0) 5(8.9) 2(3.6) 1(1.8) 29(51.8) 13(23.2) 6(10.7) 436(63.4) 252(36.6) 669(10.9) 5488(89.1) 1023(16.5) 5178(83.5) 858(13.4) 968(15.1) 1217(19.0) 1427(22.3) 1929(30.1) 1771±1605 0(0.0) 0(0.0) 1(3.1) 1(3.1) 15(46.9) 8(25.0) 7(21.9) 0.816 228(65.3) 121(34.7) < 0.0001 354(10.9) 2902(89.1) < 0.0001 612(18.7) 2654(81.3) < 0.0001 393(11.7) 414(12.3) 598(17.8) 822(24.5) 1130(33.7) 2129±2434 P

Characteristic Sex Male Female Marital status Married Never married Divorced Separated Widowed Self-reported diagnosed illness Acute conditions Influenza Diarrhoea Respiratory Chronic conditions Diabetes mellitus Hypertension Arthritis Other Health care-seeking behaviour Yes No Self-reported illness Yes No Health insurance Yes No Social hierarchy Poorest 20% Poor Middle Wealthy Wealthiest 20% Per capita consumption mean ± SD (in USD)

Urban n (%) 7727(50.7) 7524(49.3)

< 0.0001

†USD 1.00 = Ja. $ 80.47 at the time of the survey) (2007) ††USD 1.00 = Ja. $50.97 (in 2002)

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Table 18.2. Particular variable by social hierarchy, 2002 Characteristic Poorest 20% Poor Social hierarchy Middle Wealthy P Wealthiest 20% 0.002

Sex Male 2454(49.3) 2345(47.3) 2440(49.0) 2482(49.4) 2611(51.4) Female 2520(50.7) 2609(52.7) 2542(51.0) 2540(50.6) 2464(48.6) Marital status Married 569(21.1) 656(22.3) 742(23.3) 860(25.4) 1223(31.7) Never married 1926(71.3) 2094(71.2) 2229(69.9) 2303(67.9) 2261(58.7) Divorced 14(0.5) 5(0.2) 16(0.5) 26(0.8) 62(1.6) Separated 30(1.1) 21(0.7) 30(0.9) 31(0.9) 73(1.9) Widowed 162(6.0) 164(5.6) 173(5.4) 172(5.1) 234(6.1) Visits to health care institutions (for last visit) Public hospitals 166(49.3) 135(38.5) 164(42.7) 175(42.1) 137(30.6) Private hospitals 14(4.2) 29(8.3) 19(5.0) 40(9.7) 52(11.7) Public health care centre 107(31.7) 102(29.1) 75(19.6) 64(15.5) 34(7.6) Private health care centre 76(22.6) 120(34.1) 137(35.6) 176(42.2) 258(57.2) Health insurance ownership Yes 84(1.7) 172(3.6) 270(5.6) 655(13.5) 1490(30.7) No 4745(98.3) 4651(96.4) 4574(94.4) 4204(86.5) 3370(69.3) Educational level Primary and below 609(24.6) 588(22.0) 628(22.7) 604(20.1) 568(16.5) Secondary 1837(74.3) 2048(76.5) 2114(75.3) 2249(75.0) 2292(66.4) Tertiary 25(1.0) 41(1.5) 57(2.0) 146(4.9) 591(17.1) Crime and victimization index mean ± SD 2.4±10.2 1.5±4.9 2.0±7.2 2.2±8.5 2.4±8.2 Age mean ± SD 25.5±22.7 26.8±22.2 28.3±21.9 29.6±21.3 33.8±20.9 Crowding mean ± SD 3.0±1.8 2.3±1.3 2.0±1.2 1.6±0.9 1.2±0.8 Total medical expenditure mean ± SD (in 15.22±28.91 21.67±37.99 22.54±42.87 33.11±70.35 45.53±79.52 USD)† †USD 1.00 = Jamaican $50.97 511

< 0.0001

< 0.0001 < 0.0001 < 0.0001 < 0.0001 < 0.0001

< 0.0001

< 0.0001 < 0.0001 < 0.0001

Table 18.3. Self-reported injury, normally go if ill/injured, why didn’t seek care for current illness, length of illness and number of visits to health practitioner by social hierarchy, 2002 Characteristic Self-reported injury No Yes Poorest 20% Poor Social hierarchy Middle Wealthy P Wealthiest 20% < 0.0001 4811(99.1) 4815(99.1) 4801(98.9) 4806(98.7) 4797(98.2) 46(0.9) 43(0.9) 54(1.1) 61(1.3) 87(1.8) < 0.0001

Normal go it ill/injury Public hospital 2252(46.4) 2004(41.3) 1786(36.8) 1449(29.7) 1049(21.5) Public health centre 1474(30.3) 1124(23.2) 854(17.6) 605(12.4) 315(6.5) Private hospital 1123(23.1) 1713(35.3) 2202(45.4) 2799(57.4) 3498(71.6) Pharmacy 2(0.0) 0(0.0) 1(0.0) 3(0.1) 3(0.1) Other 7(0.1) 8(0.2) 12(0.2) 17(0.3) 10(0.4) Why didn’t seek care for current illness Could not afford it 72(35.1) 61(26.3) 47(21.3) 23(11.2) 19(8.6) Was not ill enough 59(28.8) 92(39.7) 111(50.2) 105(51.2) 97(43.9) Use home remedy 50(24.4) 43(18.5) 35(15.8) 47(22.9) 61(27.6) Did not have the time 2(1.0) 2(0.9) 10(4.5) 6(2.9) 14(6.3) Other (unspecified) 22(10.7) 34(14.7) 18(8.1) 24(11.7) 30(13.6) Length of illness (in 11.5±10.4 10.8±10.0 10.4±10.9 9.8±9.7 9.9±9.7 days) mean ± SD 6.1±8.8 5.5±8.6 4.9±7.7 4.6±6.3 4.8±7.7 Number of visits to health practitioner mean ± SD

< 0.0001

0.038 0.007

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Model χ2 =56.45, P < 0.001 -2 Log likelihood = 368.58 Nagelkerke R2 =0.148

Table 18.4. Logistic regression: Self-reported illness by particular variables Variable Std. Wald Odds Coefficient error statistic P ratio Injury -0.20 0.32 0.40 0.53 0.82 Health care-seeking 0.57 0.43 1.81 0.18 1.78 Middle -0.80 0.51 2.49 0.12 0.45 Two Wealthy quintiles -1.03 0.51 4.02 0.04 0.36 †Two poor quintiles 1.00 Logged medical -0.49 0.14 12.00 0.00 0.61 expenditure Durable goods 0.01 0.07 0.01 0.91 1.01 Separated, divorced or 0.27 0.64 0.18 0.67 1.31 widowed Married 0.08 0.42 0.03 0.86 1.08 †Never married 1.00 Physical environment -0.43 0.33 1.74 0.19 0.65 Semi-urban -0.01 0.37 0.00 0.99 0.99 Urban 0.96 0.77 1.58 0.21 2.62 †Rural 1.00 Secondary -0.33 0.44 0.55 0.46 0.72 Tertiary -0.90 0.87 1.07 0.30 0.41 †Primary or below 1.00 Sex 0.81 0.32 6.54 0.01 0.44 Crowding -0.15 0.16 0.88 0.35 0.86 Age 0.03 0.01 5.51 0.02 1.03 Total expenditure 0.00 0.00 3.54 0.06 1.00

95.0% C.I. Lower Upper 0.44 1.52 0.77 4.09 0.17 1.21 0.13 0.98 0.47 0.88 0.38 0.47 0.34 0.48 0.59 0.31 0.08 0.24 0.63 1.01 1.00 0.81 1.16 4.57 2.47 1.23 2.07 11.72 1.71 2.23 0.83 1.18 1.05 1.00

Hosmer and Lemeshow goodness of fit χ2= 6.53, P = 0.59
Overall correct classification =97.1% Correct classification of cases of self-rated illness =100.0% Correct classification of cases of not self-rated ill =54.9% †Reference group

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Table 18.5. Logistic regression: Self-reported chronic illness by some variable Variable Middle Two wealthy quintiles †Two poor quintiles
Model χ2 =6.42, P < 0.001 -2 Log likelihood = 368.58 Nagelkerke R2 =0.06

Coefficient -0.34 -0.33

Std. error 0.66 0.58

Wald statistic 0.26 0.31

P 0.61 0.58

Odds ratio 0.72 0.72 1.00 0.31

95.0% C.I. Lower Upper 0.20 2.62 0.23 2.26

Sex

-1.16

0.49

5.75

0.02

0.12

0.81

Hosmer and Lemeshow goodness of fit χ2= 1.34, P = 0.854

Overall correct classification =93.2% Correct classification of cases of self-rated illness =100.0% Correct classification of cases of not self-rated ill =49.9% †Reference group

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Chapter

19

Modeling social determinants of selfrated health status of Hypertensive in a middle-income developing nation
Paul A. Bourne, Christopher A.D. Charles

Introduction
In 2007, statistics revealed that there were 2,682,120 Jamaicans (end of year population) [1], of whom 22.4% had hypertension [2]. A study conducted in 2007/2008 on Jamaicans between 15 and 74 years of age, found that 25% of Jamaicans had hypertension as well as obesity [3]. This denotes that between 1 in 5 and 1 in 4 Jamaicans are living with at least one chronic illness. In the 1950s, tuberculosis, heart diseases, nephritis, syphilis, pneumonia and influenza were the leading causes of mortality in the Caribbean, and in the 1980s, a shift occurred which saw cardiovascular disease, heart disease, malignant neoplasm, hypertension and diabetes being the leading causes of death. Another shift was observed in the 1990s when malignant neoplasm, cardiovascular disease, diabetes mellitus, ischaemic heart disease, other heart diseases and hypertension were among the 10 ten leading causes of death. In 2007, diabetes mellitus was the third leading cause of mortality in males (5+ years old) and the leading cause for females (5+ years) in Jamaica, while hypertension stood as the third leading cause of mortality in females and

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the 6th cause for males. Hypertension is not only a silent killer; it is an epidemic and needs to be examined as such in the developing world. Globally, chronic diseases account for 60% of deaths, and this is as high as 80% in lowto-middle income nations [4]. Jamaica like the rest of the developing world is experiencing an epidemic in cardiovascular diseases, as they are the leading cause of mortality [5], but despite this reality, obesity is the studied epidemic in the Americas, and not the face behind hypertension [6]. While 11 to 21% of Latinos in the Americas are obese, obesity accounts for between 20 to 33 1/3% of the populations in Chile, Jamaica, Mexico, Peru and Venezuela [3, 5]. Hypertension, on the other hand, increases exponentially in middle to late ages and accounts for more deaths in the world as well as in developing countries, than obesity. Diabetes, cardiovascular disease, cancers, and hypertension are among the main causes of death in the world except in South Asia and sub-Saharan Africa. The sedentary lifestyle of urban dwellers explains much of the chronic illness in the world, and come 2030 with 80% of the globe’s population residing in cities compared to over 50% in 2008, more people will be expected to die from chronic diseases. Urban zones continue to attract many people and some of them, being poor, will not be able to change their lifestyles (cigarette consumption, sugar, diet, saturated fat and environmental factors) like the wealthy. While urban settings appeal to too many people, the better financial pull factors that appear to people do not mean that they will have less chronic illness. In fact, it is well established that there is a direct relationship between poverty and chronic illness [7- 9], which suggests that those in the lower socioeconomic strata in the developing world will in the future be vulnerable to more illnesses, and in particular chronic diseases, despite urban-rural migration.

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In 1998, Forrester et al. [10], using hypertension as an indicator of the emergence of chronic cardiovascular diseases, found that early blood pressure problems were virtually nonexistent in rural Africans, and were modest in Caribbean people. They noted, however, that in recent times hypertension in Nigeria, Jamaica and the US has seen remarkably steep gradients. In Jamaica [2, 3], as in Nigeria, hypertension is an important cardiovascular risk factor which affects between 20-25% of the population [11]. Clearly, hypertension in Jamaica as well as some nations in Africa is a silent epidemic [12], and while researchers have recognized this as the case in the latter state, those in the former are still to admit this reality. Studies on hypertension have shown differences between areas of residence [13, 14], stressors [15], diet [16], Western lifestyle [10], sex [17], measurement and treatment [18], and educational level [19, 20], income [20] and advanced aging [21-23]. Since blood pressure was measured for the first time in 1733 by Stephen Hales, many piecemeal studies have been conducted on the matter. An extensive research of the literature unearthed no study on selfreported hypertension that evaluates who hypertensives are, as well as modelling their self-rated health status. In 2001, Swab et al. [24] stated that 3 in every 10 Jamaicans (ages 30+ years) had hypertension, and in 2007 1 out of every 4 Jamaicans had the disease. The face of hypertension is no longer middle-to-late ages in Jamaica, as the current study found that 2.9% are young adults (15-30 years). Chronic diseases are the next tsunami facing developing countries. The swelling increases in those conditions, and in particular the high prevalence of hypertension which is a predisposing factor for cardiovascular diseases [25, 26], highlight the importance of a comprehensive study of the face of the hypertensive person. This is no longer a silent epidemic, as mortality figures indicate that a ‘red alert’ needs to be sounded for hypertension among the

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other chronic ailments in developing countries. If the ‘Rule of Halves’ (half of those detected are treated or controlled) holds true [27-29], hypertension requires an immediate assessment of the sociodemographic characteristics and health status of its patients. The current study will comprehensively seek to examine who are the hypertensives in Latin American and Caribbean nations, as well as to model their self-rated health status. Using the 2007 national survey data for Jamaica, the present research found that 60% of hypertensives are 60+ years old (average age = 63 years), mostly rural residents (57%), married, females (72%), in the lower socioeconomic strata (40%), without health insurance (72%), 37% middle aged (31-59 years), had fair self-rated health status (44%), and utilised health care services (55%). Three variables emerged as statistically significant factors of the self-rated health status of hypertensives in Jamaica, and they accounted for 22% of the variability in health status.

Methods and materials
Sample The current study used the 2007 Jamaica Survey of Living Condition (JSLC) dataset to carry out the analyses. The 2007 JSLC was conducted in May and August of that year. The current study extracted a sub-sample of 206 respondents who indicated being diagnosed with hypertension from a larger nationally cross-sectional survey of 6,782 Jamaicans. The JSLC was conducted by the Planning Institute of Jamaica (PIOJ) and the Statistical Institute of Jamaica (STATIN). The PIOJ and STATIN are non-profit organizations focusing on data collection and policy assessment, and they aid in the evaluation of government’s social programmes including census taking, among other issues. Funded by the central government, the organizations deliver evidence-based information. Since 1989, the organizations have been collecting data on Jamaicans in order to evaluate social programmes instituted by the government. The data is

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collected by way of an administered questionnaire, and published in a document entitled the Jamaica Survey of Living Conditions (JSLC). The JSLC is a modification of the World Bank’s Living Standards Measurement Study (LSMS) household survey [30]. The survey was drawn using stratified random sampling. This design was a two-stage stratified random sampling design where there was a Primary Sampling Unit (PSU) and a selection of dwellings from the primary units. The PSU is an Enumeration District (ED), which constitutes a minimum of 100 residences in rural areas and 150 in urban areas. An ED is an independent geographical unit that shares a common boundary. This means that the country was grouped into strata of equal size based on dwellings (EDs). Based on the PSUs, a listing of all the dwellings was made, and this became the sampling frame from which a Master Sample of dwellings was compiled, which in turn provided the sampling frame for the labour force [30, 31]. The sample was weighted to reflect the population of the nation.

Measurement

Age is a continuous variable which is the number of years alive since birth (using last birthday). Age group is a non-binary measure: children (ages less than 15 years); young adults (ages 15 to 30 years); other-aged adults (ages 31 to 59 years); young elderly (ages 60 to 74 years); old elderly (ages 75 to 84 years) and oldest elderly (ages 85 years and older). Self-reported illness (or self-reported dysfunction): The question was asked: “Is this a diagnosed recurring illness?” The answering options were: Yes, Cold; Yes, Diarrhoea; Yes, Asthma; Yes, Diabetes; Yes, Hypertension; Yes, Arthritis; Yes, Other; and No.

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Self-reported health status: “How is your health in general?” And the options were very good; good; fair; poor and very poor. For this study the construct was categorized into 3 groups – (i) good; (ii) fair, and (iii) poor. A binary variable was later created from this variable (1 = good and fair 0 = otherwise) [32-35]. Social class: This variable was measured based on income quintile: The upper classes were those in the wealthy quintiles (quintiles 4 and 5); the middle class was quintile 3, and those in lower classes quintiles 1 and 2. Income is measure using total expenditure.

Statistical analysis

We used the SPSS computer statistical package, Version 16.0 (SPSS Inc; Chicago, IL, USA). Chi-square tests were performed to test associations in demographics, health, and particular variables. We also performed F-tests and t-tests in order to compare differences between means. Multiple logistic regressions were used to analyse possible predictors (health care-seeking behaviour in the last 4weeks, health insurance coverage, medical expenditure, marital status, income, area of residence, sex, household head and age) of self-rated health status. The results were presented using unstandardised B-coefficients, Wald statistics, Odds ratio and confidence interval (95% CI). The predictive power of the model was tested using the Omnibus Test of Model, and Hosmer & Lemeshow [36] was used to examine goodness of fit of the model. In order to develop accurate tests of statistical significance, the researchers used SUDAAN statistical software (Research Triangle Institute, Research Park, NC; 1989), adjusted for the survey’s complex sampling design [37]. A p-value < 0.05 was selected to indicate statistical

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significance. The final model was based on those variables that were statistically significant (p < 0.05). Categorical variables were coded using the ‘dummy coding’ scheme.

Where collinearity existed (r > 0.7), variables were entered independently into the model to determine those that should be retained during the final model construction. The final decision on whether to retain was based on the variables’ contribution to the predictive power of the model and its goodness of fit [38].

Results
Table 19.1 presents information on the sociodemographic characteristics of the sample, illness, health care utilisation, and health care-seeking behaviour. The sample was 206 respondents (mean age = 62.5 years ± 16.8 years). Twenty-eight percent of respondents had health insurance coverage (private, 8.3%). The majority of the respondents indicated fair self-rated health status (44.2%) compared to 26.7% who said at least good (very good, 4.9%) and 29.1% who mentioned at least poor (very poor, 3.9%). Most of the sample purchased the prescribed medication (70.2%), and 3.9% had been involved in an accident in the last 4weeks. The preferred health care utilisation of the sample was private health facilities (including hospitals, 55.2%). Predominantly, the face of hypertension in Jamaica was elderly (60+ years, 60.2%). The average number of visits to medical practitioners(s) in the last 4 weeks were 1.3 (SD = 0.7); and the mean length of illness of the sample was 24.8 days (SD = 85.3 days). The mean cost of private medical expenditure (USD 15.54± 36.95) was 3.7 times more than that for public medical expenses – (US $1.00 = Ja. $80.47, in 2007).

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Table 19.2 examines sociodemographic characteristics and health care utilisation by selfrated health status. A significant statistical association emerged between area of residence and self-rated health status (χ2 = 24.69, P = 0.002, contingency coefficient = 0.33). Table 19.3 presents information on sociodemographic characteristics and health care utilisation by population income quintile of sample. No significant statistical association existed between self-reported illness and self-rated health status (χ2 = 2.98, P = 0.562); and health care-seeking behaviour and population income quintile (χ2 = 5.49, P = 0.241) as well as between health care-seeking behaviour and sex (χ2 = 0.072, P = 0.788). Figure 19.1 presents information on the health care-seeking behaviour of people in different marital statuses and sex of respondents. Married people had sought the most medical care (42.1%) in the last 4weeks, compared to never married people (36.4%) and other social partnerships. Married men were 2.2 times more likely to have visited a health care practitioner in the last 4 weeks compared to never-married men.

Multivariate analyses

Using logistic regression analyses, one variable emerged as a statistically significant factor of the self-rated health status of hypertensive Jamaicans (Table 19.3): area of residence (urban: OR = 4.15, 95% CI =1.44 – 11.97; other towns: OR = 3.47, 95% CI = 1.23 – 9.78). The model had statistically significant predictive power (Model χ2 = 32.6, P = 0.003; Hosmer and Lemeshow goodness of fit χ2 = 9.6 (8), P = 0.8), and it correctly classified 75.1% of the sample

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(correctly classified 93.4% of those who self-rated their health as moderate-to-very good and 31.6% of those who self-rated their health as poor-to-very poor).

Discussion
Diabetes mellitus, cardiovascular diseases and neoplasm are among the leading causes of mortality in the world, and more so in developing countries. While infectious diseases, low nutrient intake, and accidents continue to claim lives, chronic conditions are rising faster and will account for more deaths in the future. Despite this reality hypertension, which is an important cardiovascular risk factor, does not have a clear face, or factors which explain the self-rated health status of this group. The current study found that 2.5 times more females than males are affected by hypertension; and the hypertensives are more likely to be married, elderly, to utilise private health care facilities, to record moderate health status and to be in the lower socioeconomic strata or rural dwellers. Most had sought medical care in the last 4 weeks, rural hypertensives recorded the greatest very poor health status, and two variables emerged as statistically significant factors of the self-rated health status of hypertensives in Jamaica. More Jamaicans have hypertension than any other type of chronic condition, yet more extensive and comprehensive studies have been conducted on diabetes, heart disease, neoplasms and arthritis. Traditionally, chronic diseases were viewed as middle-to-late life ailments, but there is a growing decrease in the age of contracting those conditions. In this paper, the findings concur with the literature that hypertension is a middle-to-later life ailment [20-23], as 97 out of every 100 hypertensive persons were ages 31+ years and 60 out of every 100, 60+ years old. What is evident is that 3 out of every 100 hypertensives are 15-30 years old, which supports the changing image of hypertension, and how we research this fact. Studies have used 30+ years old

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to examine chronic illness [24], which means that public health planning, relying on research, will be under-planning for a critical cohort in the population. Public health planners use information from within and outside of their geopolitical boundaries to enhance decision-making. While outside information affords a pertinent source of data in understanding a phenomenon, this may not provide the correct knowledge about a localized group with different socioeconomic, biological and environmental conditions. Urbanization is well established in the literature as having a key role to play in human health conditions such as hypertension, diabetes mellitus and other chronic ailments. While urbanisation affects people’s lifestyle in relation to the food they eat, where they work, the surrounding environmental conditions and concern as to what they are exposed to, and their sedentary lifestyle, with almost 50% of Jamaicans residing in cities, 6 out of every 10 hypertensive person in this nation dwells in urban zones. Clearly, low nutritional intake and poverty account for more hypertensive people than the ‘bad’ elements of urbanization. In Jamaica, statistics reveal that 71% of poverty is in rural areas [2]. Poverty means the incapacitation of financial resources, material deprivation, nutritional deficiency and environmental degradation, which are associated with low health and higher morbidity and mortality. Those realities form the core of the rationale for developing nations having more deaths owing to chronic illness than the developed world. A study by Van et al. [7] found that chronically ill people in the Netherlands were more likely to be poor, suggesting that material deprivation is directly associated with particular health conditions. This research concurs with Van et al.’s work, and went further to find that poverty is associated with area of residence, area of residence is related to illness, and by extension hypertension is higher among rural respondents.

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Smith and Kington [39] postulated that money is able to buy health, from which it can be extrapolated that poverty is associated with low health, increased morbidity and mortality. While their argument is not entirely true, as health is not exchangeable (cannot be bought), money provides access to better nutrition, lifestyle, choice of health care services, good sanitation and physical milieu, which otherwise is difficult for the poor to obtain without governmental or other interventions. In this paper 40 out of every 100 hypertensive persons were poor compared to 37 out of every 100 in the wealthy social strata. So when it is said that chronic illness is becoming the next tsunami in developing countries, the swelling increases in chronic illness, and in particular hypertension, are more evident among those in the lower socioeconomic group in those societies. The push-pull factors associated with migration in developing countries are accounted for by poverty, among other psychosocial conditions. Poverty hinders opportunity, life expectancy, quality of life, economic progress, and brings nutritional deficiencies, and material deprivation, which are the very reasons that pull rural residents to urban areas. In this research, urban dwellers were 4.1 times more likely to record moderate-to-very good self-rated health status than their rural counterparts; and those who live in semi-urban areas were 3.5 times more likely to have greater moderate-to-excellent self-rated health status. Material deprivation in rural areas in Jamaica is accounting for more morbidity and low health status, and clearly this will be a push factor for urban-rural migration, despite the negatives of urban living. In this study no significant statistical relationship existed between health care-seeking behaviour and population income quintile (social standing). This may appear paradoxical, as financial deprivation should affect people’s ability to afford health care, and rightfully so, but since 2005, the Jamaican government has instituted free health care in all public hospitals except

525

the University Hospital of the West Indies, which means that money will influence the choice of care and not health care demand. This therefore accounts for the greater percentage of hypertensives having sought medical care in the last 4 weeks (68%) compared to the population (66%) [2]. Despite the removal of access fees from public health care institutions, there is a preference for private health care utilisation. The preference for private health care utilisation among hypertensives is embedded in long queues, low privacy, social treatment of patients, and milieu – the environment of public health care facilities - that push people into private health care demand. The reality still exists that public health care is the choice of 44 out of every 100 hypertensive Jamaicans, suggesting that public health will be required to plan for this group. While the onset of hypertension commences at 15 years in Jamaica, the non-children public health care system needs to cater to this cohort, as their choices, lifestyle, demands and tolerance for disrespectful behaviour are not the same as elderly or middle-aged adults. A public health concern must be the ratio of males to females with hypertension in Jamaica. Swaby et al. [24] opined that there is a preponderance of females with chronic illness and treatment for chronic illness, as compared to males, but this study found that the disparity was as much as 2.5 females to 1 male (using hypertension). There was no statistical association between the health care-seeking behaviour of male (67.2%) and female hypertensives (69.2%) in Jamaica, which refutes Swaby et al.’s [24] earlier findings. Furthermore, the preponderance of females to males with hypertension accounts for why this health condition is the third leading cause of mortality in the former, and the sixth leading cause for the latter group. Hypertension is brought on by various stressors in lifestyle practices, and with the influx of females into the labour force, top managerial positions, higher education and single parents,

526

they are now exposing themselves to the risk factors associated with those social roles that were once dominated by males. Statistics reveal that the unemployment rate for females (14.3%) is 2.6 times more than that for males [40], indicating that unemployment, as well as other types of social deprivation, are associated with greater hypertension among females. A study by Atallah et al. [41] found that hypertension was greater among unemployed Caribbean people than those who were employed, which also emerged in the current research. The unemployed females are vulnerable to the dictates of males, and during this period there are the social challenges of child rearing for mothers, the psychological stressors of unemployment, the psychological situation of a dictatorial male, the material deprivation, dietary deficiency, and these influence the higher blood pressure count seen in them, compared to males. The 21st Century has brought with it urbanization, lifestyle and role changes, and risk factors related to chronic diseases for many Caribbean peoples, as well as the economic burden of chronic illnesses such as diabetes mellitus and hypertension. For some time now Caribbean governments have instituted data collection units to examine epidemiological data [42] on prevalence, gender-specific population and age-specific mortality, but for the purpose of effective public health policy planning more information is needed on the face behind hypertension. The current work opens a comprehensive discussion and analysis of the hypertensives in Jamaica, and while economic development is associated with economic growth, increased employment of females in the labour force means lower male dependency, and while money reduces material deprivation, the side effect is increased hypertension among this group. Interestingly, in this study there is a greater prevalence of hypertension among married than non-married Jamaicans, but no difference in the self-rated health status between the groups. According to Smith and Waitzman [43] “many observers have theorized that married individuals

527

have access to more informal social support than do non-married individuals”, which explains the social reality of a higher quality of life for married couples than ‘non-married’ individuals [44]. Furthermore, studies have shown that married people have a lower mortality risk in the healthy category than the ‘non-married’ [45], and this justifies why they take less life-threatening risks [46]. Clearly, the benefits of marriage as put forward by other scholars do not provide protection from hypertension among this cohort. In fact they recorded a greater prevalence of hypertension than other marital states. Married people are more likely to seek medical care than non-married people, and this accounts for the greater prevalence of hypertension among them. Although males do not like to seek medical care, those who are married seek more care on the request of their wives which accounted substantially for more of them visiting a medical practitioner in the last 4-week period, compared to those who were never married. Smith and Waitzman [43] opined that wives were found to dissuade their husbands from particular risky behaviours such as the use of alcohol and drugs, and would ensure that they maintain a strict medical regimen coupled with proper eating habits. With more married people utilising health care services, this means that more nonmarried Jamaicans would be ill but have not yet been diagnosed. If the ‘Rule of Halves’ (half of those detected are treated or controlled) holds true [27-29], the greater prevalence of hypertension among married people is as a result of the greater half seeking more medical care than non-married people. This speaks to a public health problem, as the treatment and prevalence of hypertension is undoubtedly greater than the percentage currently planned for in the nation. There is a need to have more people seeking medical care, but this must be done in a holistic way, as outlined earlier from the findings of this paper. The hypertension epidemic is clearly highlighted as an important public health problem, but in order to effectively combat this

528

reality,

poverty,

opportunity,

social

exclusion,

unemployment,

malnutrition,

disease

management, early testing and lifestyle practices must be coalesced by health planners. A study as early as in the 1980s had stated that hypertension was the most prevalent chronic illness in the West Indies [47] and in 2000 Barcelo [48] called it a silent killer, but researchers have continued to examine its aetiology, management, programmes and even a study conducted in 2007/08 [3], like its predecessors, used the standard age-specific, gender and education-specific conditions. The social explanations are rarely examined, and when done the traditional variables (age, gender, and educational level) are examined by scholars, instead of the more demographic variables such as marital status, area of residence, social class and health care utilisation, as well as self-rated health status. This study is more comprehensive than other works and provides research experts with social justification for the face behind hypertension in Jamaica. It should be used to help public health practitioners, policy makers and governments to understand the complexity of effectively implementing programmes to address the management of hypertension, as well as other chronic illnesses. Poverty is the underlying challenge to greater health in the population, despite the gains of economic development, growth, removal of health care user fees, and social programmes.

Conclusion
In summary, the current evidence shows that the burden of hypertension in Jamaica is equally the responsibility of the state, and that the image of hypertension has changed compared to the traditional middle-to-late years. While urbanisation accounts for a particular lifestyle (sedentary, fast food, carbonated soft drinks), decision-makers and public health practitioners need to recognize that chronic diseases afflict the poor, females, the elderly, married and rural dwellers more than urban and affluent Jamaicans.

529

References
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18. van Onzenoort HAW, Verberk WJ, Kroon AA, Kessels AGH, Nelemans PJ, van der Kuy, P-HM, Neef C, de Leeuw PW. Effect of self-measurement of blood pressure on adherence to treatment in patients with mild-to-moderate hypertension. J of Hypertension 2010; 28:622-627. 19. Williams RB. How does lower education get inside the body to raise blood pressure? What can we do to prevent this? Hypertension 2010; 55:617-618. 20. Mendez MA, Cooper R, Wilks R, Luke A, Forrester T. Income, education, and blood pressure in adults in Jamaica, a middle-income developing country. Int J of Epidemiol 2003; 32:400-408. 21. Ragoobirsingh D, McGrowder D, Morrison E, Lewis-Fuller E, Fray J, Johnson P. The Jamaican Hypertension Prevalence Study. Journal of National Medical Association 2002; 94 (7): 561-565. 22. Eldemire D. A situational analysis of the Jamaican elderly, 1992. Kingston: Planning Institute of Jamaica; 1995. 23. Wilks R. Hypertension: Burden and risk factors. In: Morgan O, ed. Health issues in the Caribbean. Kingston: Ian Randle Publishers; 2005: pp. 98-114. 24. Swaby P, Wilson E, Swaby S, Sue-Ho R, Pierre R. Chronic diseases management in the Jamaican setting: HOPE worldwide Jamaica’s experience. PNG Med J 2001; 44:171-175. 25. Wilber JA. The problem of undetected and untreated hypertension in the community. Bull NY Acad Med 1973; 49: 510-520. 26. Cooper RS, Walf-Maier K, Luke A, Adeyemo A, Banegas JR, Forrester T, Giampaoli S, Joffres M, Kastarinen M, Primatesta P, Stegmayr B, Thamm M. An international comparative study of blood pressure in populations of European vs. African descent. BMC Medicine 2005; 3:2. 27. Boume PA, McGrowder DA. Health status of patients with self-reported chronic diseases in Jamaica. North Am J Med Sci 2009; 1: 356-364. 28. Smith WCS, Lee AJ, Crombie IK, Tunstall-Pedoe H. Control of blood pressure in Scotland: the Rule of Halves. BMJ 1990; 300: 981-983. 29. Cruickshank JK, Mbanya JC, Wilks R, BAlkau B, Forrester T, Anderson SG, Mennen L, Forhan A, Riste L, McFarlane-Anderson N. Hypertension in four African-origin populations: current ‘Rule of Halves’, quality of blood pressure control and attributable risk of cardiovascular disease. J of Hypertension 2001; 19:41-46. 30. World Bank, Development Research Group, Poverty and Human Resources. Jamaica Survey of Living Conditions, 1988-2000. Basic information. Washington: The World Bank; 2002. (September 2, 2009, at http://siteresources.worldbank.org/INTLSMS/Resources/33589861181743055198/3877319-1190214215722/binfo2000.pdf). 31. Statistical Institute Of Jamaica, Jamaica Survey of Living Conditions. [Computer file]. Kingston, Jamaica: Statistical Institute Of Jamaica [producer], 2007. Kingston, Jamaica: Planning Institute of Jamaica and Derek Gordon Databank, University of the West Indies [distributors]; 2008. 32. Finnas F, Nyqvist F, Saarela J. Some methodological remarks on self-rated health. The Open Public Health Journal 2008; 1: 32-39. 33. Idler EL, Benjamin Y. Self-rated health and mortality: A Review of Twenty-seven Community Studies. Journal of Health and Social Behavior 1997; 38: 21-37.

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34. Bourne PA. Dichotomising poor self-reported health status: Using secondary crosssectional survey data for Jamaica. North Am J Med Sci 2009; 1: 295-302. 35. Bourne PA, McGrowder DA. Rural health in Jamaica: Examining and refining the predictive factors of good health status of rural residents. Journal of Rural and Remote Health 9 (2), 2009:1116. 36. Homer D, Lemeshow S. Applied logistic regression, 2nd edn. John Wiley & Sons Inc., New York; 2000. 37. LaVange LM, Stearn SC, Lafata JE, Koch GG, Shah BV. Innovative strategies using SUDAAN for analysis of health surveys with complex samples. Stat Methods Med Res 1996; 5:311-329. 38. Polit DF. Data analysis and statistics for nursing research. Stamford: Appleton & Lange Publisher; 1996. 39. Smith JP, Kington R. Demographic and economic correlates of health in old age. Demography 1997; 34: 159-170. 40. Planning Institute of Jamaica (PIOJ). Economic and Social Survey Jamaica 2007. Kingston: PIOJ; 2008. 41. Atallah A, Inamo J, Larabi L, Chatellier G, Rozet J-E, Machuron C, de Gaudernaris R, Lang T. Reducing the burden of arterial hypertension: what can be expected from an improved access to health care? Results from a study in 2420 unemployed subjects in the Caribbean. J of Human Hypertension 2007; 21:316-322. 42. Cunninghma-Myrie C, Reid M, Forrester TE. A comparative study of the quality and availability of health information used to facilitate cost burden analysis of diabetes and hypertension in the Caribbean. West India Med J 2008; 57:383-392. 43. Smith KR, Waitzman NJ. Double jeopardy: Interaction effects of martial and poverty status on the risk of mortality. Demography 1994; 31:487-507. 44. Lillard LA, Panis CWA. Marital status and mortality: The role of health. Demography 1996; 33:313-327. 45. Goldman N. Marriage selection and mortality patterns: Inferences and fallacies. Demography 1993; 30:189-208. 46. Umberson D. Family status and health behaviors: Social control as a dimension of social integration. Journal of Health and Social Behavior 1987; 28:306-19. 47. Grell GAC. Hypertension in the West Indies. Postgraduate Med J 1983; 59:616-621. 48. Barcelo A. Diabetes and hypertension in the Americas. West Indian Med J 2000; 49:262265.

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Figure 19.1. Health seeking behaviour (in %) by marital status and sex

533

Table 19.1. Sociodemographic characteristics of study population, n = 206 Characteristic n Sex Male 58 Female 148 Marital status Married 91 Never married 69 Divorced 3 Separated 5 Widowed 37 Partner in household Yes 93 No 12 Did not respond 105 Social assistance (PATH) Yes 41 No 165 Area of residence Urban 47 Semi-urban 41 Rural 118 Population income quintile Poorest 20% 47 Poor 35 Middle 48 Second wealthy 38 Wealthiest 20% 38 Age cohort Young adults 6 Other aged adults 76 Young-old 61 Old-old 49 Oldest-old 14 Illness (self-reported) Yes 205 No 1 Health care seeking behaviour Yes 140 No 64 Health care utilization Public hospital 35 Private hospital 7 Public health centre 34 Private health centre 78 534

% 28.2 71.8 44.4 33.7 1.5 2.4 18.0 45.1 5.8 51.0 19.9 80.1 22.8 19.9 57.3 22.8 17.0 23.3 18.4 18.4 2.9 36.9 29.6 23.8 6.8 99.5 0.5 68.6 31.4 22.7 4.5 22.1 50.7

Table 19.2. Sociodemographic characteristics and health care utilization by self-rated health status
Characteristic Area of residence* Urban Semi-urban Rural Population income quintile Poorest 20% Second poor Middle Second wealthy Wealthiest 20% Health care seeking behaviour No Yes Age cohort Young adults Other aged adults Young-old Old-old Oldest-old Sex Male Female Marital status Married Never married Divorced Separated Widowed
*P < 0.05

Very good n (%) 1 (10.0) 5 (50.0) 4 (40.0) 1 (10.0) 1 (10.0) 2 (20.0) 2 (20.0) 4 (40.0) 3 (30.0) 7 (70.0) 1 (10.0) 6 (60.0) 2 (20.0) 0 (0.0) 1 (10.0) 3 (30.0) 7 (70.0) 3 (33.3) 6 (66.7) 0 (0.0) 0 (0.0) 0 (0.0)

Good n (%)

Self-reported health status Fair n (%) 26 (28.6) 24 (26.4) 41 (45.1) 22 (24.2) 16 (17.6) 17 (18.7) 19 (20.9) 17 (18.7) 22 (24.7) 67 (75.3) 2 (2.2) 34 (37.4) 26 (28.6) 22 (24.2) 7 (7.7) 26 (28.6) 65 (71.4) 43 (47.3) 28 (30.8) 1 (1.1) 1 (1.1) 18 (19.8)

Poor n (%) 7 (13.5) 5 (9.6) 40 (76.9) 13 (25.0) 8 (15.4) 16 (30.8) 9 (17.3) 6 (11.5) 16 (30.8) 36 (69.2) 0 (0.0) 16 (30.8) 17 (32.7) 16 (30.8) 3 (5.8) 17 (32.7) 35 (67.3) 25 (48.1) 14 (26.9) 1 (1.9) 2 (3.8) 10 (19.2)

Very poor n (%) 0 (0.0) 1 (12.5) 7 (87.5) 2 (25.0) 2 (25.0) 2 (25.0) 1 (12.5) 1 (12.5) 2 (25.0) 6 (75.0) 0 (0.0) 0 (0.0) 2 (25.0) 5 (62.5) 1 (12.5) 4 (50.0) 4 (50.0) 4 (50.0) 0 (0.0) 0 (0.0) 1 (12.5) 1 (12.5)

13 (28.9) 6 (13.3) 26 (57.8) 9 (20.0) 8 (17.8) 11 (24.4) 7 (15.6) 10 (22.2) 21 (46.7) 24 (53.3) 3 (6.7) 20 (44.4) 14 (31.1) 6 (13.3) 2 (4.4) 8 (17.8) 37 (82.2) 16 (35.6) 21 (46.7) 1 (2.2) 1 (2.2) 6 (13.3)

535

Table 19.3. Sociodemographic characteristics and health care utilization by Population Income Quintile
Characteristic Area of residence Urban Semi-urban Rural Health care seeking behaviour No Yes Age cohort Young adults Other aged adults Young-old Old-old Oldest-old Sex Male Female Marital status Married Never married Divorced Separated Widowed Self-reported illness Yes No Health Insurance* – no coverage private public
*P < 0.05

Poorest 20% n (%) 3 (6.4) 7 (14.9) 37 (78.7) 26 (56.5) 20 (43.5) 1 (2.2) 14 (29.8) 16 (34.0) 12 (25.5) 4 (8.5) 12 (25.5) 35 (74.5) 19 (40.3) 18 (38.3) 1 (2.1) 1 (2.1) 8 (17.0) 47 (100.0) 0 (0.0) 38 (80.9) 1 (2.1) 8 (17.0)

Population Income Quintile Second poor Middle Second wealthy n (%) n (%) n (%) 8 (22.8) 3 (8.6) 24 (68.6) 27 (77.1) 8 (22.9) 0 (0.0) 12 (34.3) 10 (28.6) 8 (22.8) 5 (14.3) 8 (22.9) 27 (77.1) 17 (50.0) 10 (29.4) 0 (0.0) 0(0.0) 7 (20.6) 35 (100.0) 0 (0.0) 23 (65.7) 3 (8.6) 9 (25.7) 5 (10.4) 16 (22.9) 32 (66.7) 32 (66.7) 16 (33.3) 1 (2.1) 15 (31.3) 13 (27.1) 15 (31.2) 4 (8.3) 10 (20.8) 38 (79.2) 20 (41.7) 13 (27.1) 0 (0.0) 2 (4.1) 13 (27.1) 47 (97.9) 1 (2.1) 38 (79.2) 0 (0.0) 10 (20.8) 10 (26.3) 12 (31.6) 16 (42.1) 26 (70.3) 11 (29.7) 1 (2.7) 17 (44.7) 9 (23.7) 11 (28.9) 0 (0.0) 14 (36.8) 24 (63.2) 19 (50.0) 12 (31.6) 1 (2.6) 2 (5.3) 4 (10.5) 38 (100.0) 0 (0.0) 27 (71.0) 6 (15.8) 5 (13.2)

Wealthiest 20% n (%) 21 (55.3) 8 (21.0) 9 (23.7) 29 (76.3) 9 (23.7) 3 (7.9) 18 (47.4) 13 (34.2) 3 (7.9) 1 (2.6) 14 (36.8) 24 (63.2) 16 (42.1) 16 (42.1) 1 (2.6) 0 (0.0) 5 (13.2) 38 (100.0) 0 (0.0) 22 (57.9) 7 (18.4) 9 (23.7)

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Table 19.4. Logistic regression: Variables of self-rated health status Variable Health seeking behaviour Health insurance (1=Yes) Logged medical expenses Never married (reference) Married Divorced, separated or widowed Lower class (reference) Middle class Upper class Logged income Rural area (reference) Urban area Other town Sex (1= male) Household head Age
β Coefficient Std. error Wald statistic Odds ratio CI (95%)

-0.57 0.04 -0.36

0.41 0.41 0.19

1.99 0.01 3.41

0.57 1.04 0.70 1.00 0.62 0.48 1.00 0.92 1.03 1.07

0.26 - 1.25 0.47 - 2.31 0.48 - 1.02

-0.48 -0.75

0.44 0.55

1.19 1.87

0.26 - 1.47 0.16 - 1.38

-0.09 0.03 0.06

0.49 0.61 0.54

0.03 0.00 0.01

0.35 - 2.39 0.31 - 3.41 0.37 - 3.07

1.42 1.24 -0.31 -0.26 -0.02

0.54 0.53 0.42 0.41 0.01

6.92 5.51 0.53 0.38 1.21

1.00 4.15** 1.44 - 11.97 3.47* 1.23 - 9.78 0.74 0.76 0.99 0.32 - 1.68 0.35 - 1.74 0.96 - 1.01

Model chi-square = 32.6, P = 0.003 Hosmer and Lemeshow goodness of fit χ2 = 9.6 (8), P = 0.8 -2Log Likelihood = 201.7 Nagelkerke R2 = 0.22 Overall correct classification = 75.1% Correct classification of cases of self-rated moderate-to-very good health status = 93.4% Correct classification of cases of self-rated poor-to-very poor health status = 31.6% *P < 0.05, **P < 0.01, ***P < 0.001

537

Chapter

20

Comparative Analysis of Health Status of men 60+ years and men 73+ years in Jamaica: Are there differences across municipalities?

Introduction From 1880–1882, life expectancy at birth for females in Jamaica was 39.8 years compared to 37.02 years for males (Table 1). One century later (2004), females were outliving males by 6 years (Table 1). In Jamaica, population ageing is a feminized phenomenon. This is typically the same around the world. From 1950-1955, world statistics showed that life expectancy at birth for females was 47.9 years compared to 45.2 years for males, indicating that former sex was outliving the latter by 2.7 years.1,2 The disparity in life expectancy at birth between the sex cohorts increased to 4.2 years between 2000-2005.1 According to the Demographic Statistics for Jamaica,
3

10.9% of

females were 60+ years compared to 10.3% of males. For the world, in 2000, 11.1% of the female population was older than 60 years compared to 8.9% of males. Concomitantly, world statistics indicated that a female who is 60 years old is likely to live for an additional 20.4 years compared to 17.0 years for males.1 Life expectancy is one of the indicators of the health status of an individual or population, which implies that females are enjoying a better health status than males. Insert Table 20.1 : Life Expectancy at Birth of Jamaicans by Sex: 1880−2004 Courtenay4 noted, from research conducted by the Department of Health and Human 538

Services and Centers for Disease Control, that from the 15 leading causes of death (except Alzheimer’s disease), the death rates were higher for men and boys in all age cohorts compared to women and girls. Embedded within this theorizing, are the differences in fatal diseases explained by gender constitution,5 years earlier than females.6 which Courtenay5

contributed to behavioural practices of the sexes causing men to die approximately 6

Studies have shown, however, that females have a higher propensity particular conditions, such as depression, osteoporosis and osteoarthritis.
7,8

to contract

Herzog8 noted

that ’…it appears that older women are more likely to be impaired by their health problems, while older men (60 years) are more likely to die from them.’ A study that was conducted by Schoen et al.9 on a group of adolescents, revealed a different finding from what was reported by the WHO. They found that males were more likely than females to feel stressed, ‘overwhelmed’, or ‘depressed’; they attributed this to the limited nature of men’s social networks. Schoen et al9 found that men in general tend to be more stressed and less healthy than females, and further argued that men are more likely to use denial, distraction, alcoholism, and other social strategies to conceal their illness or disabilities.10-13 On the other hand, Herzog8 in Physical and Mental Health in Older Women – referring to studies from a number of experts - wrote that females had higher rates of depression than their male counterparts. Could suicide among the aged be the result of depression? This is likely to be underreported, because other illnesses are often present and given as cause of death? He noted that data on suicide and depression yielded different results, and therefore, suicide is not necessarily an indicator of depression.

Along with the longer life spans, particularly of females, unhealthy years are on the rise in keeping with the longer life expectancy.14 The WHO14 developed DALE (Disability Adjusted Life Expectancy) in order to account for unhealthy years in relation to life expectancy. In an attempt to calculated ‘quality of lived years’, the WHO introduced an approach that allows for the evaluation this, called the DALE (Disability adjusted life 539

expectancy). DALE does not only use length of years to indicate health and well-being status of an individual or a nation, but incorporate the number of years lived without disabilities. The institution found that these accounted for a 14 % reduction in life expectancy for poorer countries and 9 % for more developed nations.

Jamaica is a developing country, which means that, according to the DALE, both sexes are experiencing 14 years of unhealthy life expectancy. In spite of this, yearly on average (since 1990), there are 565 men who cross the threshold of the life expectancy in Jamaica (72 years at birth). In addition, there are 1842 men who cross the 60+ years bar; 30, 8% are older than their life expectancy at birth. Males and females are living longer, but the former seek health care less frequently (Table 2). Table 2 shows that males reported less illness/injury than females, sought less medical care, and spent more time in health care facilities, all of which accounts for the disparity in life expectancy between the sexes.

Insert Table 20.2: Seeking Medical Care, Self-reported illness, and Gender composition of those who report illness and Seek Medical Care in Jamaica (in %age), 1988-2007 Irrespective of the self-reported health conditions given by males, they experience higher rates of morbidity and mortality than women in Jamaica.15 The Jamaica Ministry of Health’s publication showed that of the five leading causes of death– malignant neoplasms, cerebrovascular disease, heart disease, diabetes mellitus and homicide – men outnumbered women in 3 of them. Malignant neoplasms is 39% greater for men than women; cerebrovascular 14% higher for females than males; heart disease was 71.2 per 100 000 for men and 66.1 per 100 000 for women; and diabetes mellitus was 64% higher for females than males.15

In 2007, approximately 11% of men were older than 60 years (N = 132 931, Table 3); 40.2% of aged Jamaicans reported suffering from at least one dysfunction (N=118 603); 13.1% of men reported ill-health (N=173 135); 75.1% of aged people who reported illhealth had recurring ill-health (N=89 071); and 72 % elderly who had self-rated ill-health 540

sought medical care – N=85 394.16 It can be extrapolated from the data that approximately 5% of the 13.1% of self-assessed health conditions are accounted for by aged men. Furthermore, it can be extrapolated from these statistics that 3.8% of elderly aged men expressed having recurring ill-health. Has the rationale for not studying older men's ill health conditions been due to the fact that only 5% were subject to such conditions? Insert 20.3 Many studies have been done on aged Caribbean nationals, in particular Jamaicans.16-33 An extensive review of the literature showed that none have examined men’s health, or those factors which influence good health of older men (60+ years) in Jamaica. In spite of pressure by the WHO and some scholars in a drive to examine the social determinants of health33-38 the Caribbean, in particular Jamaica, no work has been done on this subject area. This study is innovative, as it seeks to investigate the social, psychological and environmental determinants of the health status of older men. Studies on older Caribbean nationals are not the same as an investigation of the health status of older men (60 years) in Jamaica. The aims of this study were to 1) ascertain factors that influence good health status of aged men (ages 60+ years) in Jamaica, 2) determinants of good health status of older men, 3) to determine the potency of each variable, and 4) distinguish between determinants of the men.

Theoretical framework Many studies have employed multivariate analyses in the examination of health status.16,
17, 26, 39-44

The use of econometric analysis in the study of health was developed by

Michael Grossman.44 This approach simultaneously captures biomedical and nonbiomedical variables, unlike the bivariate analysis that is only able to investigate two variables. Based on the WHO’s definition, health45 is inclusive of biomedical, socioeconomic and psychological factors. Health, therefore, is determined by many factors, and the use of an econometric model makes it possible to identify these. A multivariate model has a fundamental advantage over bivariate relations, as health is a multidimensional phenomenon; this model is able to capture more variables and without excluding some variables which cannot be accommodated in a bivariate association. 541

The theoretical framework that underlines the current work was developed by Bourne, 17 which is a modification of Michael Grossman44 and Smith and Kingston’s works.43 Grossman was the first to establish an econometric model which evaluated the health status of people. The model encapsulates some variables that determine health status of people in the world (Eqn. 1).

Ht (1)

=

ƒ

(H t-1 ,

Go ,

Bt ,

MC t ,

ED)

in which the H t – current health in time period t , stock of health (H t-1 ) in previous period , Bt

smoking and excessive drinking, and good personal health behaviours

(including exercise – G o ), MC t ,- use of medical care, education of each family member (ED), and all sources of household income (including current income). Grossman’s model was further expanded upon by Smith and Kington to include socioeconomic variables (Eqn. 2).

H t = H* (H t-1 , Pmc , Po , ED, Et , R t , A t , G o )

(2)

Eqn. (2) expresses current health status H t as a function of stock of health (H t-1 ), price of medical care Pmc , the price of other inputs Po , education of each family member (ED), all sources of household income (Et ), family background or genetic endowments (G o ), retirement related income (Rt ), asset income (At ,). Given that particular conditions influence the aged that are some different from other age cohort, Bourne used econometric analysis to build a model that captures variables that influence subjective well-being of elderly Jamaicans. Bourne’s model is as follows (Eqn. 3):

Wi =ƒ (lnPmc , ED, Ai , En, G, MS, AR, P, N, lnO, H, T, V)

(3)

In Eqn. 1 Wi is well-being of the Jamaican elderly, is a function of cost of medical (health) care (Pmc), the educational level of the individual, age (Ai , where i is 542

the individual), the environment (En), gender of the respondents (G), marital status (MS), area of residents (AR), positive affective conditions (P), negative affective conditions (N), household crowding (. average occupancy per room) (O), home tenure (H), property ownership, (T), crime and victimization, (V). The current study will examine aged men’s health status, and so the Bourne model is ideal to use in examining this research.

Methods

The current research used secondary data collected jointly by the Planning Institute of Jamaica (PIOJ) and the Statistical Institute of Jamaica (STATIN). For this paper, the subsample was 1,423 aged men (person aged 60+ years). The mean age of the sub-sample was 71.14 years (SD=7.97 years). Another sub-sample was extracted from the survey, which constituted 633 men 73+ years (men living beyond the life expectancy, for Jamaica it is 72+ years). The two sub-samples were extracted from a larger, nationally prevalence study, conducted between June and October 2002, of some 25018 respondents. Stratified random sampling techniques were employed to design the survey (. the Jamaica Survey of Living Conditions (JSLC)), and detailed self-administered questionnaires were used to collect the data from the respondents. The questionnaire was modeled from the World Bank’s Living Standards Measurement Study (LSMS) household survey. There were some modifications made to the LSMS as the JSLC is more focused on policy impacts. The questionnaire covered questions on socio-demographic, economic and wealth variables, crime and victimization, social welfare, health status, health services, nutrition, housing, and physical environment. Interviewers who collected the data were trained to address the questions and concerns of interviewees. Data were stored and retrieved in the SPSS program (SPSS Inc; Chicago, IL, USA); and for the present research descriptive statistics were used to provide certain socio-demographic characteristics of the subsampled population.

Based on the principles of parsimony (all variables that should be included were included and not those which should be excluded were not included), the final model would only constitute those variables that were statistically significant (. p < 0.05). This was attained 543

by the using the health literature and the variables that were included within the framework of the current data set.

Demographic characteristics were provided for the sample and the sub-sample of men 60+ years and 73+ years. Logistic regression was used to establish 1) a model for good health status of aged men in Jamaica; 2) Wald statistics to examine the contribution of each significant variable in the model; and 3) the odds ratios interpreted to address the difference within each variable.

Multivariate analysis (logistic regression) was used because the researcher wanted to test a number of variables simultaneously, and the fact that the dependent variable was binary; the most fitting statistical technique was logistic regression. The model that was tested in this study is (Eqn. 4):

Wi =ƒ (Pmc, ED, Ai, En, MS, AR, P, N, O, H, V)

(4)

In Eqn. 4 Wi is well-being of the aged men in Jamaica which is a function of cost of medical (health) care (Pmc), the educational level of the individual, age (Ai), where i is the individual), the environment (En), marital status (MS), area of residents (AR), positive affective conditions (P), negative affective conditions (N), household crowding (. average occupancy per room) (O), home tenure (H), crime and victimization, (V). Property ownership (T) was omitted, owing to the number of missing cases (in excess of 15%). The study examined aged men’s health status, and Bourne’s model was considered ideal for use in this research.

The results were presented using unstandardized coefficients, Wald statistics, Odds ratio (OR) and confidence interval (95% CI). The predictive power of the model was tested using Hosmer and Lemeshow test46 to examine goodness of fit of the model. The correlation matrix was examined in order to ascertain if autocorrelation (or multicollinearity) existed between variables. Based on Cohen and Holliday,47 the correlation can be weak (0 - 0.39), moderate (0.4-0.69), or strong ( 0.7-1.0). This matrix 544

was used to exclude (or allow) a variable in the model. Wald statistics were used to determine the magnitude (or contribution) of each statistically significant variable in comparison with the others, and the OR for the interpretation of each significant variable. Measure Health: The self-rated health status of an individual Good health: This variable is derived from a number of questions which enquired about particular health conditions. It is a binary variable where 1=not reporting an ill-health and 0 = reported at least one health condition.39 Age: This is the total number of years lived since birth, measured from one birthday to the next. Psychological condition: This is the psychological state of an individual, sub-divided into positive and negative affective psychological conditions. Positive affective psychological condition: This denotes hopefulness, optimism and life satisfaction. For this study the variable was measured using a number of responses with regards to being hopeful and optimistic about the future and life generally. Negative affective psychological condition: It means the degree to which an individual experiences feelings of hopelessness, pessimism and fear. In this study these were measured from a number of responses from a person experiencing loss of a breadwinner and/or family member, loss of property, loss of income, failure to meet household and other obligations. Household crowding: This indicates the average occupancy of persons per room - the total number of individuals in a household divided by the number of rooms occupied by the household (excluding the kitchen and bathroom). Married: A binary variable - where 1 = those who indicated being married, and 0 = otherwise Poverty level : A binary variable - where 1 = those people who are in two poor quintiles (. poorest and poor), and 0 = otherwise (. those in quintiles 3 to the wealthiest, or quintile 5)

545

Crime: Crime index = Σ k i T j, This equation represents the frequency with which an individual witnessed or experience a crime, where i denotes 0, 1 and 2: 0 indicates not witnessing or experiencing a crime; 1 means witnessing 1 to 2 crimes; and 2 indicates seeing 3 or more crimes. Ti denotes the degree of the different typologies of crime witnessed or experienced by an individual: j = 1 valuables stolen; 2 = attacked with or without a weapon; 3 = threatened with a gun; j = 4 sexually assaulted or raped. The summation of the frequency of crime by the degree of the incident ranges from 0 to a maximum of 51. Aged: An individual who has celebrated 60 years or more. Area of residence: The general geographic locale in which an individual resides. 1 = Kingston Metropolitan Areas are all the areas which are 100% urban, 0 = otherwise 1 = Peri-urban areas are places which are not 100% urban; 0 = otherwise The Reference group is from a rural area

Results Demographic Characteristic of sampled population: Men 60+ years Of the population of 1 432 aged respondents, the mean age was 71.14 years ± 7.97 years (Table 20.4). A substantial majority of the population was married (50%); owned their own homes (85%); resided in rural areas (68%); and reported good health (63%). The majority men had at most primary level education (62%); however, 3 % had attained tertiary level education, and 98.6% reported that they were the head of their household. Per capita income quintile was evenly distributed, with 23.8% being in the wealthiest quintile. Furthermore, crime seems to have a minimal affects on the respondents.

Results: Demographic Characteristic of sampled population: Men 73+ Of the population of 633 men aged 73+ years, the mean age was 78.5 years ± 5.64 years (mode year= 77yrs, median = 77 yrs). A substantial majority of the population was married (48.8%, N = 302), 23.6% never married (N=146) and 22.6% widowed (N = 140). 546

Most owned their own homes (88%, N = 557). In terms of area of residence, 70.9% (N=449) resided in rural areas; 19.3% (N=122) in peri-urban areas; and 9.8% (N=62) in urban areas. A little more than half (53.5%; N=333) reported good health. The majority of aged men had at most primary level education (67.4%, N = 402); only, 2.7% had attained tertiary level education. Almost all the men (98.4%) indicated that they were the heads of their households.

Per capita income quintile was evenly distributed, with the minority being in the wealthiest quintile (23.4%,N = 148), and the poorest quintile (21.6%, N = 137). In addition, crime seems to have a minimal affects on men 73+ years. The average consumption per person in the men 73+ yearscohort was JA.$77 877.07 (SD=$72 014) – USD1.00 = Ja. 50.97.

Analysis of Logistic Regression on Good Health of Men 60+ years Of the 16 predisposed variables that were used in the model (Table 20.5), 5 were statistically significant (p < 0.5). The 5 factors that determine good health of older men in Jamaica – age, secondary education, health insurance ownership, area of residence and positive affective psychological conditions – accounted for 27.4% of the model (chi square test (19) = 289.45, p-value = 0.001, -2 log Likelihood = 1,419.72). Of the 5 predictors of good health, 3 negatively influence health. These are age, secondary level education and health insurance. The model had statistically significant predictor power (model χ2 = 289.45, p < 0.001, Homer and Lemeshow goodness of fit χ2 = 12.84, p = 0.117) and correctly classified 73% of the sample (correctly classified 93% of those who had good health and 40% of those who did not report poor health).

Of those variables that negatively determine good health, ownership of health insurance carries the most weight in determining good health (Wald statistic=122.88, 95% CI: 0.03 to 0.09, p = 0.001), followed by age (Wald statistic=39.2, 95% CI: 0.93 to 0.97, p = 0.001). Embedded in these findings is the revelation that an individual who possessed health insurance is 0.06 times (odd ratio) less likely to experience good health compared 547

to someone who does not have the same. Similarly, as older men age, he is 0.95 (odds ratio) less likely to have good health compared to a younger aged man. In addition, those who had obtained a secondary education, in comparison to primary level education, is 0.64 times (odds ratio) less likely to report good health (95% CI: 0.49 to 0.84). Furthermore, there is no statistical difference between men who had at most primary level education compared to with tertiary level education, suggesting that those with primary level education have better health.

With respect to factors which have a positive affect on health, also positively affected the men’s psychological conditions (Wald statistic = 11.67, 95% CI: 1.04 to 1.16) and accounted for more variability than area of residence. On examining positive affective psychological conditions, the more an aged man experiences a positively affective condition; he is 1.1 times more likely to report good health. If an aged man experiences a positively affective condition, he is 1.1 times more likely to report good health. Findings revealed that men who reside in rural areas suffer from diminished good health. This means that those in peri-urban areas, 1.5 times (odds ratio, 95% CI: 1.06 to 2.13) more likely to report good