Understanding Health and Health Measurements in

Jamaica

Editor Paul A. Bourne

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Understanding Health and Health Measurements in

Jamaica

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Understanding Health and Health Measurements in

Jamaica

Paul A. Bourne
Socio-Medical Research Institute, Kingston, Jamaica (Formerly Biostatistician and Social Demographer, Dept of Community Health and Psychiatry, University of the West Indies, Mona)

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Paul Andrew Bourne 66 Long Wall, Stony Hill Kingston 9, Jamaica

© 2010 by Paul Andrew Bourne All rights reserved. Published 2010

CATALOGUING IN PUBLICATION DATA

Understanding Health and Health Measurements in Jamaica by Paul Bourne Includes bibliographical references ISBN:

Covers design by Paul Bourne Book design by Paul Bourne

Printed in Jamaica

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Dedicated to

Paul A. Bourne, Jnr. DruAnn Bourne Kerron and Kimani Bourne And My wife - Evadney Bourne

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Contents
Prologue Chapter One Health Measurement Paul A. Bourne Chapter Two 25 xiv 1

Variations in social determinants of health using an adolescence population: By different measurements, dichotomization and non-dichotomization of health Paul A. Bourne Chapter Three 51

Social Determinants of Health in a developing Caribbean nation: Are there differences based on municipalities and other demographic characteristics? Paul A. Bourne Chapter Four Sociomedical Public Health in Jamaica Paul A. Bourne Chapter Five The validity of using self-reported illness to measure objective health Paul A. Bourne Chapter Six 135 116 85

Modelling social determinants of self-evaluated health of poor older people in a middle-income developing nation Paul A. Bourne Chapter Seven Men’s health in Jamaica: Those in the wealthy social hierarchies vi 160

Paul A. Bourne Chapter Eight

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Determinants of self-reported health conditions of people in the lower socioeconomic strata, Jamaica Paul A. Bourne Chapter Nine Paradoxities in self-evaluated health data in a developing country Paul A. Bourne Chapter Ten Self-reported health and health care utilization of older people Paul A. Bourne, Christopher A.D. Charles, Cynthia G. Francis & Stan Warren Chapter Eleven Health of females in Jamaica: using two cross-sectional surveys Paul A. Bourne Chapter Twelve Self-rated health of the educated and uneducated classes in Jamaica Paul A. Bourne Chapter Thirteen 318 294 274 233 209

Dichotomising poor self-reported health status: Using secondary cross-sectional survey data for Jamaica Paul A. Bourne Chapter Fourteen 339

Retesting and refining theories on the association between illness, chronic illness and poverty: Are there other disparities? Paul A. Bourne

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Chapter Fifteen

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Child Health Disparities in an English-Speaking Caribbean nation: Using parents’ views from a national survey Paul A. Bourne, Cynthia Grace Francis & Elaine Edwards Chapter Sixteen 391

Disparities in self-rated health, health care utilization, illness, chronic illness and other socioeconomic characteristics of the Insured and Uninsured Paul A. Bourne Chapter Seventeen Social determinants of self-reported health across the Life Course Paul A. Bourne Chapter Eighteen 443 422

Variations in health, illness and health care-seeking behaviour of those in the upper social hierarchies in a Caribbean society Paul A. Bourne Chapter Nineteen Self-reported health and medical care-seeking behaviour of uninsured Jamaicans Paul A. Bourne Chapter Twenty Health of children less than 5 years old in an Upper Middle Income Country: Parents’ views Paul A. Bourne Chapter Twenty One 515 491 468

An Epidemiological Transition of Health Conditions, and Health Status of the Old-Old-ToOldest-Old in Jamaica: A comparative analysis Paul A. Bourne

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Chapter Twenty Two

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Hypertensive and modeling their social determinants of self-rated health status in a middleincome developing nation Paul A. Bourne and Christopher Charles Chapter Twenty Three Chronic health conditions in Jamaica: Diabetes mellitus, hypertension and arthritis Paul A. Bourne Chapter Twenty Four Childhood Health in Jamaica: changing patterns in health conditions of children 0-14 years Paul A. Bourne Chapter Twenty Five 624 595 570

Gender differences in self-assessed health of young adults in an English-speaking Caribbean nation Paul A. Bourne and Christopher AD. Charles Chapter Twenty Six Self-reported health and medical care-seeking behaviour of uninsured Jamaicans Paul A. Bourne Chapter Twenty Seven Self-evaluated health and health conditions of rural residents in a middle-income nation Paul A. Bourne Chapter Twenty Eight 704 677 654

Health Status of Urban and Peri-Urban Residents: Are there Health Disparities between the municipalities in Jamaica? Paul A. Bourne

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Chapter Twenty Nine Self-rated health status of young adolescent females in a middle-income developing country Paul A. Bourne Chapter Thirty The quality of sample surveys in a developing nation P.A. Bourne, C.A.D. Charles, N. South-Bourne, D. Eldemire-Shearer, M.D. Kerr-Campbell Chapter Thirty One The image of health status and quality of life in a Caribbean society Paul A. Bourne, Donovan A. McGrowder, Christopher A.D. Charles, Cynthia G. Francis Chapter Thirty Two Determinants of Quality of Life of youths in an English Speaking Caribbean nation Paul A. Bourne Chapter Thirty Three The uninsured ill in a developing nation Paul A. Bourne Chapter Thirty Four Health of males in Jamaica Paul A. Bourne Chapter Thirty Five

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Good Health Status of Older and Oldest Elderly in Jamaica: Are there differences between rural and urban areas? Paul A. Bourne

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Chapter Thirty Six Quality of Life of Youths in Jamaica Paul A. Bourne Chapter Thirty Seven Factors that Influence Wellbeing of the Working Aged Population in Jamaica Paul A. Bourne Chapter Thirty Eight A conceptual framework of wellbeing in some Western nations Paul A. Bourne Chapter Thirty Nine Social parameters of self-evaluated health of poor aged Jamaicans Paul A. Bourne Chapter Forty

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A Comparative Analysis of Health Status of men 60 + years and men 73 + years in Jamaica: a Multivariate Analysis Paul A. Bourne Chapter Forty One 1050

A Multi-level Comparative Assessment of Self-rated Wellbeing of Young Adults and Elderly Jamaicans Paul A. Bourne

Chapter Forty Two Self-reported Health of Youth: Using Health Conditions to measure Health Paul A. Bourne xi

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Chapter Forty Three Patient care: Is interpersonal trust missing? Paul A. Bourne, Cynthia G. Francis & Maureen D. Kerr-Campbell

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Chapter Forty Four Does Trust Change Well-Being: Different typology of trust Paul A. Bourne

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Chapter Forty Five

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Subjective psychosocial wellbeing in Jamaica: should religiosity, governance of the country and interpersonal trust be into consideration in patient care? Paul A. Bourne Chapter Forty Six 1217

Difference in social determinants of health between the poor and the wealthy social strata in a Caribbean nation Paul A. Bourne

Chapter Forty Seven

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Socioeconomic correlates of self-evaluated health status of elderly with diagnosed chronic medical conditions, Jamaica Paul A. Bourne Chapter Forty Eight Paul A. Bourne Chapter Forty Nine 1284 1269

Factors associated with objective wellbeing in Jamaica: Is objective index still a good measure of health? Paul Andrew Bourne, Donovan McGrowder and Oniel Jones xii

Chapter Fifty Health status and Medical Care-Seeking Behaviour of the poorest 20% in Jamaica Paul Andrew Bourne Chapter Fifty One

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Is income a stronger determinant of self-rated health status than other socioeconomic and psychological factors? Paul A. Bourne Chapter Fifty Two Biosocial determinants of health and health seeking behaviour of male youths in Jamaica Paul A. Bourne 1367

Chapter Fifty Three Determinants of self-rated private health insurance coverage in Jamaica Paul Andrew Bourne and Maureen Kerr-Campbell

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Chapter Fifty Four Ill-males in an English-Speaking Caribbean Society

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Paul A. Bourne, Christopher A.D. Charles, Donovan A. McGrowder

Chapter Fifty Five Happiness among Older Men in Jamaica: Is it a health issue? Paul Andrew Bourne, Chloe Morris, Denise Eldemire-Shearer

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Chapter Fifty Six Good Health Status of Rural Women in the Reproductive Ages Paul A. Bourne and Joan Rhule

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Chapter Fifty Seven Predictors of Good Health Status of Rural Men in Jamaica Paul A Bourne Chapter Fifty Eight 1570 Decomposing Mortality Rates and Examining Health Status of the Elderly in Jamaica Paul A. Bourne, Donovan A. McGrowder and Tazhmoye V. Crawford

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Chapter Fifty Nine

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Difference in social determinants of health between men in the poor and the wealthy social strata in a Caribbean nation Paul A. Bourne and Denise Eldemire-Shearer Epilogue Paul Andrew Bourne 1621

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Prologue
Health is a final product, an ingredient, an end, and a means to an end. This means it provides answers to and for many issues as such it cannot be left unresearched in any population as many matters would be left unresolved. It holds a society together, and is germane to the stock of wealth of the individual, community, country, region and world. Economic growth, socioeconomic development, quality of life, work and prosperity are based on the health of people, a community, society, nation and the world. The conceptualization of health whether it is (1) antithesis of illness, (2) self-rated health status, (3) life expectancy or (4) health life expectancy are embedded in life - cognitive functionality and functional status of people, which accounts for the contribution of people to production, productivity and the social world. While health is well established as a by-product in a society as was stated earlier, it is more needed because of its importance in existence than the end product of being healthy. The importance of health to quality life, production, productivity and social functionality provides the impetus for studying this phenomenon. Clearly with the significance of health to standard of living, economic growth and development of a society, then it is critical to the planning process of people, a nation and the world. The crux of health is such, therefore, that its measurement, image, conceptualization, realities and culture are primary to the understanding of many ends – the economic realities, productivity, happiness, life satisfaction, life expectancy and healthy life expectancy. Health is embedded in any conceptualization and/or measurement of life expectancy and healthy life expectancy because the former construction provides the primary ingredient in the calculations of long life, lived years and healthy lived years. Thus, by denying a study on health and its measurement is to create absence in understanding peoples’ perception,

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practice and culture as health is apart of the cultural expression of people and more than a social construction. The outlook of Jamaicans on what constitutes health is not necessarily the dictates of international agencies’ perspectives because they are the bodies’ response for so doing as the culture in this geopolitical space is different while is similar to those in other jurisdictions. It follows, therefore, that the definitions health and its influence are linked to the culture. Within the contextualization of health based on peoples’ experiences means that examining health in one jurisdiction cannot be superimposed on another geopolitical space, indicating the value of exploring peoples’ perspectives in any planning and administration of policies for them. Despite the World Health Organization’s (WHO) conceptualization of health, which was outlined in the Preamble to its Constitution in 1946, the discourse on health continues even in 2000. Prior to WHO’s definition of health which expanded from the absence of illness to social, psychological and physical wellbeing, health was measured used the antithesis of illness. Using the “antithesis of diseases” to measure health is viewed as narrowed which B.B. Longest says is the “…absence of infection or the shrinking of a tumour” which can be called dysfunctions. 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’. 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, personal responsibility, lifestyle, environmental and economic influences as well as quality nutrition. Those conditions are termed determinants of health.

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One economist began the study of the determinants of health, Michael Grossman. As such, Grossman’s work forwarded that health was more than the absence of illness to increase income, education, occupation and many other determinants. In 2005, the WHO began a thrust into the study of the social determinants of health, which was supporting the previous study by Michael Grossman, Smith and Kingston and others. The empirical research, therefore, was recognizing the value of an expanded definition of health as was the intent of WHO. Again, the discourse of health did not cease propositition of WHO’s definition of health or the works of many scholars. The antithesis of illness (not reporting a health condition) marks an old conceptualization of health that appears to linger in contemporary societies, instead of the use of wellbeing to indicate the new position of health. Dr. Buzina admits that wellbeing is fundamentally a biomedical process (using health conditions, morbidity or diagnosed illness). 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 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 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

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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. Many studies on the health of Jamaicans have been on reproductive health matters, health conditions, and sexual behaviors. Caribbean scholars have failed to recognize the discourse on health and the disparities which may exist between the international conceptualization and peoples’ perspective of health. Because health is an ingredient in health and its measurement is critical to other areas in the socioeconomic life of a people, then the difference perspectives of health must be examined in order to provide a better understanding of how people view this construct, and how planning an effective address their concerns owing to a better position of people. The current work emerged out of a need to grapple with the different perspective of health held by Jamaicans, their health, health measurement and likely disparities which may occur because of those differences. This book is the enveloped of a new of published manuscripts on health measurement, and health as viewed by Jamaicans. The book commences with a discussion on health measurement as it seeks to provide a comprehensive expression of the differences in viewpoints, their existence, historical perspectives and influence on health. The proceeding chapters will be an expansion of social determinants, health measurement, validity of health and dichotomization of health, and quality of sample surveys, using only data on Jamaicans. This book is intended to provide insights into health and health measurement in Jamaica, and to depict disparities which exist between particular perspectives on health and health measurement, using data on Jamaicans and comparing these with other societies. Of the many chapters in this book, I collaborated with a number of scholars from different academic

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institutions in the researching of image of health status and quality of life in a Caribbean society. This provides further insights into the health data and quality of life of Jamaicans. While this chapter create an understanding of the disparities between health and quality of life, it highlights the growing differences in the two concepts, and the validity of adopting a new approach in the collection of health data away from self-rated (or reported) health status, antithesis of illness, and self-reported health conditions. The various postulations, perspectives and conceptualizations which exists outside of Jamaica, do not guarantee the same in a particular geopolitical space as this emerged in many of the chapter of this text. The introduction of interpersonal trust in this text was by design as it allows medical practitioners, medical sociologists, and policy makers an insight into the inclusion of trust in discourse on health, health measurement and wellbeing. Thus, it is fitting that the last chapters of this book be on trust as it symbolizes the way forward in health research and health measurement. The final chapter examines religiosity, governance of the country, and interpersonal trust as they interface with health and health measurement, and they thereby are significant in a health discourse.

Paul Andrew Bourne Socio-Medical Research Institute

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Acknowledgement
Health is an end, a product and an ingredient in all human production as well as a means to an end. People want to be healthy because it offers opportunities, privilege, economic growth and development, and happiness. Thus, ill-health contributes to lower satisfaction with life as it retards choices and increase peoples’ perspectives of a likeliness of suppressed opportunities. These opportunities are more than economic pursuits, costs and economic choices as health is life, and life is health. The health of a people, society, community and nation is a blueprint for life. As such, without this guiding blueprint, life ceases and emptiness unfolds itself. The emptiness to which we speak is a life without health, as there can be no health with life. Health is not merely the absence of illness, ailment or infirmity. As it is the dream of all upper animals and provide an avenue for the pursuit of other internal and external things. On the contrary, with the absence of health, the desire of all other things become minute as health embodies life. Following the ill-health of my six year old son (Kimani Bourne), I was brought into the recognition of the importance of health to life, and without it how distasteful your accomplishments are. Kimani was diagnosed with diabetes on February 8, 2010, and later went in a diabetic coma about three weeks later that month. This spiraled a search into understanding diabetes mellitus, juvenile diabetes and chronic health conditions. Following the examination of health conditions (ailment or illness) and general health status emerged some empirical studies on Jamaicans. These are as follows: i. ii. Disparities in self-rated health, health care utilization, illness, chronic illness and other socioeconomic characteristics of the Insured and Uninsured; Health of children less than 5 years old in an Upper Middle Income Country: Parents’ views; xx

iii. iv. v. vi. vii.

An Epidemiological Transition of Health Conditions, and Health Status of the Old-OldTo-Oldest-Old in Jamaica: A comparative analysis; Hypertensive and modeling their social determinants of self-rated health status in a middle-income developing nation; Chronic health conditions in Jamaica: Diabetes mellitus, hypertension and arthritis Childhood Health in Jamaica: changing patterns in health conditions of children 0-14 years, and Self-reported Health of Youth: Using Health Conditions to measure Health

Outside of the ill-health of my son (younger of the twins, Kerron and Kimani Bourne), which is the primary purpose for this book, there are many other peoples that contribute to the completion of the text. Mr. Maxwell S. Williams who implore me to evaluate the health conditions affecting Jamaican children. This gave rise of the evolution of many empirical works on health, health measurement and health conditions in Jamaica. Then there were literature search on health, health measurement and health conditions in Jamaica. Limited findings emerged on the texts that assess the general health of the Jamaican populace as well as health measurement. Those facts challenge a need for a landscape of information on health and health measurement. This then gave impetus to the collating of different studies on health and health measurement, particularly on Jamaica. A number of the chapters were firstly written as research for presentation on a radio programme on Nationwide FM, Jamaica. The programme was hosted by Messrs. Dennis Brooks and Damion Blake. Following the departure of Mr. Blake as co-host of the programme, he was replaced by Mr. George Davis. A few chapters were cowritten with some Caribbean and Non-Caribbean scholars. I wish to thanks all the authors who coauthored some of the chapters with me as well as the named individuals identified previously. My heart felt appreciation and thanks to you as well as those who critique the chapters. In addition to the aforementioned individuals, many of the chapters were submitted to and published different journals. These journals are North American Journal of Medical xxi

Sciences; HealthMed Journal; International Journal of Collaborative Research on Internal Medicine and Public Health; Journal of Clinical and Diagnostic Research (JCDR); Maxwell Publishers, and Journal of Men’s Health. As the holders of the copyright of the various articles, the editors of those journals were contacted, I am indeed thankful for their additional permission to publish the chapters. Finally, I am wholehearted thankful to my son, Paul Andrew Bourne, Junior, who named the book. Thank you all, and to the readers, I hope the book will provide invaluable information on the issues of health and health measurements in Jamaica.

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Chapter One Health Measurement
Paul A. Bourne

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 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. 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

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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 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 (i.e. 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

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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 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
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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 (see Figure 1.1).

Health Policy

Determinants of Health – Biological conditions

Health

Figure 1.1: 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 functioning (i.e. 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

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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 (i.e. behaviour modification), curative (surgical procedures, visits to health practitioners), restorative (physical rehabilitation), and palliative (i.e. 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 (i.e. 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. psychological and ecological conditions. 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 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 (i.e. 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 This paper however is not arguing for a

biopsychosocial hybrid model, which would include biological, economic, social, cultural,

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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 (i.e. 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 (i.e. ages 60 and over). Accompanying this period of the ‘age of degenerative and man-made illnesses’ are life expectancies that now exceed 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, i.e. physical functioning or illness and/or disease-causing organisms [4].

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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 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
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perspective of the scholars that what guided their intervention were the biomedical sciences (i.e. physical functionality or dysfunctions). In this case, health is the ‘antithesis of diseases’. It is the narrow definition of health – negative health (i.e. 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. 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, 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

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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 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
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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. 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 than 64 years who has been a victim of crime and violence and continues to be a victim; seniors
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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. 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, and we use a qualitative study to show people’s perception of what contributes to a particular
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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 (i.e. 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]. 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 influence wellbeing [50,51]. Happiness is not a mood that does not change with time or

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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 (i.e. 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. 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
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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 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). 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 1.1 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

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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 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 (i.e. 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

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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 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
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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 nonexpectancy. 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 (i.e. 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

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his/her health and wellbeing, social involvement in various institutions, and issues on positive affective conditions. 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 (i.e. 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

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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 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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32. Bourne, P.A. (2009). Social determinants of self-evaluated good health status of rural men in Jamaica. Rural and Remote health 9, 1280. [Pub Med]. ISSN 33. Bourne, P.A. (2009) A theoretical framework of good health status of Jamaicans: using econometric analysis to model good health status over the life course. North American Journal of Medical Sciences, 1, 86-95. 34. Hambleton IR, Clarke K, Broome HL, Fraser HS, Brathwaite F, Hennis AJ. (2005) Historical and current Correlates of self-reported health status among elderly persons in Barbados. Revista Panamericana de Salud Pứblica, 17, 342-352. 35. WHO. (2008) The Social Determinants of Health; 2008. Available at http://www.who.int/social_determinants/en/ (accessed April 28, 2009). 36. Walkinson, R.G., and Marmot, W. (2003) Determinants of Health. The Solid Facts, 2nd ed. World Health Organization, Copenhagen. 37. Kelly M, Morgan A, Bonnefog J, Beth J, Bergmer V. (2007) The Social Determinants of Health: developing Evidence Base for Political Action, WHO Final Report to the Commission. 38. Khetarpal A, and Kocar G. (2007) Health and well-being of rural women. The Internet Journal of Nutrition and Wellness, 3, 1. 39. Graham H. (2004) Social Determinants and their Unequal Distribution Clarifying Policy Understanding. The MilBank Quarterly, 82, 101-124. 40. Pettigrew M, Whitehead M, McIntyre SJ, Graham H, and Egan M. (2004) Evidence for Public Health Policy on Inequalities: 1: The Reality According To Policymakers. Journal of Epidemiology and Community Health, 5, 811 – 816. 41. Anthony, B. J. (1999) Nutritional assessment of the elderly. Cajanus, 32, 201-216. 42. Dowling, A.S. (2005) Images in psychiatry: George Engel. 1913-1999. http://ajp.psychiatryonline.org/cgi/reprint/162/11/2039 (accessed May 8, 2007). 43. Brown, T. M. (2000). The growth of George Engel's biopsychosocial model. http://human-nature.com/free-associations/engel1.html. (Accessed May 8, 2007). 44. Saddock, B. J., and Saddock, V. A. (2003) Kaplan and Saddock’s Synopsis of psychiatry: Behavioral Sciences/Clinical Psychiatry (9th ed). Lippincott Williams and Wilkins, Philadephia. 45. Low, W-Y., Ng, C-J., Choo, W-Y., and Tan, H-M. (2006) How do men perceive erectile dysfunction and its treatment? A qualitative study on opinions of men. The Ageing Male, 9,175-180. 46. Crimmins, E. M., Hayward, M. D., and Saito, Y. (1994) Changing mortality and morbidity rates and the health status and life expectancy of the older population. Demography, 31, 159-175. 47. Portrait, F., Lindeboom, M., and Deeg, D. (2001) Life Expectancies in specific health states: Results from a joint model of health status and mortality of older persons. Demography, 38, 525-536. 48. Leung, B. W., Moneta, G.B., and McBride-Chang, C. (2005) Think positively and feel positively: Optimism and life satisfaction in late life. International Journal of Aging and human development, 61, 335-365. 49. Lyubomirsky, S., L. King, and E. Diener. 2005. The benefits of frequent positive affect: Does happiness lead to success? Psychological Bulletin, 6, 803-855.

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50. Sheldon, K., M., and Lyubomirsky, S. (2006). How to increase and sustain positive emotion: The effects of expressing gratitude and visualizing best possible selves. Journal of Positive Psychology, 1, 73-82. 51. Abbe, A., Tkach, C., and Lyubomirsky, S. (2003) The art of living by dispositionally happy people. Journal of Happiness Studies, 4, 385-404. 52. Diener, E. and Seligman, M. E.P. (2002) Very happy people. Psychological Science, 13, 81–84. 53. Watson, D., Wiese, D., Vaidya, J., and Tellegen, A. (1999) The two general activation systems of affect: Structural findings, evolutionary considerations, and psychobiological evidence. Journal of Personality and Social Psychology, 76, 820-838. 54. Evans, R. G. (1994) Introduction. In Evans, R. G., Barer, M. L., and Marmor, T. R. (Eds.). Why are some people healthy and others not? The Determinants of Health of Populations. Aldine de Gruyter, New York. 55. Harris, P.R., and Lightsey Jr., O. R. (2005). Constructive thinking as a mediator of the relationship between extraversion, neuroticism, and subjective well-being. European Journal of Personality, 19, 409-426. 56. Kashdan, T. B. (2004) The assessment of subjective wellbeing (issues raised by the Oxford Happiness Questionnaire). Personality and Individual Differences, 36, 1225– 1232. 57. Fromson, P. M. (2006) Self-discrepancies and negative affect: The moderating roles of private and public self-consciousness. Social behavior and Personality, 34, 4:333-350. 58. McCullough, M. E., Bellah, C.G., Kilpatrick, S.D., and Johnson, J.L. (2001) Vengefulness: Relationships With Forgiveness, Rumination, Well-Being, and the Big Five. Personality and Social Psychology Bulletin, 27, 601-610. 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

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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 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 Two

Variations in social determinants of health using an adolescence population: By different measurements, dichotomization and nondichotomization of health
Paul A. Bourne

Introduction Adolescents aged 10 to 19 years are among the most studied groups in regard health issues in the Caribbean, particularly sexuality and reproductive health matters [1-4]. Apart of the rationales for the high frequency of studies on those in the adolescence years are owing to the prevalence of HIV/AIDS, unwanted pregnancy, inconsistent condom usage, mortality arising from the HIV/AIDS virus, and other risky sexual behaviour. With one half of those who are infected with the HIV/AIDS virus being under 25 years old [1], this provides a justification for the importance of researching this aged cohort. Statistics revealed that the HIV virus is the 3rd leading cause of mortality among Jamaicans aged 10-19 years old (3.4 per 100,000, for 1999 to 2002) [5], and again this provides a validation for the prevalence of studies on this cohort. Outside of the Caribbean, sexuality and reproductive health matters among adolescents are well studied [6-11], suggesting that those issues are national, regional and international. While sexuality and reproductive health matters are critical to the health status of people [1], reproductive health problems as well as sexuality form a part of the general health status. Health is more that the ‘antithesis of diseases’ [12] or reproductive health problems as it extends

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to social, psychological or physical wellbeing and not merely the antithesis of diseases [13]. Bourne opined that despite the broadened definition of health as offered by the WHO [14], illness is still widely studied in the Caribbean, particularly among medical researchers and/or scholars. A search of the West Indian Medical Journal for the last one half decade (2005-2010), a Caribbean scholarly journal, revealed that the majority of the studies have been on different variations of illness, and antithesis of diseases instead of the broadened construct of health. Outside of the West Indian Medical Journal, few Caribbean studies have sought to examine the health status of adolescents [15-18] but even fewer published research were found that examine quality of life of those in the adolescence years [19]. Even though quality of life is a good measure of general health status, international studies exploring quality of life and selfrated health status among the adolescence years are many [20-25] compared to those in Jamaica. A comprehensive review of the literature on health status, particularly among the adolescence population, revealed that none has used a national survey data to examine social determinants of health across different measurement and dichotomization of health (the recoding of the measure into two groups) to assess whether there is variability in determinants as well as explore the health of this cohort. Even among studies which have examined social determinants of health, particularly among the population [26-34], few have used the elderly population [35-37] and only men in the poor and the wealthy social strata [37, 38], but none emerged in a literature research that have used the adolescent population (ages 10-19 years). On examining health literature, no study emerged that evaluated whether the social determinants of health vary across measurement, dichotomization and non-dichotomization of health (using the measure in its Likert scale form), and age cohort. With the absence of research on the aforementioned areas, it can be extrapolated
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that social determinants of health are constant across measurement, dichotomization and nondichotomization, and this assumption is embedded in health planning. The absence of such information means that critical validity to the discourse and use of social determinants would have been lost, as social determinants of health are used in the planning of health policies, future research and in explaining health disparities. Statistics revealed that one in every five Jamaican is aged 10-19 years old [39], which means this is a substantial population and because of its influence of future labour supply it is of great value. Although Pan American Health Organization (PAHO) [5] stated that adolescents enjoy good health, and only about 2% of morality in 2003, which was equally the case for adolescents in the Americas, this information does not indicate distancing examination from their health status. The current work, therefore, will bridge the gap in the literature by evaluating social determinants of health among those in the adolescence years across varying measurement of health. Using data for 2007 Jamaica Survey of Living Conditions (2007 JSLC), this paper seeks to elucidate (1) whether social determinants of health vary across measurement of health status (ie self-rated health status or self-reported antithesis of disease) or the cut-off (dichotomization) and/or the non-cut-off of health status (non-dichotomization), (2) are there similarities between social determinants found in the literature and that of using an adolescence population, (3) whether particular demographic characteristic as well as illness and health status vary by area of residence of respondents, (4) what is the health status of the adolescence population, (5) typology of health conditions that they experience, and (6) evaluate the antithesis of illness (disease) and self-rated health. Methods and measure

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Data The current study extracted a sample of 1, 394 respondents aged 10 to 19 years old from the 2007 Jamaica Survey of Living Conditions (JSLC). The inclusion/exclusion criterion for this study is aged 10 to 19 years old. The present subsample represents 20.6% of the 2007 national cross-sectional sample (n = 6,783). The JSLC is an annual and nationally representative crosssectional survey that collects information on consumption, education, health status, health conditions, health care utilization, health insurance coverage, non-food consumption expenditure, housing conditions, inventory of durable goods, social assistance, demographic characteristics and other issues [40]. The information is from the civilian and noninstitutionalized population of Jamaica. It is a modification of the World Bank’s Living Standards Measurement Study (LSMS) household survey [41]. An administered questionnaire was used to collect the data. 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. 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. Overall, the response rate for the 2007 JSLC was 73.8%. Over 1994 households of individuals nationwide are included in the entire database of all ages [40]. A total of 620

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households were interviewed from urban areas, 439 from other towns and 935 from rural areas. This sample represents 6,783 non-institutionalized civilians living in Jamaica at the time of the survey. The JSLC used complex sampling design, and it is also weighted to reflect the population of Jamaica. This study utilized the data set of the 2007 JSLC to conduct our work [42]. Measure Age is a continuous variable which is the number of years alive since birth (using last birthday) Adolescence population is described as the population aged 10 to 19 years old [23] 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. For the antithesis of disease (illness) a binary variable was created, where 1= not reported a health condition (no to each illness) and 0 = otherwise (absence of reporting an illness). The use of two groups for selfreported illness denotes that this variable was dichotomized into good health (from not reported a health condition) and poor health (i.e. having reported an illness or health condition). Thus, the seven health conditions were treated as dichotomous variables, coded as was previous stated. Self-rated health status: This was taken from the question “How is your health in general?” The options were very good; good; fair; poor and very poor. For purpose of this study, the variable was either dichotomized or non-dichotomized. The dichotomization of self-rated health status denotes the use of two groups. There were four dichotomization of self-rated health status – (1) very poor-to-poor health status and otherwise; (2) good and otherwise; (3) good-to-very good

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health status and otherwise and (4) moderate-to-very good self reported health status and otherwise. The dichotomized variables were measured as follow: 1= very poor-to-poor health, 0 = otherwise 1= good, 0 = otherwise 1 =good-to-very good, 0 = otherwise 1= moderate-to-very good, 0 = otherwise The non-dichotomization of self-rated health status means that the measure remained in its Likert scale form (i.e. very good; good; moderate; poor and very poor health status). Social class (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). Family income is measure using total expenditure of the household as reported by the head.

Statistical analysis

Statistical analyses were performed using the Statistical Packages for the Social Sciences v 16.0 (SPSS Inc; Chicago, IL, USA) for Windows. 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 nonmetric variables, and analysis of variance for metric and non-dichotomous nominal variables. Logistic regression was used to evaluate a dichotomous dependent variable (self-rated health status and antithesis of illness) and some metric and/or non-metric independent variables.
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However, ordinal logistic regression was used to examine a Likert scale variable (self-rated health status) and some metric and/or non-metric independent variables. A pvalue of < 5% (twotailed) was used to establish statistical significance. Each model begins with variables identified in the literature (Models 1-5), will be tested using the current data and the significant variables highlighted using an asterisk (Tables 3 and 4).

Models The use of multivariate analysis to study health status and subjective wellbeing (i.e. self-reported health) is well established in the literature [36-38]. Previous works have examined the dichotomization of health status in order to establish whether a particular measurement of health status is different from others [43-45]. The current study will employ multivariate analyses to examine health by different dichotomization and statistical tools to determine if the social determinants remain the same. 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 [33], Smith & Kingston [34], Hambleton et al. [37], Bourne [46], Kashdan [47], Yi & Vaupel [48], and the World Health Organization pilot work a 100question quality of life survey (WHOQOL) [49] have used subjective measures to evaluate health. Diener [50,51] has used and argued that self-reported health status can be effectively applied to evaluate health status instead of objective health status measurement, and Bourne [46] found that self-reported health may be used instead of objective health. Embedded in the works of those researchers is the similarity of self-reported health status and self-reported dysfunction in assessing health. Thus, in this work we will use self-reported health status and the antithesis of illness to measure health, and dichotomize self-reported health status as follows (1) good health = 1, 0 = otherwise; (2) good-to-excellent health=1, 0 = otherwise; (3) moderate-to-excellent
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health=1, 0 = otherwise; and (4) very poor-to-poor health= 1, 0 = otherwise. Another measure was that health was evaluated by all the 5-item scale (from very poor to excellent health status), using ordinal logistic regression. The current study will examine the social determinants of self-rated health of Jamaican adolescents and whether the social determinants vary by measurement and dichotomization and/or non-dichotomization of health. Five hypotheses (models) were tested in order to determine any variability in social determinants based on the measurement of health status. Model (1) is the antithesis of disease, non-dichotomization of self-reported health (antithesis of disease); Model (2) is the non-dichotomization of self-rated health status (ie using the 5-item Likert scale as a continuous variable), and Models (3-6) are the different dichotomized self-rated health status (ie. 3= very poor-to-poor; 4=good, 5=moderate-to-very good 6=good-to-very good). All the models were tested with the same set of social determinants of health, with the only variability being the measurement of health status (self-rated health status), cut-off of health (dichotomization) and/or non-dichotomization of self-rated health status.

H A=f (A i , G i , AR i , It , lnD i , ED i, US i , S i , HIi , lnY, CR i , lnMC t , SA i , ε i )

(1)

where H A (i.e. self-rated antithesis of diseases) is a function of age of respondents, A i ; sex of individual i, G i ; area of residence, AR i ; current self-reported illness of individual i, It ; logged duration of time that individual i was unable to carry out normal activities (or length of illness), lnD i ; Education level of individual i, ED i ; union status of person i, US i ; social class of person i, S i ; health insurance coverage of person i, HIi ; logged family income, lnY; crowding of individual i, CRi; logged medical expenditure of individual i in time period t, lnMC t ; social assistance of individual i, SA i ; and an error term (ie. residual error).
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Note that length of illness was removed from the model as it had 93.5% of the cases were missing as well as union status which had 58.2%.

H ND=f (A i , G i , AR i , It , lnD i , ED i, US i , S i , HIi , lnY, CR i , lnMC t , SA i , ε i ) Where H ND denotes the non-dichotomization of self-rated health status.

(2)

Note that length of illness was removed from the model as it had 93.5% of the cases were missing as well as union status which had 58.2%.

H D1 =f (A i , G i , AR i , It , lnD i , ED i, US i , S i , HIi , lnY, CR i , lnMC t , SA i , ε i ) Where H D1 is very poor-to-poor self-rated dichotomized health status.

(3)

Note that length of illness was removed from the model as it had 93.5% of the cases were missing as well as union status which had 58.2%. H D2 =f (A i , G i , AR i , It , lnD i , ED i, US i , S i , HIi , lnY, CR i , lnMC t , SA i , ε i ) Where H D2 is good self-rated dichotomized health status. Note that length of illness was removed from the model as it had 93.5% of the cases were missing as well as union status which had 58.2%. (4)

H D1-4 =f (A i , G i , AR i , It , lnD i , ED i, US i , S i , HIi , lnY, CR i , lnMC t , SA i , ε i )

(5)

Where H D3 is very moderate-to-very good self-rated dichotomized health status. Note that length of illness was removed from the model as it had 93.5% of the cases were missing as well as union status which had 58.2%.

H D1-4 =f (A i , G i , AR i , It , lnD i , ED i, US i , S i , HIi , lnY, CR i , lnMC t , SA i , ε i ) Where H D4 is good-to-excellent self-rated dichotomized health status.
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(6)

Note that length of illness was removed from the model as it had 93.5% of the cases were missing as well as union status which had 58.2%.

Results Demographic characteristics of studied population Table 2.1 presents information on demographic characteristic of the sampled population. Of the population (n = 1,394), 43.9% has primary or below primary level education, 53.1% secondary level and 3.0% had tertiary level education. Table 2.2 presents information on the particular demographic characteristic as well as health status and self-reported illness of respondents by area of residence. Table 2.3 depicts information of variables which explain the antithesis of illness among the adolescence population. Table 2.4 shows the different dichotomizations of self-rated health status and nondichotomized self-rated health status, and the various social determinants which explain each. Table 2.5 examines associations between self-rated health status and antithesis of illness (or disease). Limitations of study This study was extracted from a cross-sectional survey dataset (Jamaica Survey of Living Conditions, 2007). Using a nationally representative cross-sectional survey dataset, this research extracted 1394 adolescent Jamaicans which denote that the work can be used to generalize about

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the adolescent population in Jamaica at the time in question (2007). However, it cannot be used to make predictions, forecast, and establish trends or causality about the studied population. Discussion

The current work showed that while the majority of Jamaican adolescents have at least self-rated good health status (92 out of every 100); some indicated at most moderate self-rated health status. Even though only 1.4% of the sample mentioned that they have very poor-to-poor health status, 6.5% indicated that they experienced a health condition in the last 30 days. Of those who reported a health condition, 5.3% were diagnosed with chronic illness (diabetes mellitus, 3.9%; hypertension, 1.3%). Although 2.4 times more adolescent in rural areas are in the lower class compared with those in urban areas, rural adolescents have a greater good health status compared to their urban counterparts, but this was the reverse for rural and periurban adolescents. Another important finding was that there is no statistical association between health conditions and area of residence, but urban and periurban adolescents were more likely to have health insurance coverage compared to those in rural areas. In Jamaica, the adolescence population’s health status is comparable to those in the United States [23], suggesting that inspite of the socioeconomic disparities between the two nations and among its peoples, the self-reported health status among adolescent Jamaicans is good. The high health status of those in the adolescence population in Jamaica speaks good of the inter dynamics within the countries, but does not imply that they are the same across the two nations or can it be interpreted that the quality of life of Jamaicans is the same as those in the United States. Simply put, the adolescence population in Jamaica is experiencing a good health status although HIV/AIDS, unwanted pregnancies, and inconsistent condom usage are high in this cohort [1-5].
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While the aforementioned results about good health status of Jamaican adolescents concurs with PAHO’s work in 2003 [5] and others [17], which has continued into 2007, the current paper provides more information on health matters of adolescents aged 10-19 years than that offered by PAHO. An adolescent in Jamaica who seeks medical attention is 100% less likely to report an illness, and those who indicated at least good self-rated health status was 13 times more likely not to report an illness. Continuing, adolescents in the upper class are 15 times more likely to report very poor-to-poor health status compared to those in the lower class. And that those who indicated very poor-to-poor health status are more likely to seek medical care (10 times), live in crowded household and less likely to spend more on consumption and nonconsumption items. On the other hand, those who stated that their health status was at least moderate were less likely to live in crowded household, spent more on consumption and nonconsumption items. Using a 2007 national probability dataset for the adolescence population in Jamaica, we can add value to the existing literature on health status as well as the social determinants of health. Grossman introduced the use of econometric analysis in the examination of health in the 1970s to establish determinants of self-rated health [33], which has spiraled a revolution in this regard since that time. Using data for the world’s population, he identified particular social determinants of health that was later expanded upon by Smith and Kington [34]. Since the earlier pioneers’ work on social determinants of health [33, 34], the WHO joined the discourse in 2000s [27] as well as Marmot [26], Kelly et al. [28]; Marmot and Wilkinson [29]; Solar and Irwin [30]; Graham [31]; Pettigrew et al. [32], Bourne [35], Bourne [36], Hambleton et al. [37] and Bourne and Shearer [38], but none of them evaluated whether there was variability in the determinants of health depending on the measurement and/or dichotomization of health.

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The variability in social determinants of health was established by Bourne and Shearer [38] in a study between men in the poor and the wealthy social strata in a Caribbean nation, but the literature at large has not recognized the variances in social determinants based on the dichotomization and non-dichotomization self-rated health status, and measurement of heath (using antithesis of illness and self-rated health status). Such a gap in the literature cannot be allowed to persist as it assumes that social determinants are consistent over the measurement of health. Bourne [43] like Manor et al. [44] and Finnas et al. [45] have dichotomized self-reported health status and cautioned future scholars about how the dichotomization can be best done. According to Bourne [43] “The current study found that dichotomi[z]ing poor health status is acceptable assuming that poor health excludes moderate health status, and that it should remain as is and ordinal logistic be used instead of binary logistic regression” [43, p.310], and others warned against the large dichotomization of self-rated health status [44,45]. Because self-rated health status is a Likert scale variable, ranging from very poor to very good health status, many researchers arbitrarily dichotomized it, but the cut-off is not that simple as was noted by Bourne [43], Manor et al. [44] and Finnas et al. [45]. From data on Jamaicans, Bourne’s work revealed that the cut-off in the dichotomization of self-rated health status should be best done without moderate health when dichotomizing for poor health status [43]. All the scholars agreed that narrowed cut-offs are preferable in the dichotomization of self-rated health status, but only a few variables were used (marital status, age, social class, area of residence and self-reported illness) [43-45]. Bourne postulated that “By categorising an ordinal measure (i.e., self-reported health) into a dichotomous one, this means that some of the original data will be lost in the process.” [43, p.295]. Using many more

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variables, the present work highlighted that some social determinants of health are lost as a result of the dichotomization process. Simply put, the social determinants of health are not consistent across the dichotomization process which concurs with the literature. While we concur with other scholars that by dichotomizing self-rated health status some social determinants are lost in the process [43-45], we will not argue with those who opined that self-rated health status should remain a Likert scale measure [52, 53]. The evidence is in that more social determinants in the non-dichotomized self-rated health do not give a greater explanatory power; instead this model had the least explanation. This indicates that more is not necessarily better, and such information must be taken into account in a decision to cut-off at a particular point. The fact that more social determinants of health emerged when health was nondichotomized coupled with a lower explanatory power compared with when it is dichotomized as very poor-to-poor health means that using self-rated health as a Likert scale valve is not preferable to dichotomizing it. A narrower dichotomization of self-rated health status, particularly very poor-to-poor health, as well as moderate-to-very good health status yielded greater explanations than non-dichotomizing health status. This study used both the antithesis of illness and self-rated health status to measure, and evaluates the social determinants of health, and assess whether antithesis of illness is still a better measure of health than self-rated health status. A comparison of the social determinants based on the measurement of health revealed that for the Jamaican adolescence population, antithesis of illness is a better measure than self-reported health status in determining social determinants because of its explanatory power (53%) compared to those that used the self-rated health status (explanatory power at most 38%). On the other hand, the antithesis of illness had fewer social determinants compared with those in self-rated health status, suggesting that more social
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determinants of health should not be preferred to fewer because the latter measure had a greatest explanation. Like dichotomizing self-rated health status, variation also exists among dichotomization of health and antithesis of illness. Thus, it appears that the antithesis of illness may provide a better measure for the social determinants of health than self-rated health status. Diener [50, 51] had postulated that self-reported health status can be effectively applied to evaluate health status instead of objective health status measurement (morbidity, life expectancy, mortality), and Bourne [46] found a strong statistical association between selfreported illness and particular objective measure of health (life expectancy, r = -0.731); but a weak relationship between self-reported illness and mortality. Using a nationally representative sample 6,782 Jamaicans, one researcher warned against using self-reported illness as a measure of health as he found that men were over-reporting their illness [54], and this means they were over-rating their antithesis of illness. Those studies highlight the challenges in using subjective measures in evaluating health as they are not consistent like the objective ones such as mortality, life expectancy, and diagnosed morbidity. Nevertheless, on examining the antithesis of illness and self-rated health status, it was revealed that 2.9% of those who indicated very good health status had an illness compared to 20% of those who reported an illness who had very good health status. From the current work again it emerged that there is disparity between self-reported illness (or antithesis of illness) and self-rated health status, indicating why caution is required in using either one or the other. Other disparities between antithesis of illness and self-rated health status highlighted that antithesis of illness is a better measure of health than self-rated health status. Clearly despite the efforts of the WHO in broadening the conceptualization of health away from the antithesis of illness, the Jamaican adolescence population has not moved to this new frontier. As when they
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were asked to report on the antithesis of illness, they gave lower values than indicated for selfrated health status. Because antithesis of illness captures health more than self-rated health status, this justifies why the former had a greater explanation when the social determinants of health were examined than that of self-rated health status. But, where were their differences in the variables used in one measure compared with the others? In fact, all the variables used in this study were social determinants that were identified in the literature [26-38], and many of them were not significant for the adolescence population of this research. It can be extrapolated from the current work that social determinants of health for a population are not the same for a sub-population, in particular adolescence population. Thus, when the WHO [27] and affiliated scholars [26, 28-32] forwarded social determinants of health, prior to that some scholars like Grossman [33] and Smith and Kington [34] had already social determinants of health of a population. However, none of them stipulated that there are disparities and variations in these based on the dichotomization, non-dichotomization, subpopulation, and measurement of health (ie self-rated health or antithesis of illness). Using a cross-sectional survey (2003 US National Survey of Children's Health) of some 102,353 children aged 0 to 17 years, Victorino and Gauthier [55] established that there were some variations in social determinants of health based on particular health outcomes. The health outcomes used by Victorino and Gauthier are presence of asthma, headaches/migraine, ear infections, respiratory allergy, food/digestive allergy, or skin allergy, which are health conditions. Another research using the 2003 US National Survey of Children's Health (NSCH) investigated the association of eight social risk factors on child obesity, socioemotional health, dental health, and global health status [56]. From a research in England, Currie et al. [57] found disparity in income gradient associated with subjectively assessed general health status, and no
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evidence of an income gradient associated with chronic conditions except for asthma, mental illness, and skin conditions. This paper concurs with the literature that there are variations in some social determinants of health status across measurement, dichotomization and non-dichotomization of health. However, the present work went further than the current literature and found that particular dichotomization of health had stronger explanatory power, and disparity in determinants. As such, the variations in social determinants of health vary across the dichotomization and measurement of health as this paper showed that more social factors do not translate into greater explanatory power; and that stronger explanation does not denotes more social determinants. And the social determinants of health had the greatest explanatory power used antithesis of illness to measure health. Conclusion In summary, the general health status of the adolescence population in Jamaica is good, but 7 in every 100 have reported an illness of which some had chronic conditions (diabetes mellitus, 3.9% and hypertension, 1.3%), and those who classified as being in the wealthy class were more likely to report very poor-to-poor health status compared with those in the lower class. Another important finding was that rural adolescents had a greater health status than urban adolescents, but periurban adolescents had the greatest health status. Outside of the aforementioned good health news, the social determinants of self-rated health status vary across the measurement of and dichotomization and non-dichotomization of health and the population used. This work provides invaluable insights into how social determinants should be examined, modify the general social determinants of health offered by

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the World Health Organization and some associated scholars. By varying the measurement, dichotomization and non-dichotomization of health, this work provide some justification as to whether a particular dichotomization of health is better or non-dichotomization is preferable to dichotomization. This researcher will not join the group of scholars who are purporting for the nondichotomization of self-rated health status, but we recognized that discourse offers some information. However, we will chide researchers against arbitrarily using a particular dichotomization, non-dichotomization and measurement without understanding peoples’ perception of health to which they seek to examine, and evaluate these. Thereby, despite the international standardized definition of a phenomenon, people may a different view as to this issue. Disclosures The author reports no conflict of interest with this work. Disclaimer The researcher would like to note that while this study used secondary data from the 2007 Jamaica Survey of Living Conditions (JSLC), none of the errors in this paper should be ascribed to the Planning Institute of Jamaica and/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 (2007 Jamaica Survey of Living Conditions, JSLC) available for use in this study.

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Table 2.1: Demographic characteristic of studied population, n = 1394 Characteristic n Sex Male Female Union status Married Common-law Visiting Single Social assistance Yes No Area of residence Urban Periurban Rural Population Income Quintile Poorest 20% Second poor Middle income Second wealthy Wealthiest 20% Self-reported illness Yes No Self-reported diagnosed illness Influenza Diarrhoea Respiratory illness (ie asthma) Diabetes mellitus Hypertension Other conditions (unspecified) Health care-seeking behaviour Yes No Self-rated health status Very good Good Moderate Poor Very poor Health insurance coverage No Yes Age, mean (Standard deviation, SD) Length of illness, median (range)

Percent 672 722 1 14 73 494 232 1108 394 287 713 320 328 287 263 196 89 1251 22 1 16 3 1 33 50 43 631 601 84 18 2 1123 194 48.2 51.8 0.2 2.4 12.5 84.8 17.3 82.7 28.3 20.6 51.1 23.0 23.5 20.6 18.9 14.1 6.6 93.4 28.9 1.3 21.1 3.9 1.3 43.4 53.8 46.2 47.2 45.0 6.3 1.3 0.1 85.3 14.7 14.2 years (SD = 2.8 years) 5 days ( 0 – 36 days)

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Table 2.2: Particular demographic variables by area of residence, n = 1,394 Characteristic Area of residence Urban Periurban Self-reported illness n (%) n (%) Yes 27 (7.1) 15 (5.4) No 352 (92.9) 264 (94.6) Self-rated health status Very good 162 (42.7) 141 (50.4) Good 172 (45.4) 132 (47.1) Moderate 38 (10.0) 7 (2.5) Poor 7 (1.8) 0 (0.0) Very poor 0 (0.0) 0 (0.0) Social class Lower 101 (25.6) 108 (37.6) Middle 88 (22.3) 58 (20.2) Upper 205 (52.0) 121 (42.2) Educational level Primary or below 138 (36.6) 136 (48.6) Secondary 213 (56.5) 136 (48.6) Tertiary 26 (6.9) 8 (2.9) Sex Male 213 (54.1) 148 (51.6) Female 181 (45.9) 139 (48.4) Health insurance coverage Yes 73 (19.4) 37 (13.6) No 303 (80.6) 235 (86.4) Length of illness, mean ± SD 6.0 ± 5.7 days 7.8 ± 9.0 days

P, χ2 Rural n (%) 47 (6.9) 635 (93.1) 328 (48.4) 297 (43.9) 39 (5.8) 11 (1.6) 2 (0.3) 439 (61.6) 141 (19.8) 133 (18.7) 312 (46.1) 359 (53.0) 6 (0.9) 361 (50.6) 352 (49.4) 84 (12.6) 585 (87.4) 6.4 ± 6.5 days 9.36, 0.009 F = 0.42, 0.857 0.628, 0.931

24.82, 0.002

172.64, < 0.0001

37.79, < 0.0001

1.20, 0.548

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Table 2.3: Logistic regression: Variables of antithesis of illness among adolescence population, n = 1,280 Characteristic OR CI (95%) Age 1.1 1.0 - 1.3 Health care-seeking (1=yes) 0.0 0.0 - 0.01* Health insurance coverage (1=yes) 1.0 0.4 - 2.5 Primary education (reference group) 1.0 Secondary 1.8 0.9 - 3.7 Tertiary 1.9 0.3 - 15.1 lnMedical 0.8 0.1 - 5.0 Male 1.4 0.7 - 2.6 Social assistance from government 1.6 0.6 - 4.4 Logged family income 0.8 0.3 - 1.8 Rural area (reference group) Urban 1.6 0.7 - 3.8 Periurban 1.2 0.5 - 2.9 Poor-to-Very poor health status (reference group) 1.0 Moderate-to-Very good health status 0.3 0.03 - 2.1 Good-to-Very good health status 12.6 6.0 - 26.3* Lower class (reference group) Middle class 1.6 0.5 - 5.2 Upper 0.8 0.2 - 3.1 Crowding 0.9 0.8 - 1.1 Model χ2, P 287.08, < 0.0001 -2 LL 327.56 R2 0.53 Hosmer and Lemeshow χ2 = 4.40, P = 0.82 OR denotes odds ratio, CI (95%) means 95% confidence interval and *P < 0.05

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Table 2.4: Logistic and Ordinal Logistic regression: Factors explaining self-reported health status of adolescents, n = 1,280 Self-rated health status Very poor-to-poor Good Moderate-to-very Good-to-very Characteristic good good OR CI (95%) OR CI (95%) OR CI (95%) OR CI (95%)
Self-reported illness (1=yes) Age Health care-seeking (1=yes) Health insurance coverage (1=yes) Primary education (reference group) Secondary Tertiary Logged Medical expenditure Social assistance from government Lower class (reference group) Middle class Upper Rural area (reference group) Urban Periurban Male Logged family income Crowding Model χ2, P -2 LL R2 Hosmer and Lemeshow OR denotes odds ratio; *P < 0.05 2.0 1.0 10.0 0.3 1.0 0.7 0.0 1.6 0.2 1.0 0.6 14.9 1.0 1.6 0.0 0.9 0.1 1.6 0.3 – 15.6 0.9 – 1.2 1.0 – 96.5* 0.04 – 2.8 0.3 – 1.9 0 – 0.0 0.7 – 3.6 0.03 – 1.7 0.1 – 2.9 1.9 – 118.3 * 0.4 – 3.0 0.0 - 0.0 0.3 – 2.3 0.04 – 0.4* 1.3 – 2.0* 59.66, < 0.0001 146.38 0.38 χ2 = 4.6, P = 0.82 0.1 0.9 0.7 1.1 1.0 0.9 0.4 0.6 1.2 1.0 2.1 0.7 1.0 0.6 3.3 1.5 1.3 0.9 0.05 – 0.2* 0.9 – 1.1 0.3 – 1.9 0.6 – 2.2 0.6 – 1.5 0.1 – 1.0 0.4 – 1.2 0.6 – 2.2 0.9 – 4.5 0.3 – 1.4 0.5 1.0 0.1 3.0 1.0 1.4 5E+007 0.1 – 4.4 0.8 – 1.2 0.01 – 0.5* 0.4 – 25.5 0.5 – 3.8 0.0 0.1 0.05 – 0.2* 0.9 0.9 – 1.1 0.7 0.3 – 2.1 1.2 0.6 – 2.4 1.0 1.0 0.6 – 1.6 0.4 0.2 – 1.3 0.7 0.4 – 1.2 1.2 0.6 – 2.3 1.0 2.2 1.0 – 4.8 0.7 0.3 – 1.6 1.0 0.6 0.4 – 1.0* 3.3 1.53– 8.2* 1.4 0.9 – 2.2 2.0 1.2 – 3.4* 0.9 0.8 – 0.98* 113.11, <0.0001 588.76 0.20 χ2 = 4.61, P = 0.80

All Estimate
1.8 0.02 1.0 0.04 1.0 0.02 0.3 0.5 0.1 1.0 - 0.7 - 0.6 1.0 0.5 - 0.01 - 0.1 - 0.30 0.1

CI (95%)
1.1 – 2.4* - 0.03 – 0.1 0.1 – 2.0* - 0.3 – 0.4 - 0.2 – 0.2 0.4 – 1.0 0.1 – 1.0* - 0.2 – 0.4 - 1.0 - - 0.4* - 1.0 - -0.1

0.4 – 1.0* 1.3 – 8.2* 1.0 – 2.4 0.9 – 2.0* 0.8 – 1.0* 113.11, < 0.0001 588.76 0.20 χ2 = 4.61, P = 0.80

4.8 0.6 – 38.5 1.0 1.8 0.3 – 9.6 0.1 0.01 – 0.5* 1.0 0.9 0.3 – 2.7 2E+0007 1.1 0.4– 3.0 8.2 2.8 – 23.8* 0.6 0.5 – 0.8* 30.37, < 0.0001 175.67 0.31 χ2 = 4.36, P = 0.94

0.2 – 0.8* - 0.3 – 0.3 - 0.3 – 1.2 - 0.6 – -0.001* - 0.01 – 0.1* 112.94, < 0.0001 2354.33 Pseudo R2 = 0.10 Goodness of fit, χ2=5451.14. P < 0.001

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Table 2.5: Self-rated health status and antithesis of illness, n = 1,330 Self-rated health status Characteristic Very good Good Moderate Poor n (%) n (%) n (%) n (%) Antithesis of illness No 18 (2.9) 38 (6.4) 26 (31.3) 7 (38.9) Yes 611 (97.1) 560 (93.6) 57 (68.7) 11 (61.1) χ2 = 125.58, P < 0.0001 Good health (Antithesis of illness) Characteristic No n (%) Self-rated health status Very good 18 (20.0) Good 38 (42.7) Moderate 26 (29.2) Poor 7 (7.9) Very poor 0 (0.0) χ2 = 125.58, P < 0.0001

Very poor n (%) 0 (0.0) 2 (100.0) Yes n (%) 611 (49.2) 560 (45.1) 57 (4.6) 11 (0.9) 2 (0.2)

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Chapter Three Social Determinants of Health in a developing Caribbean nation: Are there differences based on municipalities and other demographic characteristics?
Paul A. Bourne

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 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. 51

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 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 52

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]).

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 53

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 (i.e. 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%. 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).

54

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 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 (i.e. self-reported health or happiness) is well established [21, 22, 37, 38] and this is equally the case in Jamaica 55

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.

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 (i.e. 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, It ; 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 ; 56

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). 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, 57 (2) (3) (4) (5) (6) (7)

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 (i.e. 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 3.1).

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 3.2 showed that more men reported good health status (85.4%) compared to women (79.2%); 58

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 3.3). 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 (i.e. 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 3.4). Examination of diagnosed self-reported illness and the age group of respondents revealed a statistical correlation (χ2 (7) =457.834, p < 0.001) (Table 3.5). Children are mostly likely to have cold (37.5%), diarrhoea (5.0%) and asthma (19.7%) compared to the other age cohorts (Table 3.5). 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 3.5). A cross tabulation of self-rated health status and age group revealed a statistical relationship (χ2 (7) =1,266.065, p < 0.001) (Table 3.6). Based on Table 3.6, the oldest elderly 59

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 (i.e. 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 3.7). Age (OR=0.951, 95% CI=0.946, 0.956); social class 60

(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 3.7). 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 3.7). 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 3.8). 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 3.8). Predictors of self-rated health status of women

61

There are six factors that were found to be predictors of self-rated health status of women in Jamaica (Table 3.9). 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 3.9). 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 3.10; 3.11; 3.12). 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 equally agreed on by a psychiatrist [17-20] in the treatment of mentally ill patients. Engel called 62

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 health status of Jamaicans. It follows from the current findings that those who do not report an 63

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 predictor of health status of men, other town and rural dwellers but was for women and urban residents. 64

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 (i.e. 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 healthy than females, and further argued that men can use denial, distraction, alcoholism and 65

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 (i.e. length of time in household) in the examination 66

of 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 67

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 68

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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72

Table 3.1: 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

73

Table 3.2: 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

74

Table 3.3: 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

75

Table 3.4: 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 (%)

76

Table 3.5: Diagnosed Self-reported illness By Age group
Age Group Diagnosed Self-reported illness Otheraged adults n (%) 22 (7.3) 6 (2.0) 18 (6.0) 44 (14.7) 76 (25.3) 17 (5.7) 85 (28.3) 32 (10.7) 300

Cold
Diarrhoea Asthma Diabetes mellitus Hypertension Arthritis Other (unspecified) NO Total
2

Children n (%) 97 (37.5) 13 (5.0) 51 (19.7) 3 (1.2) 0 (0.0) 0 (0.0) 54 (20.8) 41 (15.8) 259

Young adults n (%) 14(13.3) 2 (1.9) 16 (15.2) 3 (2.9) 6 (5.7) 1 (1.0) 43 (41.0) 20 (19.0) 105

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

χ (7) =457.834, p < 0.001, cc=0.561, n=999

77

Table 3.6: 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

78

Table 3.7: 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 3.8: 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 3.9: 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 3.10: Predictors of Self-rated Health Status of Jamaicans in Urban Areas Predictors
Coefficient Std. Error Odds ratio

95.0% C.I.

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

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

82

Table 3.11: 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

83

Table 3.12: Predictors of Self-rated Health Status of Jamaicans in Rural Areas Predictors
Coefficient Std. Error Odds ratio 95.0% C.I.

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

-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*** -

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

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

84

Chapter Four

Sociomedical Public Health in Jamaica
Paul A. Bourne

Introduction

The discipline of public health unlike medicine relies on individuals’ perceptions, beliefs, customs, idiosyncrasies, culture and practices in order to improve health and quality of life and not merely an understanding the aetiology of diseases. Public health is, therefore, left with the arduous task of comprehending the human experiences and practices, and using them to enhance, modify and change peoples’ unhealthy behavioural lifestyle. Although Albert
[1]

opined that

public health can improve health and quality of life of older people, this also extends to all peoples. In 2005, the Pan-American Journal of Public Health had an exclusive issue which examined health, well-being, ageing, and proposed a framework for public health action.
[2]

Public health can only enhance health and quality of life if it understands the people it serves, and this denotes that its programmes will only be effective if they are supported by sociomedical research (including epidemiologic inquiry) on national and sub-national populations. While peoples’ behaviours share some general similarities across geopolitical boundaries, a case can also be made equally about the dissimilarities, inequalities and socio-economic differences in and among people within the same nation. Those similarities and differences are responsible for the thrust to study and document information on particular phenomena in order to 85

effectively implement public health programmes that will address the weaknesses, inequalities, deficiencies and challenges of people. It is for this reason why much information have been collected and documented on chronic diseases, mortality, disability and health care cost these pose a challenge to the healthy life expectancy of humans. The present body of knowledge on mortality, morbidities and disability in the world [3-10], and in particular the Caribbean, owes much too continuous biomedical research. But by simply understanding the aetiology of diseases does not mean that technology and medicine can eradicate the presence of diseases in humans, without an understanding of the social aspects of the targeted group. Peoples’ beliefs, customs, perception and biases pose a challenge to public health from attaining its mandate because beliefs guide practices. [11] Within the context that humans’ perspective is important in science and public health, without an understanding of their image on things, it will be impossible for medicine and the natural sciences to effectively address medical conditions that are deemed public health problems. Population health and population health in transition is each a function of social, environment, psychological and biomedical conditions, and not only disease composition and history. It is for this very rationale why public health must rely on sociomedical research and good quality data.
[12-14] [3-5]

as

Hence, this is a justification for researchers’ continuous mode of

investigation of phenomena in order to understand issues experienced by humans. The Caribbean is no different from the rest of the world in this regards, and this provide some explanation why Caribbean scholars, the Planning Institute of Jamaica (PIOJ) and the Statistical Institute of Jamaica (STATIN) continue to embark on social research which include health, lifestyle

86

practices and data quality

[13-20]

in order to aid public health practitioners to effectively

understand phenomena and address changes in peoples’ behaviour. Pappaioanou et al. [12] forwarded a perspective that the capacity of evidence-based public health must be strengthened in developing countries in order to identified priority health problems, respond to public health crises, implement effect strategies and evaluate cost effective interventions. This therefore justifies PIOJ and STATIN, Wilks et al and Bourne’s continuous examination of self-reported health, lifestyle of people of Caribbean people in order to set the platform of public health programmes. Books have been dedicated to ‘Health issues in the Caribbean,’ ‘Equity and Health’, and ‘Investment in Health’ in Latin American and the Caribbean
[21-24]

, but none of those text or other studies in the region, and in particular Jamaica,

have examined in a single research factors that explain health status and health care seeking behaviour as well as health conditions and the disparities by socioeconomic conditions. An extensive review of health and health care-seeking behaviour revealed that studies that have examined health care-seeking behaviour or health status have used a piecemeal approach by either investigating health, health care-seeking behaviour [25-36] or health conditions. The current research bridge the gap by examining (1) demographic characteristics of health care-seekers; (2) sociomedical characteristics of health status; (3) factors that account for health status; (4) health conditions; (5) factors that explain health care-seeking behaviour and (6) characteristics of those who reported having been diagnosed with particular health conditions.

Materials and methods Method

87

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.
[37]

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 (i.e. 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%.

88

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) and independent sample t-test were used to examine 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 [38] 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
[39]

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. The correlation matrix was examined in order to ascertain
if autocorrelation or collinearity existed between variables. Where collinearity existed (r > 0.7), variables were entered independently into the model to help determine which one must retained during the final model construction (the decision was based on the variable’s contribution to the predictive power of the model and the goodness of fit) [40].

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.

89

Multivariate regression framework [35,41] 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. simultaneously.
[33,34,36]

This approach allowed for the analysis of a number of variables

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 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.

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). Self-reported illness (or self-reported dysfunction): The question was asked: “Have you had an illness such as influenza, asthma et cetera in the past 4-week?” Health conditions (i.e. parent-reported illness or parent-reported dysfunction): The question was asked: “Is this a diagnosed recurring illness?” The answering options are: Yes, Influenza; Yes, Diarrhoea; Yes, Asthma; Yes, Diabetes; Yes, Hypertension; Yes, Arthritis; Yes, Other; and No.

90

Self-rated health status: “How is your health in general?” And the options were: Very Good; Good; Fair; Poor and Very 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. 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
Table 4.1 presents information on the demographic characteristic of the sample by area of residence. The sample was 6 782 respondents: 48.7% males and 51.3% females. Based on Table 4.1, 34.2% of urban residents were in the wealthiest 20% compared to 24.1% of those in the periurban and 10.4% in rural areas. On the other hand, poverty was substantially a rural phenomenon (29.8%) compared to peri-urban (11.5%) and urban areas (9.3%). There is a significant statistical association between medication purchased by respondents and area of residence. Twenty percent of respondents who attended public health-care facilities purchased medication, while 81.4% of those who visited private health-care facilities purchased medication. Twenty-five percent (25.2%) of those in rural area who attended public health-care facilities purchased medication 91

compared to 13.6% of those in peri-urban and 14.2% of those in urban areas. Almost ninety-one percent (90.5%) of those in urban area who visited private health-care facilities purchased medication compared to 86.8% of peri-urban and 74.7% of rural residents. Rural residents reported the most illness (16.6%) compared to urban (13.4%) and peri-urban respondents (12.9%). Eighty percent (82.2%) of the respondents indicated at least good health status (with 37.0% said excellent health status) compared to 0.8% who claimed very poor health status. One percent (1.1%) of the sample was injured in the 4-week period of the survey, while 14.9% was reported an illness and 43.2% indicated a chronic illness (i.e. Diabetes mellitus, 13.8%; hypertension, 23.1%; and arthritis, 6.2%) compared to 30.4% reported acute illness (influenza, 16.7%; diarrhoea, 3.0%; and asthma, 10.7%). Almost 66% (i.e. 65.5%) of the sample visited a health care practitioner (i.e. doctor, nurse, healer, pharmacist) in the 4-week period of the survey; 29.6% was heads of households; married, 23.3%; never married, 69.2%; divorced, 1.7%; separated, 0.9%; widowed, 4.9%; and the median number of person per room was 4 (range = 1, 17). The median annual income was USD 7 050.66 (range = USD 261.56, USD 6 523.66) and median per capita consumption was USD 1 523.88 (range = USD 179.57, USD 20 325.55). Table 4.2 highlights information on sociomedical characteristics of sample by sex of respondents. Males were more likely to be married (24.3%) than females (22.4%), and the latter was more likely to be widowed (7.3%) than the former (2.3%). Females reported more illnesses (17.5%) than males (12.1%), and they were more likely to have hypertension and diabetes mellitus than males. However, there was no significant statistical relationship between health care utilization and sex of respondents: males, 62.3% and females, 67.6% (χ2 = 3.004, P < 0.083).

92

There was no significant statistical relationship between those who purchased medication and their sex. Twenty percent (20.2%) of females who visited public health care facilities purchased medication compared to 19.7% of males (χ2 = 0.023, P = 0.879). Eight-one percent of females who attended private health-care facilities purchased medication compared to 81.9% of males (χ2 = 0.100, P = 0.752). Males were more likely to be household heads (32.7%) than females (26.7%) - χ2 = 29.207, P < 0.0001. When the significant statistical association between marital status and social standing was disaggregated by sex, this was explained by females (χ2 = 54.48, P = 0.0001) and not males (χ2 = 24.77, P = 0.074). Almost 49% (48.8%) of divorced females were in the wealthiest 20% compared to 27.0% of those who are married, 21.8% of widowed; 20.0% of separated as well as those who were never married respondents. Table 4.3 shows sociomedical characteristics of sample by marital status. Divorced respondents were most likely to be in the wealthiest 20% (44.2%) compared to separated respondents (31.7%); married, 28.3%; never married, 21.8% and widowed respondents, 21.4% (χ2 = 67.45, P < 0.0001). Forty percent of the widowed respondents indicated an illness compared to those who are separated, 29.3%; divorced, 28.6%; married, 24.6% and never married, 10.8%. A significant statistical association was found between area of residents and those who attend public hospitals (χ2 = 7.94, P < 0.019), private hospitals (χ2 = 30.30, P < 0.0001), and private health care centres (χ2 = 10.19, P < 0.006), while no between area of residents and public health care centres (χ2 = 4.23, P < 0.13). Rural residents were most likely to visit public hospitals (37.2%) compared to urban (27.7%) and peri-urban residents (25.6%). With respect to private hospital utilization, rural residents recorded the least visits (2.3%) than peri-urban (6.8%) and urban residents (15.0%). Similarly, rural dwellers recorded the least utilization of private health care centres (46.2%) than urban (52.7%) and periurban residents (63.2%).

93

Rural dwellers recorded the longest time spent in illness (56.6 days ± 169.3) compared to urban dwellers (9.6 days ± 17.9) and peri-urban residents (53.3 days ± 154.4) – F-statistic = 9.58, P < 0.0001.

There is a significant statistical association between area of residence and educational levels (χ2=78.02, P < 0.0001). Sixty-eight percent of those with tertiary level education dwelled in urban areas compared to 16% of those in peri-urban and 20.6% in rural areas. No significant statistical association was found between social class and self-reported illness (χ2=3.28, P < 0.512) as well as between self-reported diagnosed health conditions and social class (χ2=28.6, P < 0.236). Figure 4.1 highlights information on self-reported diagnosed illness by marital status of respondents disaggregated by sex of respondents. A significant statistical association was found between self-reported diagnosed illness by marital status even when the data was disaggregated by sex (male – χ2 = 52.43, P < 0.001; females - χ2 = 56.2, P < 0.0001), but the relationship was strong for males (contingency coefficient = 0.425) than females (contingency coefficient = 0.339). A significant statistical relationship existed between self-reported diagnosed health conditions and age group (χ2 = 436.8, P < 0.0001). Younger people were more likely to have acute conditions and older people are likely to have chronic conditions (Figure 4.2). Despite this fact 1.4% of Jamaica children have diabetes mellitus. Table 4.5 examines factors that are correlated with self-evaluated health status of Jamaicans. Of the 13 variables that were tested in the model, 9 emerged as statistically correlated with health status and that the model was a good fit for the data (Hosmer and Lemeshow goodness of fit χ2=18.49 (8), P = 0.78; -2LL = 3321.07). The model (i.e. 9 significant correlates of self-evaluated health status) accounted for 40.3% of the variability in self-reported health 94

status: 84.8% of the data were correctly classified, 95.3% of those in good or excellent selfevaluated health status and 47.5% of those in fair to poor health status. Two-thirds of the variability in health status was accounted for medical factors such as self-reported illness and length of illness compared to one-third by social factors (i.e. age, sex, per capita consumption, health care-seeking behaviour, area of residence, marital status and social class). Of the social factors, consumption accounted for less than 1% of the variance in self-evaluated health status (i.e. 0.5%) and social class accounted for 0.1%. Table 4.6 presents information on the self-reported health care-seeking behaviour of respondents by explanatory variables. Four variables accounted for 71.1% of the variability in self-reported health care-seeking behaviour. Using logistic regression analyses, 4 variables emerged as statistically significant correlates of self-reported health care-seeking behaviour: selfreported illness, (OR = 358.31, 95% CI = 233.31, 550.30); health status, (OR = 0.46, 95% CI = 0.31, 0.67); health insurance coverage, (OR = 1.74, 95% CI = 1.26, 2.40); age, (OR = 1.01, 95% CI = 1.00, 1.01); and per capita consumption, (OR = 1.00, 95% CI = 1.00, 1.00). From the correlation matrix, there is a moderate statistical correlation between self-reported health illness and self-evaluated health status (r = 0.64).

Discussion
The current study revealed that 29.8% of rural residents were in the poorest 20% (i.e. poorest income quintile) in Jamaica compared to 11.5% of peri-urban and 9.3% of urban residents. Rural poverty lies between 2.5 to 3.3 times more than peri-urban and urban poverty, and 1.3 times more people report illness in those areas than in peri-urban or urban areas. Rural residents are not only rural and report more illness than other residents; they are 1.9 times less likely to have health insurance coverage than urban residents and 1.5 times less likely than peri-urban dwellers. 95

They are also more likely to utilize public hospitals and spent more time nursing in illness than other residents, and also had the least consumption per person. However, their self-evaluated health status was the same as urban dwellers but less than that for peri-urban settlers, and there was no significant statistical correlation among health care-seekers based on their area of residences. Concurrently, males were more likely to record greater moderate-to-excellent health status than females; more likely to be married; less likely to be widowed; less likely to report an illness; less likely to have diabetes mellitus and hypertension; more likely to have asthma, arthritis; unspecified conditions and influenza than females. Irrespective of the more female than males reporting having been diagnosed with chronic conditions, there was no significant correlation between health care seeking behaviour and sex of respondents. The findings continued as those in the wealthiest 20% were more likely to be divorced people; but those who were classified as divorced, separated and widowed were less likely to be healthier than those who were never married. Those who were never married reported the lowest percent of having had an illness in the 4-week period of the survey. Two-thirds of the variability was accounted for medical factors such as self-reported illness and length of illness compared to one-third by social factors (i.e. age, sex, per capita consumption, health care-seeking behaviour, area of residence, marital status and social class). Four variables accounted for 71.1% of the variability in self-reported health care-seeking behaviour, and self-reported illness accounted for 70% of the explanatory power. People who reported moderate-to-excellent health status were 55% less likely to seek health care and those who reported an illness were 358.3 times more likely to seek health care. Less than one-half percent of the variance in health care-seeking behaviour can be explained by health insurance coverage, and that an individual who indicated that he/she is ill is 81% less likely to stated moderate-to-excellent health status. 96

Public health is influenced by both the continuous revelations in research as well as science of people’s behaviour in order to effectively plan behaviour modifications. The behaviour change required for developing countries must be tailored within the context of the research findings [42], and cannot be left to the dictates of studies on developed nations. Apart of the justification for studies on a particular geo-political boundary are based on inequalities, economic and health disparities among and between people within a nation, and this is particularly in reference to Latin America and the Caribbean.[43-45] With public health taking must of its cue from both medical and social sciences, there is obviously a rationale for the social determinants in the study of public health. The some time ago embarked a thrust of examining social determinants in understanding health, health conditions and health treatment. In recent years the World Health Organization (WHO) has increasingly drawn attention to the importance of the relationship between health and social conditions in determining the health of individuals and populations [46]. The social determinants (non-biological factors), produce inequalities in health and need to be considered in health development. Addressing social determinants and health policy now includes the basis for political action both nationally and internationally.[47-51] The findings of the present work highlights and concur with the literature about the dominant of the biomedical conditions in health. The findings revealed that two-thirds of variability in health status can be accounted for by self-reported illness and length of illness. Although this fact speaks to the dominance of biomedical conditions, it does also recognize the importance of social determinants in health. A study by Hambleton et al.
[36]

on elderly

Barbadians found that as much as 88% of the variability in self-reported health status could be explained by current diseases. While the current work has a lower percent of explanation model which is due to the sample that include young people, it highlights a rationale for the ease of use 97

of the biomedical conditions and in the process sideline the need for the social determinants in health, health utilisation and health treatment. Clearly illnesses are fundamental in the health discourse, and it is also critical in the understanding health care-seeking behaviour of people. In this research, a respondent who is ill is 358.3 times more likely to seek care. This highlights not only the dominance of illness to health care-seeking, but the image of health that is held by Jamaica and how this influence outcome. This is supported by the finding that revealed that people who self-reported their health status to be moderate-to-good were 54% less likely to seek health care. Embedded in such a finding is structure of the health care delivery in Jamaica, which dates back to 130ce to 200ce in Ancient Rome, when health and health care was in keeping with traditional biomedical model that views the exposure to specific pathogen as the cause of diseases in organisms. Within this image of health was people’s perception of what constituted a need to demand health care services which were illness and this fashioned the health care industry at the time. Clearly the image of health and health care delivery in Jamaica is framed around the aetiology of diseases and the not the multidimensional approach to the image of health which is in keeping with the broad definition offered by the WHO in 1948.
[52]

The

overemphasis on illness, disability and severity of illness in framing people’s willing to seek medical care is not atypical to Jamaica as this was found in other societies. [26-31, 53] Money is well established as being positively correlated with health status.
[54]

Money

does matter in access to resources, opportunities, choices and quality of care. The current findings found that people whose consumption expenditure are higher have a greater health status, which concurs with the literature that money does matter for health. Money does not only matter for health, it also is important for health seeking behaviour. Despite the positive of money, those who are most likely to be in the wealthiest 20% had lower health status. This paper 98

found that divorced, separated and widowed Jamaicans were more likely to have a lower health status than those who were never married and this was also the case for the upper class with reference to the lower class. Although the finding does indicate that divorced and separated respondents were wealthier than other marital statuses, this is a negative for their health status. Also embedded in this finding is the fact that significant statistical association between social standing and marital status was among females. This denotes that wealthiest females were most likely to be divorced which offers an explanation that money can buy health, psychological comfort, happiness and these would have been the case for these females in the study. Divorced therefore provides females with more economic resources, but this does not compensate for the lost of the spouse, and further removes the benefits of the economic gains from health. In addition divorced females recorded the highest percent of diabetes mellitus among all respondents followed by separated women. Hypertension was substantially more among separate males and widowed females, suggesting that separation from spouse becomes a disbenefit for Jamaica and therefore account for the unhealthy life style practices which were not identified in never married and/or married respondents. There are obvious benefits from having money as this was evident in rural residents having the least money, the most self-reported illness, and the highest public hospital utilisation. Despite the income inequalities and economic disparities between rural and other residents in Jamaica, the former residents are able to experience a self-reported health status which is the same of those in the affluent urban areas. This means that there are some basic standard of living enjoyed by rural Jamaica which cushioned the wide income inequalities that exist between them and urban dwellers. Apart of what creates the cushion for rural residents is the quality of primary health care facilities offered to them by public hospitals in the country. With most rural residents 99

utilizing public hospitals, public health offerings have played a critical role in removing some of the health inequalities that could have been owing to income inequalities. Another factor which mitigates the negatives of income inequalities among the different area of residents is the communal settings in rural areas, and how this aids in providing socio-economic support among residents. Poverty in rural areas is therefore shared by the wider community as people seek to assist others in need, vulnerable, less fortunate and economic challenged in life. It is this communal culture that sees sharing of food, finances and social institutions that helps to retard the negative of poverty from rural residents. The poor are classified as in the lower socioeconomic status. It is empirically well established in research that they are less likely to be healthy than those in the higher socioeconomic groups [55, 56], which is not the case in Jamaica. They have a greater selfevaluated health status than those in the higher socioeconomic groups. Concurrent this research does not concur with the literature that poverty is more common among the chronically ill [57] or that the poor reported having more illness than the higher socioeconomic class. This was also highlighted in the fact that rural residents were substantially more likely to poor, but shared the same health status as those in urban areas. However what emerged from the current findings is that peri-urban residents had a greater health status than other residents, and this could be due to the fact that more of them were in the never married group who had the lowest rate of illness as well as chronic illnesses. Residents in peri-urban area has greater income than those who dwelled in rural areas but less than those in urban areas which indicates that some money is important in health, but that is not responsible for greater health. It can be extrapolated from this finding that peri-urban residents are more involved in healthier lifestyle choices than residents in other

100

geographic areas, which is accounting for their health more than money and higher formal education. This study uncovers a paradox between subjective health and objective health. The present work found that males reported less illness, had greater self-evaluated health status, but using statistics on life expectancy in Jamaica females outlive males between 4 to 7 years.
[58, 59]

In 1880-1882, Jamaica females outlive males by 2.9 years and in 2002-2004, this was increased to 5.8 years.[20] For 2007, statistics published by the WHO revealed that this difference was 5 year. [59] This questions the validity of subjective health data in the evaluation of health, and begs the question “How valid is subjective health data in Jamaica?” A study by Bourne
[17]

found a

strong statistical correlation between life expectancy at birth for the Jamaicans and self-reported illness (r = - 0.731); and this association was weaker females (r = - 0.683) than males (r = 0.796). Hence, there is validity in the use of subjective index to measure health. This suggests that the afore-mentioned disparity in subjective and objective indexes to measure health is not a paradox, but an issue which needs further examination. The inverse relationship between health and age is long established in research literature
[1, 34, 35]

as well as the shift from acute to chronic conditions in old ages. [60, 61] Morrison

[60]

in an

article entitled ‘Diabetes and hypertension: Twin Trouble’ forwarded that diabetes mellitus and hypertension have now become two problems for Jamaicans and in the wider Caribbean. Callender
[61]

concurred with Morrison

[60]

that there is a positive association between diabetic

and hypertensive patients (i.e. 50% of individuals with diabetes had a history of hypertension), and that this is a public health problem in the Caribbean. This study narrows the chronic conditions to older people, but also noted that 1.4% of children in Jamaica had diabetes mellitus, 3.5% of young adults and 16.4% of other adults. If Callender’s are true then in a short while one101

half of those afore-mentioned individuals will have dual chronic conditions. A recently conducted study by Wilks et al.
[13]

provide some historical background to chronic illnesses in

Jamaica as they found that 31% of Jamaicans indicated that their parent and/or grand parents had diabetes mellitus; 47% said that hypertension, 17.1% strokes and 15.7% said their parents and/or grandparents had cancer. Diabetes mellitus and hypertension therefore continue to be silent killers in Jamaica, and their history dates back to former generations. Public health practitioners need to urgent begin a campaign of lifestyle practices geared towards children as there is evidence to support healthy lifestyle practices among all groups, and in particular children, who are frequently, omitted from healthy lifestyle programmes. The current study highlighted that there are many inequalities (i.e. systematic, avoidable and important difference) in health status among Jamaicans and that these need to be rectified in order to attain the resolution of the World Health Assembly (WHA48.8).[62] Jamaica now has a primary health care system which is free to all, but this has still not met equity (i.e. unnecessary and avoidable differences which are considered to be unfair and unjust) in health care throughout the society. Free health care for all in Jamaica have not addressed issues such as exposure to unhealthy, stressful living and working conditions; natural selection or related social mobility; transient health advantage; gender discrimination; socioeconomic discrimination; inequitable deployment of resources around the nation; and the organization of some health services around the country. Inequalities and inequities in Latin America and the Caribbean have been empirically researched by Pan American Health Organization (PAHO), and further readings can be had by examining two of its publications [23, 24] as well as Whitehead. [63] It is clear from the current findings that merely making primary health care free for all will not reduce many of the public health challenges in a nation and among its people. So while Jamaica has done the former, 102

there are obvious signs that reaching the poor with health care does not address many other health inequalities and inequities. Using statistics for 90 countries, the WHO [59] revealed that in many of these nations there are health disparities and inequities between and among people which is concurred by Global Forum for Health Research [64] and this study. This reinforces the need for public health practitioners not to rely on national averages and information which originates from within the health sector but on sociomedical determinants on groups and subgroups within the population.

Conclusion
Although biomedical conditions accounted for more of health than social determinants, the current study highlighted the value of the social determinants in the health discourse. The social issues in this research brought to the fray the fact that separation from one spouse influenced health status, healthy behaviour and health conditions. It does not cease there as the image of health is substantially driven by illness which account for seeking (or not seeking) medical care. In addition to the afore-mentioned issues, there is a clear public health challenge that exists in Jamaica which is how to address the unhealthy lifestyle practices of people who have been separated from their spouses as well as the fact that particular health conditions appear to be associated with particular social characteristics. Another public challenge is how to change the image of health in Jamaica from illness to wellness or wellbeing. This public health challenge must commence with the restructuring of the health care system and its delivery which is primary driven by the biomedical factors instead of holistic health. Increasing attention must be placed on this reorganization as if the health care is fashioned more around curative care, then people will use this image of health care to frame their concept of health and health demands. Some of the disparities that emerged from the current work from the literature highlights the fact 103

that public health in Jamaica cannot rely on the research findings in other geo-political boundaries to craft policies and intervention programmes as the will be ineffective in addressing its mandate owing to the sociodemographic differences of Jamaicans. Public health therefore must rely on research findings within it geo-political area while understanding what obtains in other areas in order to embark on intervention programmes that will improve health and quality of life of people. Within this context, one of the problems which must be addressed by public health policy makers is how to address the high percent of Jamaicans who are current diagnosed with chronic illness (i.e. 43 %) as well the fact that even children are now diagnosed with diabetes mellitus suggesting that public health must embark on programmes that address living longer and healthier with (and without) chronic illnesses. In sum, the inequalities and/or inequities which emerged in this study are social issues which explain medical conditions and it is this merger of medicine and sociology that is needed to effectively improve the health and quality of life of people. Concurrently, policy makers need to change the concept of health of Jamaicans and this can be enhanced by (1) leisure and exercise facilities in communities as well as in health care facilities; (2) reduce the inequalities in working and living conditions of the vulnerable and disadvantaged groups; (3) address the healthdamaging behaviour of some social groups; (4) administrative reform of professionals in regards to the dissemination of information to lay people; (5) examine, monitor and evaluate the implication of health policies on the socioeconomic groups within the society; (6) pollution control caps; (7) assist in food hygiene, nutrition, sanitation and health education moreso in times of economic hardships; and (8) commence a databank that collects data on the cultural and behavioural practices of people in order to effectively formulate health policies. In addition to the afore-mentioned issues, while the current study is not a representation of the Caribbean, 104

based on the Pan American Health Organization research on Latin America and the Caribbean investment in health and health care modernization have not reduced the inequalities and inequities in nations among different social groups within those nation
[23, 24]

, which is what

emerged from the current work. Clearly, health inequalities and inequities in Latin America and the Caribbean are very much the same, and any public health intervention programmes that do not address this reality will be ineffective in aiding health and quality of life of its people. Health protection therefore must be embedded in science of human behaviour (i.e. social determinants) as well as an understanding of the pathogenesis of diseases (i.e. sociomedical public health).

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

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46. WHO: The Social Determinants of Health; 2008. Available at http://www.who.int/social_determinants/en/ (accessed April 28, 2009). 47. 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. 48. Wilkinson RG, Marmot M: Social Determinants of Health. The Solid Facts, 2nd ed. Copenhagen: World Health Organization; 2003. 49. 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). 50. Graham H: Social Determinants and their Unequal Distribution Clarifying Policy Understanding The MilBank Quarterly 2004; 82 (1), 101-124. 51. 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. 52. World Health Organization, (WHO): 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: WHO, 1948. 53. Brown PH, de Brauw A, Theoharides C: Health-seeking behavior and hospital choice in China’s New cooperative medical stystem. Social Sci Research Network 2008. [Abstract]. 54. 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. 55. Fox J, ed: Health inequalities in European Countries. Aldershot: Gower Publishing Company Limited; 1989. 56. Illsley R, Svensson PG, eds: Health inequities in Europe. Soc Sci Med 1990; 31(special issue):223-420. 57. van Agt HME, Stronks K, Mackenbach JP: Chronic illness and poverty in The Netherlands. European J of Public Health 2000; 10(3):197-200. 58. Statistical Institute of Jamaica, (STATIN): Demographic statistics, 1989-2007. Kingston, STATIN; 1989-2008. 59. World Health Organization, (WHO): World health statistics, 2009. Geneva: WHO; 2009. 60. Morrison E: Diabetes and hypertension: Twin trouble. Cajanus 2000; 33:61-63. 61. Callender J: Lifestyle management in the hypertensive diabetic. Cajanus, 2000; 33:67-70. 62. World Health Organization, WHO: Doctors for health: A WHO global strategy for changing medical education and medical practice for health for all. Geneva: WHO; 1996. 63. Whitehead M: The concepts and principles of equity and health. Copenhagen: WHO; 1985. 64. Global Forum for Health Research: Global forum update on research for health: Poverty, equity and health research, vol.2. London: Pro-Brook Publishing; 2005

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Figure 4.1. Self-reported diagnosed illness by marital status for sex

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Figure 4.2. Self-reported diagnosed illness by age group

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Table 4.1. Demographic characteristic by area of residence
Characteristic Social standing Poorest 20% Poor Middle Wealthy Wealthiest 20% Self-reported Injury Yes No Sex Male Female Marital status Married Never married Divorced Separated Widowed Self-evaluated illness Yes No Self-reported diagnosed illness Influenza Diarrhoea Asthma Diabetes mellitus Hypertension Arthritis Other Health insurance coverage Area of residence Urban Semi-urban n (%) n (%) 186 (9.3) 243 (12.1) 389 (19.4) 499 (24.9) 685 (34.2) 167 (11.5) 273 (18.7) 312 (21.4) 354 (24.3) 352 (24.1) P Rural n (%) 990 (29.8) 838 (25.2) 650 (19.6) 499 (15.0) 345 (10.4) χ2 = 881.51 P < 0.0001

χ2 = 2.25 P = 0.325 χ2 = 3.67 P = 0.16 χ2 = 15.46 P = 0.05

16 (0.8) 1933 (99.2)

16 (1.1) 1408 (98.9)

41 (1.3) 3186 (98.7)

943 (47.1) 1059 (52.9)

706 (48.4) 752 (51.6)

1954 (49.8) 1668 (50.2)

326 (23.3) 972 (69.3) 32 (3.2) 9 (0.6) 63 (4.5)

217 (21.6) 702 (70.0) 23 (2.3) 12 (1.2) 49 (4.9)

513 (24.1) 1462 (68.7) 22 (1.0) 20 (0.9) 112 (5.3)

χ2 = 15.43 P < 0.0001 χ2 = 29.59 P = 0.003

261 (13.4) 1690 (86.6)

183 (12.9) 1231 (87.1)

536 (16.6) 2688 (83.4)

25 (10.9) 4 (1.9) 33 (14.4) 32 (14.0) 47 (20.5) 16 (7.0) 72 (31.4)

44 (26.0) 4 (2.4) 11 (6.5) 27 (16.0) 41 (24.3) 10 (5.9) 32 (18.9)

80 (16.3) 19 (3.9) 51 (10.4) 64 (13.0) 118 (24.0) 30 (6.1) 130 (26.4)

χ2 = 138.80 P < 0.0001 χ2 = 5.21 P = 0.07

Yes 542 (28.0) No 1397 (72.0) Health care-seeking behaviour Yes 190 (71.2) No 77 (28.8) Consumption per capita 2632.57±2040.89 (in USD)

310 (22.1) 1091 (77.9)

462 (14.5) 2715 (85.5)

119 (63.6) 349 (63.3) 68 (36.4) 202 (36.7) 2223.76±1753.22 1499.18±1095.70

F =344.31, 0.0001

P <

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Table 4.2. Sociomedical characteristic by sex of respondents
Sex Male Characteristic Consumption per capita (in USD)1 2018.20±1712.76 Total Expenditure (on food) (in USD)1 3488.32±2187.43 No. of days in public health care facilities 6.6 ±6.2 No. of days in private health care facilities 5±0 Medical expenditure - public 3.67±17.51 (in USD)1 Medical expenditure – private 14.05±21.12 (in USD)1 Self-reported diagnosed illness Influenza 69 (20.2) Diarrhoea 11 (3.2) Asthma 47 (13.7) Diabetes mellitus 31 (9.1) Hypertension 58 (17.0) Arthritis 24 (7.0) Other 102 (29.8) Social standing Poorest 20% 671 (20.3) Poor 640 (19.4) Middle 636 (19.3) Wealthy 667 (20.2) Wealthiest 20% 689 (20.9) Self-reported Injury Yes 41 (1.3) No 3169 (98.7) Marital status Married 522 (24.3) Never married 1528 (71.1) Divorced 34 (1.6) Separated 16 (0.7) Widowed 50 (2.3) Self-evaluated illness Yes 388 (12.1) No 2820 (87.9) Health care-seeking behaviour Yes 253 (62.3) No 153 (37.7) USD 1.00 = Ja $80.47 at the time of the survey Female 1962.30±1592.01 3616.80±2201.34 6.0±4.7 1±0 8.36±67.69 14.15±30.58 P t =1.39, P = 0.16 t = -2.41, P = 0.016 t = 0.35, P = 0.73 t = -1.02, P = 0.31 t = -0.044, P = 0.97 χ2 = 30.25, P < 0.0001 80 (14.6) 16 (2.9) 48 (8.8) 92 (16.8) 148 (27.0) 32 (5.8) 132 (24.1) 672 (19.3) 714 (20.5) 715 (20.6) 685 (19.7) 693 (19.9) 32 (0.9) 3358 (99.1) 534 (22.4) 1608 (67.4) 43 (1.8) 25 (1.0) 174 (7.3) 592 (17.5) 2789 (82.5) 405 (67.6) 194 (32.4)

χ2 = 4.35, P = 0.361

χ2 = 1.68, P = 0.196 χ2 = 61.94, P < 0.0001

χ2 = 38.12, P < 0.0001 χ2 = 3.004, P < 0.083

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Table 4.3. Sociomedical characteristic by marital status of respondents
Characteristic Social standing Poorest 20% Poor Middle Wealthy Wealthiest 20% Self-reported Injury Yes No Self-evaluated illness Yes No Self-reported diagnosed illness Influenza Diarrhoea Asthma Diabetes mellitus Hypertension Arthritis Other Health insurance coverage Yes No Health care-seeking behaviour Yes No Head of household Yes No Marital status Married Never married n (%) n (%) 153 (14.5) 564 (18.0) 181 (17.1) 928 (20.0) 185 (17.5) 633 (20.2) 238 (22.5) 626 (20.0) 299 (28.3) 685 (21.8) 16 (1.5) 1040 (98.5) 259 (24.6) 795 (75.4) 18 (7.4) 2 (0.8) 10 (4.1) 48 (19.7) 91 (37.3) 24 (9.8) 51 (20.9) 357 (34.1) 691 (65.9) 173 (65.3) 92 (34.7) 564 (53.4) 492 (46.6) 37 (1.2) 3091 (98.8) 338 (10.8) 2789 (89.2) 28 (9.2) 7 (2.3) 31 (10.2) 39 (12.8) 69 (22.6) 22 (7.2) 109 (35.7) 552 (17.9) 2528 (82.1) 239 (68.1) 112 (31.9) 1163 (37.1) 1973 (62.9) P Divorced n (%) 4 (5.2) 6 (7.8) 18 (23.4) 15 (19.5) 34 (44.2) 0 (0.0) 77 (100.0) 22 (28.6) 55 (71.4) 1 (4.8) 1 (4.8) 2 (9.5) 10 (47.6) 3 (14.3) 1 (4.8) 3 (14.3) 27 (35.1) 50 (64.9) 15 (68.2) 7 (31.8) 57 (74.0) 20 (26.0) Separated Widowed χ2 = 67.45, P < 0.0001 9 (22.0) 3 (7.3) 10 (24.4) 6 (14.6) 13 (31.7) 1 (2.4) 40 (97.6) 12 (29.3) 29 (70.7) 1 (8.3) 1 (8.3) 0 (0.0) 4 (33.3) 5 (41.7) 1 (8.3) 0 (0.0) 8 (19.5) 33 (80.5) 8 (61.5) 5 (38.5) 27 (65.9) 14 (34.1) 43 (19.2) 36 (16.1) 58 (25.9) 39 (17.4) 48 (21.4) 3 (1.3) 220 (98.7) 90 (40.4) 133 (59.6) 4 (4.5) 3 (3.4) 1 (1.1) 19 (21.6) 37 (42.0) 8 (9.1) 16 (18.2) 60 (26.9) 163 (73.1) 90 (40.4) 133 (59.6) 181 (80.8) 43 (19.2)

χ2 = 2.16, P = 0.71 χ2 = 233.86, P < 0.0001 χ2 = 75.36, P < 0.0001

χ2 = 127.20, P < 0.0001 χ2 = 233.86, P < 0.0001 χ2 = 258.12, P < 0.0001

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Table 4.5. Stepwise logistic regression: Self-evaluated health status by explanatory variables
Explanatory variables Illness (1= yes) Age Per capita consumption Health care-seeking behaviour Sex (1= male) Upper class †Lower class Peri-urban †Rural Length of illness Coefficient -1.648 -0.045 0.000 -0.720 0.348 -0.345 Std. Error 0.152 0.003 0.000 0.178 0.091 0.164 P 0.000 0.000 0.000 0.000 0.000 0.035 Odds ratio 0.192 0.956 1.000 0.487 1.417 0.708 1.000 1.405 1.000 0.997 95.0% C.I. Lower Upper 0.143 0.951 1.000 0.343 1.184 0.513 0.259 0.961 1.000 0.690 1.695 0.977 R2 change 0.266 0.114 0.005 0.004 0.006 0.001

0.340

0.114

0.003

1.125

1.756

0.002

-0.003

0.001

0.004

0.995

0.999

0.003

Divorced, separated or widowed -0.355 †Never married

0.153

0.021

0.701 1.000

0.519

0.947

0.002

Hosmer and Lemeshow goodness of fit χ =18.49 (8), P = 0.78 Nagelkerke R2 =0.403 -2LL = 3321.07 †Reference group
2

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Table 4.6. Stepwise logistic regression: Self-reported health care-seeking behaviour by explanatory variables 95.0% C.I. Explanatory variable Coefficient Health status (1=moderate-toexcellent) -0.787 Health insurance Self-reported illness Age Per capita consumption 0.554 5.881 0.005 0.000 Std. Error 0.191 0.163 0.219 0.003 0.000 P 0.000 0.001 0.000 0.037 0.021 Odds ratio 0.455 1.741 358.313 1.005 1.000 Lower 0.313 1.263 233.307 1.000 1.000 Upper 0.662 2.398 550.297 1.010 1.000 0.005 0.004 0.700 0.001 0.001 R2 change

Hosmer and Lemeshow goodness of fit χ2=7.12 (8), P = 0.52 Nagelkerke R2 =0.711 -2LL = 1525.53 †Reference group

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Chapter Five The validity of using self-reported illness to measure objective health
Paul A. Bourne

Introduction
There is a longstanding discourse on whether self-reported health is a good measure of objective health. Objective health indexes include mortality, life expectancy and diagnosed morbidity, which provide a great degree of precision in the measurement of health. Those measures have been used for centuries by mathematicians, demographers and epidemiologists to provide insights into the health of an individual, community or population. While the objective health indexes do have a high probability of mathematical empiricism, which make for validity and reliability in comparisons across different population characteristics, they are narrow in evaluating a range of issues affecting the health of people. Life expectancy germinates from mortality data, which speaks to lived years and not quality of the lived time. Like life expectancy and mortality, morbidity is caused by some disease causing pathogens that further justify the causal relation between morbidity and health. Historically, policy makers including doctors relied on research findings on the causes of particular dysfunctions in order to formulate measures to address their reduction or eradication. Health therefore was viewed as the absence of diseases; hence, the alleviation of morbidity meant a healthy person or population. But the absence of diseases still does not imply that an individual or population is healthy, as this is the further extreme of the health continuum. It was this gap in the discourse and the accepted

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limitation of objective indexes of health that led the World Health Organization (WHO), in the late 1940s, to forward a conceptual definition of health [1]. The WHO’s definition of health stipulated that it goes beyond the mere absence of diseases to social, psychological and physical wellbeing. Health was no longer the absence of diseases but different tenets of ‘wellbeing’. Although WHO’s perspective outlined the way forward, and sought to provide a platform for which an expansion in objective health could begin, some scholars opined that it was too vague and elusive a conceptualization [2,3]. In spite of those critiques, some researchers began using subjective indexes to measure health instead of the traditional objective indexes. The subjective measures are 1) happiness; 2) life satisfaction, 3) self-reported health status, and self-reported illness [4-15]. Diener [5, 6] postulated that happiness can be used to measure subjective wellbeing (ie health). He opined that happiness expends beyond and implicitly takes into account more aspects of an individual’s life than the objective indexes. Happiness like life satisfaction, selfreported health has a common denominator, people’s perception of their general quality of life. Although this is in keeping with that comprehensive broad conceptual definition of health forwarded by the WHO – more than the narrow biomedical approach diagnosed morbidity, life expectancy or mortality – the debate about the validity of those subjective indexes continue. Scientific literature on health has revealed that self-rated health status is highly reliable a measure to proxy health and that this ‘successfully crosses cultural lines’ [16]. O’Donnell and Tait [17] concluded that self-reported health status can be used to indicate wellbeing as they found that all respondents who had chronic diseases reported very poor health. Another group of scholars concurred with the aforementioned findings when their findings revealed that the statistical association between happiness and subjective wellbeing (ie self-reported health) was a 117

strong one - correlation coefficient r = 0.85 in the 18 OECD countries [18]. In that same study, the research found a weak relation between objective measures of health and self-reported health. This highlights the disparity in measures, the need for more empirical studies and implicitly has not address the biasness in the subjectivity of the subjective indexes. The subjective indexes introduced the issue of biasness in recall and perception as subjectivity denotes people’s perceptions. Perception is highly biased as people can provide an inflated or deflated account of their state in an interview or on a self-administered questionnaire. It is for this reason why empirical researchers avoid and decry its utilization in the measurement of health. Although subjective indexes are in keeping with the WHO’s widened definition of health, their biasness must be understood as challenges for researchers. The discourse on subjective wellbeing, using survey data, cannot be denied that it is based on person’s judgement, and therefore must be prone to systematic and non-systematic biases [19]. In an earlier work, Diener [5] argued that the subjective measure seemed to contain substantial amounts of valid variance; suggesting that this indicated the validity of subjective indexes. Kahneman [20] devised a procedure of integrating and reducing the subjective biases when he found that instantaneous subjective evaluations are more reliable than assessments of recall of experiences. This highlights the biasness therefore that remain in cross-sectional survey that asked people to remember over a long time. Embedded in the aforementioned findings are whether particular subjective indexes that comprised of recall over 2-4 weeks is a good measure for objective indexes of health. Embodied in the literature is the need to carry out empirical research on subjective and objective indexes with emphasis on subjective indexes that are not on instantaneous assessment.

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Using data for Jamaica, the aims of this study are to 1) examine the relationship between particular subjective and objective indexes; 2) investigate the validity of 2-4 week subjective index (self-reported illness over a 4-week period) in measuring objective indexes (ie life expectancy and mortality); 3) evaluate the differences that exist between the measurement of subjective and objective indexes by the sexes; and 4) provide policy makers, other researchers, public health practitioners as well as social workers with research information with which can be used to inform their directions.

Materials and method
The current study utilized secondary published data from the Statistical Institute of Jamaica [21], and the Planning Institute of Jamaica and the Statistical Institute of Jamaica [22]. Life expectancy and mortality were from the Statistical Institute of Jamaica, and self-reported illness from the Planning and Statistical Institutes of Jamaica. Generally, data were for two decades (1989-2007); however, life expectancy data were only available for some of those years. Life expectancy for some years was taken from the Human Development Reports [23]. Data were stored, retrieved and analyzed using SPSS for Windows 16.0 (SPSS Inc; Chicago, IL, USA). Descriptive statistics were used to provide background information on data. Scatter diagrams were employed to establish 1) statistical associations, and 2) linearity and nonlinearity between variables under examination. Multiple regression, using the enter method, was employed to a predictive model of linear associations. Models were built for 1) general life expectancy and self-reported illness of Jamaicans; 2) life expectancy and self-reported illness of the sexes. A 95% confidence interval would be used to examine whether a variable is statistical significant or not. LEp = ƒ (SPI p, ε ) 119 [1]

LEm = ƒ (SPIm, ε ) LEf = ƒ (SPI f, ε )

[2] [3]

Where LEp (life expectancy at birth for the population at a given period) is a function of selfreported illness (SPI p) of population at a given period and some residual error (ε). LEm is life expectancy at birth for males at a given period SPIm is self-reported illness for males at a given period LEf is life expectancy at birth for females at a given period SPIm is self-reported illness for females at a given period Measure Self-reported illness. The percent of people who reported having had an illness/injury in the 4week period of the survey for a given year. Mortality. The number of death of people in Jamaica for a given year. Life expectancy at birth. The average number of years of new-born would live if subject to the mortality patterns of the cross-sectional population at the time of his/her birth. Subjective health is self-evaluated (or assessed) illness of an individual. Objective health. This variable constitutes life expectancy and mortality of a given population at a particular time.

Results
In 1989, life expectancy at birth for the Jamaican population was 72.5 years and this has increased to 73.12 year in 2007 (Table 5.1). Disaggregating population life expectancy at birth revealed that in 1989, a female child was likely to outlive a male-child by 3 years. One and onehalf decades later this difference increased to 6 years. Over the 2 decades, the self-assessed 120

difference in ill status of females increased from 3.5% (in 1989) to 4.7% in 2007. Concurrently, general self-reported illness over a 4-week period declined from 16.8% to 15.5%, with a mean self-reported illness of 12.5% (SD = 2.6%). Mortality declined by 9.2%; with a mean mortality over the 2 decades being 15,829 people (SD = 1,616 people). Life expectancy of population by self-reported illness (for a 4-week period) Assessing illness from a 4-week period, Figure 5.1 found a strong significant association between life expectancy at birth for the Jamaican population and self-reported illness (correlation coefficient, r = -0.731). Fifty-four percent of life expectancy can be accounted for by selfreported illness (R2 = 0.535). Based on Table 5.2, if all other things remain constant (ie not change) which denotes that self-reported illness would be naught, a Jamaican child at birth on average would be expected to live for 75.6 years (95% confidence interval: 73.9, 77.3 years). With every 1% increase in selfreported illness, life expectancy is expected to decline by 0.17 years (ie 2 months). Life expectancy of female child at birth by self-reported illness of females (for a 4-week period) Life expectancy at birth of female Jamaica and self-reported illness of female (assessed based on a 4-week period) are moderately negatively correlated with each other (correlation coefficient, r = - 0.683). Forty-seven percent of the variance in life expectancy at birth of a female child in Jamaica can be explained by 1% change in self-reported illness of females (Figure 5.2). Table 5.2 revealed that if self-reported illness were equals to zero, life expectancy of a female child at birth on average would be 83.3 years (9% % Confidence interval = 75.4, 91.3 years). With every 1% increase in self-reported illness, life expectancy will decline by 0.53 years (or 6 months) (95% confidence interval = -1.031, -0.024 years). 121

Life expectancy of male child at birth by self-reported illness of males (for a 4-week period)

Life expectancy at birth for a male is strongly associated with self-reported illness of males (in %) – correlation coefficient, r = - 0.796. Sixty-three percent of the variance in life expectancy at birth of a male can be explained by self-reported illness (in %) (Figure 5.3). If self-reported illness were zero, average life expectancy of a male child in Jamaica would be 72.7 years (95% Confidence interval = 71.3, 74.1 years) (Table 5.2). With each additional increase in self-reported illness (ie 1%), life expectancy of a male will decline by 0.17 year (2 months) – (95% confidence interval = 0.289, 0.055). Mortality and self-reported illness of population (in %) Based on Figure 5.4 the data for mortality (in number of people) and self-reported illness (in %) is best fitted by a non-linear curve. Concomitantly, when self-reported illness of the population (in %) is less than 11%, the significant statistical correlation between self-reported illness and mortality is a negative one. When self-reported illness lies between 11% and 16%, mortality begins to increase indicating the direct statistical association between both variables. When selfreported illness exceeds 16%, the association between the two variables changed to a negative one.

Limitation
The use of a single variable to explain the objective indexes may create the impression that only one explanatory variable is important. This is a limitation of the study as the researcher wants to examine one independent variable (ie self-reported illness in a 4-week reference period) in order to establish whether it is a good measure of objective indexes and whether differences exist between the sexes. 122

Discussion
Empirical analyses have examined the subjective and objective wellbeing phenomenon, and have provided some platform for a partial resolution of the matter. Using cross-sectional data, researchers established that there was a significant statistical relation between subjective wellbeing (self-reported wellbeing) and objective wellbeing [5, 6, 19]. Diener [5] found a strong correlation between the two variables, which disagreed with Kahneman and Riis [18], who found correlation coefficient between subjective happiness and self-reported health to be strong; but the statistical association between self-reported health and objective health. The current research concurs with both Diener and not Kahneman and Riis in one instance as the correlation between self-reported illness (ie subjective index) and objective health (ie life expectancy) for the population was a strong one, correlation of coefficient, r = 0.731. The evidence here is both that the association is a strong one and that it is negative, suggesting that life expectancy deteriorates with more self-reported illness. This justifies the increase in life expectancy at birth for Jamaicans in 2007 over 1989 as the percentage of self-reported illness declined by 1.3%. However on the other hand, when the objective index is mortality, the statistical association between objective health and self-reported illness (ie subjective index) was very weak. The studies of Diener and Kahneman and Riis assume that the sexes operate in the same manner which means that what applies to the general populace is the same across the sexes. This study did not make that assumption; instead the researcher examined whether there was a disparity between the sexes and if there were any, what these were. This work revealed that strong significant correlation between objective health (ie life expectancy at birth for Jamaicans) and self-reported illness of both sexes differs by male and female. The findings showed that self123

reported illness was more an explanation of life expectancy of males than of females. Interestingly to note that self-reported illness accounted for less than one-half of life expectancy of females but close to two-thirds for males. Kahneman [20] suggested that instantaneous self-assessment of health is a good measure of subjective health unlike self-evaluations that occur over a longer period of time. This study found that self-reported illness over a 4-week period of time is not immediate and is still a good measure of life expectancy; but not mortality. Embedded in this finding is the fact that subjective index can be instantaneous unlike Kahneman’s finding. The current study did not examine beyond a 4-week period and while it was not immediate does not say that we can totally disregard time in recall. The matter may not show any difference for the general population; but this would be different for particular age cohorts – elderly. Evolutionary biology has shown that cells degenerate with ageing, suggesting that functional capacity in particular mental faculties will not on average be as good as in earlier years [24-29]. It is within the context of ageing that Kahneman’s perspective may be even more potent as a 4-week period will not seek challenges in recall for the young or middle age people but this could be so for the aged. Gaspart [30] opined on the difficulty of using objective quality of life in measuring wellbeing and put forward a perspective that self-reported wellbeing should replace this measurement. 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” [30] which speaks to the necessity of using a measure that captures more of the multidimensional construct of health than the traditional income per capita. Wellbeing depends on both the quality and the quantity of life lived by people, which argues more for subjective indexes than objective ones [14]. The current study revealed that self-reported health is a good measure of life 124

expectancy but a poor measure of mortality in Jamaica. Therefore those studies that have used self-rated illness (or health conditions) [31-34] to evaluate health of Jamaicans or particular subgroupings with the population were good in capturing health; but that researchers must be cognizant of the differences that do exist between the validity of particular objective indexes used and self-reported illness as well as the sex disparity in validity of subjective index in measuring health. Self-reported illness therefore is a good measure of health as self-rated health status or life expectancy. But the former is a better measure for health of males than females. Hence, this must be taken into consideration in the interpretation of health. Simply put, using self-reported illness to evaluate health of females is less reliable than of assessing males’ health; and that subjective health (self-reported illness) is a good measure of objective health (life expectancy) in Jamaica.

Conclusion
Life expectancy at birth is widely used to measure quality of life in a country or of a people in particular geographic region. It is among the objective indexes used by some demographers and economists to evaluate health status of people and a population. This study found that selfreported illness in a 4-week reference period is a good measure of objective health (life expectancy at birth for the population of Jamaica). However, self-reported illness is a poor measure of mortality. On disaggregating life expectancy and self-reported illness data by sexes, it was revealed that self-reported illness for males was a better measure for objective health than for females. The literature revealed that subjective indexes of health is a good measure if people are asked to report on their health current and not over any long period of time. The current study disagrees with the literature that for subjective index (ie self-reported illness) to be a good measure of health it must be instantaneous as this work found that subjective index over a 4125

week was a good measure of life expectancy. This does not denote that the period extends beyond 4 weeks; but that 1) self-reported illness is a good measure of objective index (life expectancy); 2) subjective index is a better measure of objective index (life expectancy) for males than females; 3) subjective index is not a good measure for mortality, and 4) self-reported illness can be used to measure health as self-rated health status, happiness, or life satisfaction.

Conflict of interest The author has no conflict of interest to report at this time. References 1. WHO. 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: WHO, 1948. 2. Crisp R. Wellbeing. The Stanford Encyclopedia of Philosophy; 2008. 3. Bok S. Rethinking the WHO definition of health. Harvard Center for Population and Development Studies, Harvard School of Public Health. Working Paper Series 2004; 14(7). 4. Di Tella R, MacCulloch R, Oswald AJ. 1998. The Macroeconomics of Happiness, mimeo, Harvard Business School. 5. Diener E. Subjective well-being. Psychological Bulletin 1984; 95: 542–75. 6. Diener E. Subjective well-being: the science of happiness and a proposal for a national index. Am Psychologist 2000; 55: 34–43. 7. Borghesi S, Vercelli A. Happiness and health: two paradoxes. DEPFID Working papers; 2008. 8. Kashdan TB. The assessment of subjective well-being (issues raised by the Oxford Happiness Questionnaire). Personality and Individual Differences 2004; 36:1225-1232. 9. Blanchflower DG, Oswald AJ. 2004. Well-Being Over Time In Britain And The USA. J of Public Economics 2004; 88:1359-1386. 126

10. Frey BS, Stutzer A. happiness and economics. Princeton University Press: Princeton; 2002. 11. Grossman M. The demand for health – a theoretical and empirical investigation. New York: National Bureau of Economic Research; 1972. 12. 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. 13. Hutchinson G, Simeon DT, Bain BC, Wyatt GE, Tucker MB, LeFranc E. Social and Health determinants of well-being and life satisfaction in Jamaica. Inter J of Social Psychiatry 2004; 50:43-53. 14. Easterlin RA. Income and happiness: towards a unified theory. Economic J 2001; 111:465484. 15. Graham C. Happiness and health: Lessons – A Question – For Public Policy. Health Affairs 2008; 27:72-87. 16. Ringen S. Wellbeing, measurement, and preferences. Scandinavian Sociological Association 1995; 38, 3-15.

17. O’Donnell V, Tait H. Wellbeing of the non-reserves Aboriginal population. Canada Catalogue 2003; 89-589.

Statistics

18. Kahneman D, Riis J. Living, and thinking about it, two perspectives. In: Huppert FA, Kaverne B, Baylis N. The Science of Well-being. Oxford University Press: New York; 2005.

19. Schwarz N, Strack F. Reports of subjective well-being: judgmental processes and their methodological implications. In: Kahneman D, Diener E, Schwarz N, editors. Well-being: The Foundations of Hedonic Psychology. Russell Sage Foundation: New York, 1999: 61-84. 20. Kahneman D. Objective happiness. In: Kahneman D, Diener E, Schwartz N, editors. Wellbeing: Foundations of hedonic psychology. Russell Sage: Foundation, New York; 1999. 21. Statistical Institute of Jamaica, (STATIN). Demographic statistics, 1989-2007. Kingston, STATIN; 1989-2008. 22. Planning Institute of Jamaica, (PIOJ), Statistical Institute of Jamaica, (STATIN). Jamaica Survey of Living Conditions, 1989-2007. Kingston: PIOJ, STATIN; 1989-2008. 23. United Nations Development Programme, (UNDP). Human Development Report 1990-2003. New York: UNDP; 1990-2003. 127

24. Gavrilov LA, Gavrilova NS. The reliability theory of aging and longevity. J. theor. Biol 2001; 213:527-545. 25. Gavrilov LA, Gavrilova NS. The biology of life Span: A Quantitative Approach. New York: Harwood Academic Publisher; 1991. 26. Charlesworth B. Evolution in Age-structured Populations, 2nd ed. Cambridge: Cambridge University Press; 1994 27. Carnes BA, Olshansky JS. Evolutionary perspectives on human senescence. Population Development Review 1993; 19: 793-806. 28. Carnes BA, Olshansky SJ, Gavrilov L A, Gavrilova NS, Grahn D. Human longevity: Nature vs. nurture - fact or fiction. Persp. Biol. Med 1999; 42: 422-441. 29. Medawar PB. Old age and natural death. Mod Q 1946; 2:30-49. 30. Gaspart F. Objective measures of wellbeing and the cooperation production problem. Social Choice and Welfare 1998; 15:95-112. 31. Bourne PA. Childhood Health in Jamaica: changing patterns in health conditions of children 0-14 years. North American Journal of Medical Sciences. 2009;1:160-168. 32. Bourne PA. A theoretical framework of good health status of Jamaicans: using econometric analysis to model good health status over the life course. North American Journal of Medical Sciences. 2009;1: 86-95. 33.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. 34. Bourne PA. (2009). An epidemiological transition of health conditions, and health status of the old-old-to-oldest-old in Jamaica: a comparative analysis. North American Journal of Medical Sciences. 2009;1:211-219.

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Table 5.1. Life expectancy at birth for the sexes, self-reported illness, and mortality, 1989-2007 Year Life expectancy at birth (e0) Ill-health (in %) Mortality Male Female Total Male Female Total 1989 69.97 72.64 72.5 15.0 18.5 16.8 16400 1990 69.97 72.64 72.5 16.3 20.3 18.3 14900 1991 69.97 72.64 72.5 12.1 15.0 13.7 13300 a 1992 73.6 9.9 11.3 10.6 13200 1993 73.7a 10.4 13.5 12.0 13900 1994 11.6 14.3 12.9 13500 a 1995 74.1 8.3 11.3 9.8 15400 1996 9.7 11.8 10.7 15800 1997 8.5 10.9 9.7 15100 1998 75.0a 7.4 10.1 8.8 17000 1999 70.94 75.58 73.25 8.1 12.2 10.1 18200 2000 70.94 75.58 73.25 12.4 16.8 14.2 17400 2001 70.94 75.58 73.25 10.8 15.9 13.4 17800 2002 71.26 77.07 74.13 10.4 14.6 12.6 17000 2003 71.26 77.07 74.13 NI NI NI 16900 2004 71.26 77.07 74.13 8.9 13.6 11.4 16300 2005 73.33 NI NI NI 17000 2006 73.24 10.3 14.1 12.2 16400 2007 73.12 13.1 17.8 15.5 14900
a

These were taken from the United Nations Development Programme

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Table 5.2. Life expectancy at birth of population and sex of children by self-reported illness Explanatory variable Coefficient Std. Error Beta t-statistic P 95% CI

Population Constant Self-reported illness

75.604 -0.173

0.738 0.054

-0.731

102.425 -3.217

< 0.001 0.011

73.934, 77.274 -0.295, -0.051

F statistic [1, 9] = 10.350, P = 0.011 R = - 0.731 R2 = 0.535

Female children Constant Self-reported illness

83.363 -0.528

3.375 0.213

-0.684

24.700 -2.478

< 0.001 0.042

75.382, 91.344 -1.031, -0.024

F statistic [1, 7] = 6.138, P = 0.042 R = - 0.684 R2 = 0.467

Male children Constant Self-reported illness

72.718 -0.172

0.587 0.050

-0.796

123.840 -3.478

< 0.001 < 0.010

71.330, 74.107 -0.289, -0.055

F statistic [1, 7] = 12.096, P = 0.010 R = - 0.796 R2 = 0.633

130

74.50

Life expectancy at birth: both sex (in years)

74.00

73.50

73.00

R Sq Linear = 0.535 72.50 8.00 10.00 12.00 14.00 16.00 18.00 20.00

Illness/Injury (in %)

Figure 5.1. Life expectancy at birth for the population by self-reported illness (in %). Life expectancy at birth of Jamaicans and self-reported illness (assessed based on a 4-week period) are strongly negatively correlated with each other (correlation coefficient, r = - 0.731). Fifty-four percent of the variance in life expectancy at birth for the population of Jamaica can be explained by 1% change in selfreported illness.

131

78.00

Life expectancy: female (at birth in years)

77.00

76.00

75.00

74.00

73.00
R Sq Linear = 0.467

72.00 12.00 14.00 16.00 18.00 20.00 22.00

Self-reported Health of female (in %)

Figure 5.2. Life expectancy at birth for female by self-reported illness of female (in %). There is a negative moderate correlation between life expectancy at birth of a female and self-reported illness of female (in %) – correlation coefficient = 0.683. Forty-seven percent of the variance in life expectancy at birth of a female can be accounted for by 1% change in self-reported illness females (in %).

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Life expectancy: male (at birth in years)

71.25

71.00

70.75

70.50

70.25

R Sq Linear = 0.633

70.00

8.00

10.00

12.00

14.00

16.00

18.00

Self-reported Health of male (in %)

Figure 5.3. Life expectancy at birth for male by self-reported illness of male (in %).

There is a strong negative significant statistical correlation between life expectancy at birth of a male and self-reported illness of male (in %) - correlation coefficient, r = - 0.796. Sixty-three percent of the variance in life expectancy at birth of a male can be explained by self-reported illness (in %).

133

19000.00

18000.00

Mortality (in No. of people)

17000.00

16000.00

15000.00

14000.00
R Sq Cubic =0.106

13000.00 8.00 10.00 12.00 14.00 16.00 18.00 20.00

Illness/Injury (in %)

Figure 5.4. Mortality (in No of people) and self-reported illness/injury (in %)

Based on Figure 1 the data for mortality (in number of people) and self-reported illness (in %) is best fitted by a non-linear curve. Concomitantly, when self-reported illness of the population (in %) is less than 11%, the significant statistical correlation between self-reported illness and mortality is a negative one. When self-reported illness lies between 11% and 16%, mortality begins to increase indicating the direct statistical association between both variables. When self-reported illness exceeds 16%, the association between the two variables changes to a negative one.

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Chapter Six

Modelling social determinants of self-evaluated health of poor older people in a middle-income developing nation
Paul A. Bourne

INTRODUCTION

Factors determining the poor health status of the elderly in Jamaica can be viewed from the perspective of a socio-medical dichotomy. Such factors include poverty (resulting in one’s inability to access loans, quality education and health care), lifestyle (e.g. smoking, sedentary habits, sexual and dietary practices and physical inactivity), resulting in prostate cancer, genitourinary disorders, hypertension, diabetes mellitus and premature death. In 2005, the World Health Organization began a thrust in examining the social determinants of health, and despite that reality there is a lack of literature in this regard on the elderly poor people in Jamaica. These parameters were explored in the current research by using a sample of 1,149 elderly poor Jamaicans. The findings of this paper reveal that the cost of medical care is positively correlated with health conditions, and that economic constraints account for the decline in the elderly seeking medical care. Older people in Jamaica do not purchase health insurance coverage as a preventative measure but as a curative measure. Health insurance coverage in this study does not indicate good health, but on the contrary, it is a proxy of poor health status. It is also noted that income is positively correlated with a higher standard of living and life expectancy. In support of 135

this claim, studies have shown that life expectancy in many developing countries [1], in particular the Caribbean (Barbados, Guadeloupe, Jamaica, Martinique, Trinidad and Tobago) has exceeded 70 years, and they are now experiencing between 8-10% of their population living to 60+ years old. Life expectancy, which is a good indicator of the health status of a populace, is higher in countries with high GDP per capita. This means that income is able to purchase better quality products [2], and indirectly affects the length of years lived by people. GDP per capita is used as an objective valuation of standard of living [3-12]. While a country’s GDP per capita may be low, 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 people, as well as the level of females’ educational attainment [6] and the nutrition intake of the poor. On the other hand, when there is economic growth, the society has more to spend on nutrition, health care, better physical milieu, better quality food, safer sanitation and education. Good health is, therefore, linked to economic growth, something which is established in a plethora of studies by economists. Developing countries (a term synonymous with poverty) do not only constitute low levels of democracy, civil unrest, corruption [13], high mortality and crude birth rates, but one must also include nutritional deficiency [14]. The WHO in 1998 put forward the position that 20% of the population in developing countries do not have access to enough food to meet their basic needs and provide vital nutrients for survival. In the Caribbean, and in particular Jamaica, poverty is typical, and many of the ills that affect other developing nations outside of this region are the same. The poor in this society are facing insurmountable challenges in buying the necessary health care. In 2007, between 51 and 53% of those in the poor quintiles in Jamaica sought medical care, compared to 61-68 % of those 136

in the middle-to-wealthiest quintiles. When those who had reported that they were ill were asked why they had not sought medical care, 51% of those in the poorest quintile indicated that they ‘could not afford it’, with 36.7% of those in the poor quintile giving the same response, and the percentage declines as the wealth of the person increases to the wealthiest quintile (7.7% of those in the wealthiest quintile). Over the last 2 decades (1988-2007), poverty in Jamaica has fallen by 67.5% and this is in the context of a 194.7% increase in inflation for 2007 over 2006. Jamaicans are reporting more health status in a 4-week period (15.5% in 2007) and at the same time this is associated with a decline in the percentage of people seeking medical care. Older people’s health status is of increasing concern, given the high rates of prostate cancer, genitourinary disorders, hypertension, diabetes mellitus and the presence of risk factors such as smoking in earlier life. Yet, there is a dearth of studies on the health status of older people in the two poor quintiles. Works which have examined the social determinants of health have used data for the population [2,3], but none emerged from a literature research using data for poor old people. This study examined (1) the health status of those elderly Jamaicans who were in the two poor quintiles, and (2) factors that are associated with their health status.

M ATERIALS AND M ETHODS
Sample A sample of 1,149 elderly respondents was extracted from a larger survey of 25,018 Jamaicans. The sample was based on being 60+ years old, and being classified in the two poorest income categorizations. The initial survey sample (n = 25, 018) was across the 14 parishes, and was 137

conducted between June and October 2002. The sample (n=25,018 or 6,976 households out of a planned 9,656 households) was drawn using a stratified random sampling technique. 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 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 PSUs, a listing of all the dwellings was made, and this became the sampling frame from which a Master Sample of dwellings was compiled, and which provided the frame for the labour force. The survey adopted was the same design as that of the labour force, and it was weighted to represent the population of the country. The survey was a joint collaboration between the Planning Institute of Jamaica and the Statistical Institute of Jamaica. The data were collected by a comprehensive administered questionnaire, which was primarily completed by heads of households for all household members. The questionnaire was adapted 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, to reflect policy impacts as well. The instrument assessed: (i) the 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 questions.

138

Data were stored and retrieved in SPSS for Windows, version 16.0 (SPSS Inc; Chicago, IL, USA). The current study is explanatory in nature. Descriptive statistics were presented 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 the statistical association between some variables, t-test statistics and analysis of variance (i.e. ANOVA) were also used 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). The logistic regression was used because in order to test the association between a single dichotomous dependent variable and a number of explanatory factors simultaneously, it was the best available technique. A p-value < 0.05 (two-tailed) was selected to indicate statistical significance in this study. 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. To derive accurate tests of statistical significance, SUDDAN statistical software was used (Research Triangle Institute, Research Triangle Park, NC), and this was adjusted for the survey’s complex sampling design. Measure Social determinants. These denote the conditions under which people are born, grow, live, work and age, including the health system. Crowding. This is the total number of persons living in a room with a particular household. ℎ Crowding = ∑𝑛𝑛=1 𝑖𝑖 , where ℎ𝑖𝑖 is each person in the household and r is the number of rooms 𝑖𝑖 𝑟𝑟 excluding kitchen, bathroom and verandah. Age: This is a continuous variable in years, ranging from 15 to 99 years. 139

Old/Aged/Elderly. An individual who has celebrated his/her 60th birthday or beyond. Negative Affective Psychological Condition: Number of responses from a person on having lost a breadwinner and/or family member, loss of property, having been 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 for self-reported ownership of private health insurance coverage, and 0 for not reporting ownership of private health insurance coverage. Gender: Gender is a social construct which speaks to the roles that males and females perform in a society. This variable is a dummy variable, 1 if male and 0 if otherwise.

Health conditions: The report of having had an ailment, injury or illness in the last four weeks, which was the survey period. This variable is a binary measure, where 1=self-reported health status or illnesses, and 0=otherwise (not reporting an illness, injured or dysfunctions). Poverty: In this study, the definition of poverty is the same as that used to estimate poverty in Jamaica. It is established from the basis of a poverty line. In order to compute the per capita poverty line in each geographical area (Kingston Metropolitan Area, Other Towns and Rural Areas), the cost of living for a basket of goods is divided by an average family of five. The basket of goods is established by the Ministry of Health based on the normal nutrients of the average family. Based on a per capita approach, there are five per capita income quintiles, with the poorest being below the poverty line (quintile 1) and the wealthiest being in quintile 5.

140

Elderly, Aged or Old persons. Using the same definition offered by the United Nations in the Report of the World Assembly on Ageing, July 26-August 6, 1982 in Vienna, that the elderly are persons who are 60+ years old. Older-poor (elderly-poor, aged-poor). All aged persons below and just above the poverty line (quintiles 1 & 2) in Jamaica.

RESULTS
Demographic characteristics of sample Consistent with the demographic characteristics of the ageing population, the sample was 1,149 of which there were 45% males (N=517) compared to 55% females (N=632). The mean age of the sample was 72.6 years (SD=8.7 years). Most of the sample were married (40%, N=452), 50.5% (N=580) of the sample were in the poorest 20% of per capita income quintile, 95% (N=1,087) were not receiving retirement income; those who were heads of households (98.3%, N=1,129), those who had at most primary education (65.2%, N=700) and those who did not have health insurance coverage (86.0%, N=973) (Table 6.1 ). Thirty-seven percent (37.2%) of the sample indicated having had an illness in the last 4week period. Approximately 64% of the respondents indicated that they sought health care for their health conditions. When the respondents were asked if they had visited a health practitioner for any other reason during the last 12 months, 57.1% reported yes and 30.3% reported going for ‘regular checkups’. Of those who indicated yes, 37.2% visited public health care institutions, and 18.7% went to private clinics, compared to 5.7% who claimed that they attended both health care facilities. The typologies of illness included colds (1.4%), diabetes mellitus (5.7%), hypertension 141

(42.9%) and arthritis (31.4%), while 18.6% did not specify their health condition(s). Only 2% of the respondents had health insurance coverage; 61% purchased the prescribed medication; and 81.8% of those who indicated having not bought their medication reported that they could not afford it. The median number of days for how long an illness lasted was 7 days, with a median medical expenditure of US $7.85 (US $1.00 = Ja. $50.97). Bivariate Correlation of Health Status and Age Cohort

Of the 1,149 sample respondents for this study, 98.8% (N=1,135) were used for the statistical correlation between health status and gender. Of the 1,135 respondents, there were 688 youngold, 327 old-old and 120 oldest-old poor Jamaicans. There was a correlation between the two above-mentioned variables – χ2 (df=2) = 22.863, p-value < 0.001. On an average, 46% of the aged-poor (N=523) reported that they had at least one illness/injury in the survey period. The most health status was reported by the oldest-old poor (59.2%, N=71), 52.9% (N=173) and the least by the young-old (40.6%, N=279). Embedded in these findings is that for every 1 youngold poor who indicated that he/she had an illness/injury, there are 1.5 oldest-old and 1.3 old-old poor.

Multivariate Analysis

The results of the multiple logistic regression model (in Table 6.2), were statistically significant [Model χ2 (df=18) = 229.47; -2Log likelihood = 1130.37; p-value < 0.001]. Table 6.2 showed that 26.6% of the variances in the health status of older people in Jamaica were accounted for by 142

the independent variables used in the multiple logistic regressions. The mold revealed that there were 6 statistically significant factors that determined health conditions. These predictors are age (OR=1.04, 95% CI=1.02-1.06), health insurance coverage (OR=13.90, 95% CI=7.98-24.19), physical environment (OR=1.42, 95% CI=1.06-1.89), cost of medical care (OR=1.00, 95% CI=1.00-1.00), secondary level education (OR=1.82, 95% CI=1.35-2.45) with reference to primary and below education, and gender of respondents (OR=0.56, 95% CI=0.42-0.75). Controlling for the effect of other variables, the average likelihood of reporting illness/injury in a 4-week reference period declined by 17 times for those who had dysfunctions. The model had statistically significant predictor power (Model χ2 (df=18) = 229.47; Homer and Lemeshow goodness of fit χ2= 3.739, P=0.880), and correctly classified 70% of the sample (correctly classified 55.4% of those with dysfunctions and 82.3% of those without dysfunctions) (Table 6.2). The logistic regression model can be written as: Log (probability of dysfunctions/probability of not reporting dysfunctions) = -4.185 + 0.039 (Age) + 2.632 (Health Insurance coverage, 1= yes, 0=no) + 0.348 (Physical Environment, 1=yes, 0=no) + 0.000 (Cost of Medical Care) + 0.598 (Secondary level education=1, 0=primary and below) – 0.581 (Sex).

DISCUSSION

People are living longer [15], which means that on average the elderly are living 15-20 years after retirement. Demographic ageing at the micro and macro levels implies a demand for certain services such as geriatric care. In addition to preventative care, there will be a need for particular equipment and products (i.e. wheelchairs, walkers etc.). Then there are future preparations for pension and labour force changes, along with the social and economic costs associated with 143

ageing, as well as the policy based research to better plan for the reality of these age groups. The World Health Organization (WHO), in explaining the ‘problems’ that are likely to occur because of population ageing, argues that the 21st Century will not be easy for policy makers as it is pivotal in the preparation process to postpone ailments and disabilities, and the challenge of providing a particular standard of health for the populace [16]. What constitutes population ageing? Some demographers have put forward the benchmark of 8-10% as an indicator of population ageing [17]. Within the construct of Gavrilov and Heuveline’s perspective, the Jamaican population began experiencing this significant population ageing as of 1975 (using 60+ years for ageing) or 2001 (if ageing is 65+ years). The issue of population ageing will double come 2050, irrespective of the chronological definition of ageing, but what about the elderly poor health conditions? Let us examine the disparity between long life and quality of lived years. Ali, Christian & Chung [18] who are medical doctors, cite the case of a 74 year-old man who had epilepsy, and presented the findings in the West Indian Medical Journal. They write that “Elderly patients are frequently afflicted with paroxysmal impairments of consciousness, because they frequently have chronic medical disorders such as diabetes mellitus and hypertension, and can also be on many medications….Many elderly patients may have more than one cause for this symptom” [18]. The case presented by the medical doctors emphasizes the point we have been arguing that long life does not imply quality of lived years. Although the case study cited here does not constitute a general perspective on all the elderly, other quantitative studies have concurred with Ali, Christian and Chung’s general findings. Scientists agree that biological ageing means 144

degeneration of the human body, and such a reality means that longer life will not mean quality years. Population ageing is going to be a socioeconomic, psychological and political challenge today, tomorrow and in the future of developing countries and nations like Jamaica. This reinforces the position postulated by the WHO that healthy life expectancy [19] is where we ought to be going, as the new thrust is not living longer but how many of those years are lived without dysfunctions. Within the context of healthy life expectancy, studies that will be used to guide policy are those that incorporate many determinants, and not only biological conditions [20-25]. But none of those studies examined poor old people. Hambleton [20] and Bourne [2325] are Caribbean scholars who have researched social determinants using the population of the poor, and this gap to date in the literature needs to be addressed, as the elderly constitute a vulnerable group, and the poor elderly group is even more vulnerable. Any policy which seeks to reduce poverty must take into account the poor elderly. ‘Ageing in poverty’ implies that persons remain in their local environments with the ability to live in their own home - wherever that might be - for as long as confidently and comfortably possible. It inherently includes not having to move from one's current residence in order to secure the necessary support services in response to changing needs. The ageing of Caribbean populations has been accompanied by a shift to chronic non-communicable diseases as major causes of morbidity. While overall national trends have been reported, examination of local patterns of morbidity are increasingly important, as they have implications for the services to be provided, the mix of human resources, and the maintenance of health and functional status that facilitate ageing in place.

145

Research has shown that crowding is strongly correlated with the wellbeing of the elderly (ages 60+ years) [23]; however this phenomenon, which is synonymous with poverty, does not influence the health status of poor elderly Jamaicans. Embedded in this finding is the fact that older people, in particular those in poor quintiles, interpret people around not as a negative force but as good social networking and interaction. What, then, influences their health conditions? Poverty speaks to a particular environment; Pacione [26] showed that one’s physical environment affects one’s quality of life, and other scholars have agreed with this finding. The current study concurs with Pacione and others, in that the physical milieu is positively correlated with health conditions. Although Michael Pacione’s work was on the general population, Bourne’s works [23, 24] examined the elderly population (ages 60+ years) and found a negative association between physical environment and wellbeing, and this study concurred with that of the aforementioned researcher on the correlation between physical environment and health conditions. In this study, an important finding is to refine the correlation. Health insurance coverage is among the many indicators of the health-seeking behaviour of a populace. For the poor elderly, it is the most significant predictor of health conditions. The correlation is a strong positive one, indicating that health insurance coverage is a good proxy for more ill-health than good health. The current research found that those elderly poor who owned health insurance were 14 times more likely to report dysfunctions (or injuries) than those who did not. Health insurance is, therefore, a cost reducer for those who are aware that they are ill, and it is not in demand as a preventative measure. Arising from this fact is the role played by the costs of medical and curative care. Health is influenced by more than disease-causing pathogens. [27] 146

The cost of medical care is positively correlated with health conditions, suggesting that the more dysfunctions (or injuries) that the elderly poor report, the more they are likely to spend on medical care. The elderly poor are prevented from seeking preventative care as against curative care. The latest data published by the Planning Institute of Jamaica and the Statistical Institute of Jamaica[28] showed that 37.3% of elderly people are at least poor, with 20.6% falling in the poorest quintile. This further explains the rationale for the reduction in the demand for medical care within the context of a precipitous increase in inflation in 2007 over 2006 (194%). With the steady rise in the cost of health care, as well as the increase in general food and nonalcoholic beverage prices in Jamaica, coupled with the fact that illness in older age requires care, the elderly poor are facing increasingly difficult times. The severity of the economic situation has seen a dramatic increase in the number of Jamaicans not seeking medical care for illness/injury. Although there is a decline in the general population seeking medical care (66%), more of the elderly do seek health care (72.3%) and this is owing to recurrent chronic illness which was shown to affect 74.2% of them28. Illnesses/injuries are precipitously affecting the elderly, and the data showed that self-reported illness for the elderly was 2.3 times more (36.6%) than in the general population (15.5%) [28]. In 2007, the elderly poor who constitute 38% of the poor-to-poorest in the population are mostly household heads (67.3%) and often unemployed, and within this context they must provide for their own health needs and those of their family, despite the harsh economic challenges and increased cost of health care. In 2002, 12.9% of Jamaicans were unable to afford medical care, and approximately 4 years later, the figure had risen by 162.8% to 33.9% in 2007. This is within the context of a 26.3% decline in poverty for the same period. Generally poverty has been falling over the last 2 decades in Jamaica, and inflation has fluctuated, justifying the increased amount spent on food 147

and beverages [28], and the corresponding reduction in health care expenditure. In Jamaica remittances, which subsidize income for many households, have fallen by 7.7% and the reduction is 33% for those in the poor-to-the-poorest income quintiles. If the cost of medical care is positively correlated with the health status of the elderly poor, then can it be said that the poor elderly have more ill-health within the context of biological ageing and lowered access to employment income? Marmot [2] opined that there is a direct association between income and poor health, and this further helps us to understand the embedded health challenge of the elderly poor, as they must meet the increasing costs of medical care, cost of living, lower income, illnesses and severity of health conditions. On examining the health statistics for 2007 [28], the indication was that 50.8% of those in the poorest income quintile were unable to afford to seek medical care, and the figure was 36.7% of those in the poor quintile. In order to understand the severity of the situation regarding the aged-poor people in Jamaica, let us analyze the aforementioned within the context of the aged-poor. The official statistical publication for Jamaica for 2007 [28] showed that 20.6% percent of the elderly people are in the poorest quintile and 17.7% in the poor quintile which means that a little over half of the aged-poorest in Jamaica (10.4%) were unable to afford medical care, and 6.5% of the aged-poor had financial difficulty affording medical care expenditure. One of the choices that must be made by the aged-poor in Jamaica is a switch from the formal medical care service to utilizing home remedies and overthe-counter medications, instead of visiting their personal physicians or health care facilities. Since 1988 when the Jamaican authorities began collecting data on self-reported health conditions, men have been reporting less health status than women [28]. The reporting of less illness does not mean that men are healthier than women, as the same statistical report [28] shows that women seek more medical care than men. Morbidity data for the sexes in Jamaica is 148

typical, as in Mexico City, Havana and Santiago-Chile at least 60% of females compared to 50% of males aged 60+ years old reported fair-to-poor health [29]. Continuing, Buenos Aires, Montevideo and Bridgetown-Barbados had twice the figures of the aforementioned geo-political zones [29]. This is in keeping with women’s protective role of self, and their willingness to have a regard for their future health status accounts for a higher health status and not a lower one, although they report more dysfunctions than men. If life expectancy were to be used to proxy good health status, females are healthier than men given that they outlive them by 6 years in Jamaica and 8 years in the world. Furthermore, in 2000-2005, life expectancy for men was 69.5 years and 74.7 years for women, and come 2045-2050 they both would have gained an additional 2 and one-quarter years more to their life span. The equal and constant rate of change in the life expectancy of both sexes in Jamaica highlights the fact that men do not enjoy better overall health status than their female counterparts. More years of life for both sexes means that the life course opens itself to coronary heart disease, stroke and diabetes mellitus, and so morbidity must be examined in this discourse. Studies done by the Ministry of Health reveal that of the five leading causes of mortality in Jamaica, which are malignant neoplasm, heart disease, diabetes mellitus, homicide and cerebrovascular diseases [30], more men die from more of the aforementioned conditions than women. Malignant neoplasms are 39% greater for men than women; cerebrovascular diseases are 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% more for females than males [30]. The greater vulnerability of men to particular mortality than women is typical across Latin America and the Caribbean [29], pointing to gender bias (that is feminization) in visits to health care facilities, which are embedded in the life expectancy rates and visits to health care institutions. 149

The matter of reporting less health status, once again, does not imply a healthier person, as health is not on a continuum, with ill-health on one extreme and good health on the other. Health is more in keeping with cyclical flow, and changes over the life course with time, experiences and socio-physical environmental conditions. Hence, asking about ill-health is not a good proxy for health status, as in 2007 a group of Caribbean scholars conducted a national representative prevalence survey of some 1,338 Jamaicans, and found that those who indicated themselves to be of the lower class had the least self-reported health status [13]. The discipline of gerontology – scientific inquiry into the biological, psychological, and social aspects of ageing - has shown that ageing is not necessarily without increased health conditions; it is natural for aged people to complain and die more of dysfunctions than other age cohorts [31, 32] and that is directly related to their basal metabolic rate [33] and the nature of the life course of the aged [34]. Here functional ageing is an explanation for the image of ageing, and it can be measured by normal physical changes, diminished short-term memory, reduced skin elasticity and a decline in aerobic capacity. It is well established in the research literature that age is directly correlated with health status for the elderly, and in this study the finding concurs with the literature. The current research shows that age is the second most significant predictor of health status for the elderly poor, and explains why the disparity in poor health in Latin and America and the Caribbean is higher for older persons than younger people [29]. Population ageing is synonymous with more disability and more non-communicable diseases such as malignant neoplasms, hypertension, diabetes, and heart diseases than younger ages. Donald Bogue [35] noted that health problems increase with ageing, and that one’s health issues intensify with ageing. Therefore, an unhealthy lifestyle – tobacco consumption, physical inactivity, unprotected sex, and unhealthy diet - over the life course will affect the elderly in 150

latter life, and the declining health of the elderly poor is the same within the sub-categories of the elderly – young-old, old-old and oldest old. Issues of the elderly cannot be discussed without an examination of area of residence. This study found no correlation between the aged-poor’s health status and area of residence. Using data since 1989 (from various issues of the Jamaica Survey of Living Conditions), population ageing is biased by gender as well as by specific area of residence. Over the last decade (1997-2007), the number of elderly Jamaicans living in rural areas has declined from 54.3% to 46.6% (a rate of 14.1%). For the same period, the rate of increase of the aged populace in the Kingston Metropolitan Area (100% cities) was 19.5%, down from 27.2% (in 1997) while the increase in the aged population over the same period in Other Towns was 12.9% over 18.5% in 1997. Regarding the prevalence of poverty for the region (2007), rural poverty was 3.8 times more than that in Other Towns, and 2.5 times more than that in the Kingston Metropolitan Area. Despite the compounding economic challenges of poverty coupled with ageing, the poor-elderly in Jamaica do not experience a difference in their health status owing to area of residence. Here the health issues of the aged poor are independent of their area of residence, suggesting that in the population the poor are age-residence insensitive. This contradicts research literature on the health status of the elderly which has shown a correlation between the aged and their areas of residence [23,24,48], indicating that the physical characteristics of the aged poor are the same in different areas of residence, and therefore do not account for any poor health, disability, functional inability or psychological conditions. Like the WHO [36], the researcher believes that although ageing is a biological phenomenon, it cannot be due only to biological conditions, as ageing relates to bio-psycho151

social [20, 25, 37-49] and environmental conditions [23-26], since people – biological organisms – must operate in a socio-physical milieu throughout their life span, and this demands an expansion of biological conditions in the ageing discourse. The very nature of gerontology must coalesce biopsychosocial and environmental conditions in assessing ageing and the health of the aged, which are in keeping with the WHO’s Constitution of 1948, and this has also been established in many Caribbean scholarships [20,23-25,42-49]. Within the context of the abovementioned challenges for elderly people, when this is coupled with poverty which affects 10.2% of elderly Jamaicans (N=29,794) in 2007, it intensifies the challenges experienced by elderly people. With the increased cost of food and non-alcoholic beverages, fuel and household supplies, housing and household operational expenses, the health status of the older-poor will continue to deteriorate, as they will not be able to afford health care services. The decline in medical care-seeking behaviour of Jamaicans speaks to the challenges of older people and the rise in instances of switching to alternative medicine. This is further intensified by poverty; and rural poverty, which is more severe than that found in urban areas [50], will further compound the challenges of the health status of the aged populace. Older people who are poor must operate within the same biopsychosocial and physical environment during their lifetimes as other persons. Even among the WHO commissioned studies [51-53], as well as other studies on the social determinants of health [2,3, 20-25], the population of the poor elderly were not examined. Likewise in the Caribbean, scholars have examined the social determinants of the population or the elderly population, with poverty being an independent variable [20, 23-25]. Any policy that seeks to address the health status of the elderly poor must take into consideration, or concentrate and/or rely on, not only the population in general, but the cohort of the elderly in particular. The 152

experiences and demands of the elderly are not the same as the general population, and the current study shows that social determinants of health are somewhat different for the general elderly population and the poor elderly cohort. The WHO [51] opined that the social determinants of health for the most part account for the health inequities between and within nations, which substantiates the differences that emerged between the elderly in other studies [20, 23-24] and the current study of the poor elderly. These findings are far-reaching, and can be used to guide policy and research. The elderly-poor in Jamaica are experiencing ‘health poverty’ which cannot be alleviated by unresearched policies or research policies on the general population, but by the elderly cohorts in particular.

Conclusion
In summary, the number of elderly persons who reported health conditions in Jamaica is 3 times more than that for the nation (i.e. 12.6%), suggesting that health care expenditure for Jamaicans is substantially used to address health care needs for the aged population. With the number of elderly come 2025 estimated to be 14.5% over 10.9% for 2007, health care expenditure will be primarily absorbed in caring for this age cohort. Public health practitioners must begin programmes to deal with this pending reality. Ageing is a process which denotes that the high number of health conditions affecting the elderly would have started earlier, based on some of the decisions that they undertook (or did not) leading up to their current age. Hence, there is a need to have a public health campaign geared towards the promotion of healthy lifestyle practices for ages close to sixty years, in conjunction with one for children and for the working-age population. The programme should target check-ups, preventative care, signs of the onset of particular health conditions, and the distinction between ill health and good health care 153

practices. The demand of the health services in Jamaica in the future must be geared towards a particular age cohort and certain health conditions, and not only to the general population, as the social determinants which give rise to inequities are not the same even among the same age cohort.

Disclosure
The author reports no conflict of interest for this study.

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 dataset for this study was made available from the databank of SALISES (Sir Arthur Lewis Economic Institute), Faculty of Social Sciences, the University of the West Indies, Mona, Jamaica and for this the researcher is indebted and greater appreciate this gesture.

The current article was published in J Biomedical Sci and Engineering, 2010;3: 700-710.

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Table 6.1: Socio-demographic characteristics of sample Description Gender Male Female Marital status Married Never married Divorced Separated Widowed Per capita Income quintile Poorest Poor Retirement Income No Yes Household head No Yes Health Insurance coverage No Yes Educational Level Primary and below Secondary Tertiary Age Total Medical Care Expenditure Per capita consumption US $1.00 = JA$50.97 N Percent

517 632

45.0 55.0

452 357 10 22 290

40.0 31.6 0.9 1.9 25.6

580 569

50.5 49.5

1087 57

95.0 5.0

20 1129

1.7 98.3

973 158

86.0 14.0

700 363 10 72.63 years (SD=8.7 years) $1,067.64 (SD=$2,000.00) $30,998.07 (SD=$9,833.00)

65.2 33.8 0.9

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Table 6.2: Logistic Regression: Socio-demographic correlates of health status of poor older people in Jamaica, N=1,033 OR 95.0% C.I. Variable Age 1.04 1.02 - 1.06*** Retirement income 0.75 0.38 - 1.49 Per capita consumption 1.00 1.00 - 1.02 Separated, divorced or widowed Married Never married (reference group) Health insurance Environment Household head Cost of medical care Secondary Tertiary Primary and below (reference group) Semi-urban Urban areas Rural areas (reference group) Sex Living arrangement Crowding Crime index Positive affective
Model Chi-square (df =18) = 229.47, p-value < 0.0001 -2Log likelihood = 1130.37; Nagelkerke R-square = 0.266 Hosmer and Lemeshow test P = 0.880 *P < 0.05, **P < 0.01, ***P < 0.001

1.07 1.11 1.00 13.90 1.42 3.34 1.00 1.82 0.43 1.00 0.78 0.86 1.00 0.56 1.20 0.89 1.00 0.96

0.74 - 1.55 0.77 - 1.58

7.98 - 24.19*** 1.06 - 1.89* 0.37 - 30.01 1.00 - 1.05** 1.35 - 2.45*** 0.07 - 2.63

0.51 - 1.19 0.50 - 1.49

0.42 - .75*** 0.77 - 1.88 0.78 - 1.02 0.98 - 1.03 0.90 - 1.01

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Chapter Seven

Men’s health in Jamaica: Those in the wealthy social hierarchies
Paul A. Bourne

Introduction Masculinity is one of the focal tenets in any discussion on the Caribbean male and/or manhood [1-3]. In the Caribbean, and in particular Jamaica, men are culturalized to be emotionless, strong, fierce, and brave [4]. This suggests that they are socialized to interpret actions and behaviour within this masculine framework. It is this cosmology that explains the rationale behind the abstinence of Caribbean males from health-care service centres, and their unwillingness to report illnesses and/or some dysfunctions such as eating disorder, depression, have a prostate examination and intermittent general medical examination to name a few issues. In Caribbean societies, illnesses indicate unwellness and this is a proxy of weakness which goes contrary to a masculine image. It is within this context that Caribbean men abscond from attending health centres, seek preventative care and view ill-health as an erosion of masculinity. Females seek more health care than males, which can be measured using health care utilisation [5]. Are Caribbean men atypical or typical? And, how does the wealthiest two quintiles of men fair within this general context? In a study conducted in Nairobi slum, Taffa & Chepngeno [6] found that parents sought more health-care for their male children than for the females, suggesting that health-care seeking behaviour has gender biases that are due to socialization. Unlike Nairobi, Pakistan and India where emphasis is place on the men [6, 7] which account for the parents investing more in the males than the females’ health status, outside 160

of those geopolitical spaces health-care seeking behaviour is substantially a female phenomenon. The Editor of International Society for Men’s Health and Gender in an editorial titled ‘More evidence why sex and gender matter: aspirin and metabolic syndrome’ advocated that women are more likely to use self-examination as the first measure of health-care seeking behaviour than men [8], which aids in the understanding of them having a higher contact with health professionals than men. In a study of eating disorder in the United States, the researchers found that this dysfunction is construed as female phenomenon [9,10,11; and so men reported the difficulty in soliciting assistance from family, friends and other agents of socialization about this matter. This reality also help to explains the high detection for illnesses and the earlier curative measure that they receive – as they use preventative as against curative care [12,13,14] which justifies the greater probability of them surviving than men as detection the dysfunctions are found at an earlier than at a later stage [15]. This suggest the gender disparity in lifestyle practices, preventative care and intervention that result from females’ willingness to take advantage of the opportunity to protect them compared to their male counterparts helps to explain the health differential. Haslam [16] encapsulated in aptly in statement that read “women care a great deal, very few men car at all” about their health. The irony is men do care, but this concern is about their body-image [17, 18] more than about health as body-image accommodates self-concept [16]. Hence, they will become more involved in activities that enhance their masculinity, confidence and attractiveness [9, 16, 17]. In regard to their health, this is left unattended to except those men who are married or common-law unions. Whereas the women are concerned about nutrition, preventative health-care, good lifestyle practices, eating behaviour, and knowledge on nutritional awareness [19] which accounts for the lower percentage 161

of men seeking assistance from health practitioners compared to their female counterparts [2024]. Literatures, on the other hand, have advocated that the average time for men to seek healthcare on the onset of an illness was 5.3 years, and this was found to be no different for women [9, 25]. A research carried out by a group of economists [26] revealed that “…women are slightly more likely to report higher levels of life satisfaction than men (mean=78.3, compared with 77.1 for men…” [26]. Based on the nature of the study, ‘…subjective wellbeing and ill being’, the reported wellbeing (measure by life satisfaction) of women is higher than that for men but that males have a higher financial wellbeing than females [26]. This brings us now to the question of the health conditions of the two wealthy social hierarchies of men. What do we know about their health conditions? We have review extensive literature on health in the Caribbean in particular and found no study that has examined the health condition of men in the wealthiest two per capita population income quintiles. This is the first study in Jamaica to elicit information on two wealthy social hierarchies of men’s perception on their health conditions. This research seeks to examine the health conditions of these men; and provide an understanding of this cohort while filling the gap in the literature. Theoretical Framework Michael Grossman [27] developed a health model, using econometric analysis, which was able to coalesce some explanatory variables that influence the health status. Grossman’s work captures the essence of multi-variables simultaneously affecting health, and so this is applicable to the current study. The model is displayed in equation (1), below:

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H t = ƒ (H t-1 , G o , B t , MC t , ED) ……………………………………….. (1) where 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 further expanded upon by Smith and Kington [28] to include socioeconomic variables (Equation 2). H t = H* (H t-1 , P mc , P o , ED, Et , R t , A t , G o ) …………………………………… (2) Eq. (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 Po , 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 ). Within the limitation of the data set with which we have to carry out this study, a number of modifications will be made; however, the general theoretical framework of model of health will be used in the current study. Hence, using econometric analysis we seek to model the health condition of men in the two wealthiest quintile, using data on Jamaicans. H i = ƒ (L i , R i , lnC,En,AR i ,SS i ,CR i ,(∑2 𝑁𝑁𝑁𝑁𝑖𝑖 , 𝑁𝑁𝑁𝑁𝑖𝑖 ), lnEi ,HH i ,A i ,HIi ,M i ,F i ) ………(3) 𝑖𝑖=1

Where: is the health conditions of person i. 1 if at least one condition, 0 if none is living alone of person i. 1 if living alone, 0 if not living alone is retirement income of person i. 1 if receiving private and/or government pension, 0 if otherwise is consumption expenditure of person i, in dollars is the physical environment. 1 if in the lived milieu there has been flooding, soil erosion, landslide, 0 if no. 163 𝐻𝐻𝑖𝑖

𝐿𝐿𝑖𝑖 𝑅𝑅𝑖𝑖 𝑙𝑙𝑛𝑛𝑙𝑙

𝐸𝐸𝑛𝑛 𝐴𝐴𝑅𝑅𝑖𝑖

𝑆𝑆𝑆𝑆𝑖𝑖 𝑙𝑙𝑅𝑅 𝑙𝑙𝑛𝑛𝐸𝐸𝑖𝑖 𝐻𝐻𝐻𝐻𝑖𝑖 𝐴𝐴𝑖𝑖 𝐻𝐻𝐻𝐻𝑖𝑖 𝑀𝑀 𝐹𝐹

(∑2 𝑁𝑁𝑁𝑁𝑖𝑖 , 𝑁𝑁𝑁𝑁𝑖𝑖 ) 𝑖𝑖=1

is area of residence. Semi-urban, URBAN with the referent group being Rural Area. is social support. 1 if yes, 0 if no. is crowding in the household of person i. is total expenditure of the person I, in dollars is household head of person. 1 if yes, 0 if no. is age of person i, in years. is health insurance coverage. 1 if have a health insurance policy, 0 if otherwise. is number of male in household of person i. is number of female in household of person i.

NPi is the summation of all negative affective psychological conditions and PP is the summation of all positive affective psychological conditions.

The final model (i.e. Eqn. [4]) that account for the social and psychological conditions that explain self-assessed health conditions of sample. The final model denotes the variables that are statistical significant determinants (i.e. P < 0.05). H i = ƒ (lnC,AR i ,NP i , HH i ,A i ,M i ,) ……………….………………………………..(4)

Methods and Measures Method The sample was 3,770 respondents who are of the two wealthiest quintiles. These were taken from a nationally representative stratified sample of 25,018 respondents (2002 Jamaica Survey of Living Conditions). The sample was collected by two reputable statistical associations (Planning Institute of Jamaica and the Statistical Institute of Jamaica), using a self-administered questionnaire. Interviewers were trained to collect data from the interviewees. The survey was weighted in order to present the population of Jamaica. For 2003 to 2006, the Jamaica Surveys of Living Conditions did not collect information on the health status of Jamaica. Data for 2008 to 164

2009 are not yet ready, at the time of writing this paper the researcher was not given access to the 2007 survey data and so the researcher had to resort to using 2002 survey data to conduct this research.

Data were stored in SPSS program, and descriptive statistics were to ascertain background information on the demographic characteristics of the sample, chi-square was used to examine the association between particular variables and logistic regression was used determine the parameters of the model as well as to identify those factors that determine health conditions.

Measure Health conditions: This is a dummy variable, where 1= self-assessed ailment, injury or illness in the last four weeks, which was the survey period; Crowding = ∑𝑛𝑛=1 𝑖𝑖 , where ℎ𝑖𝑖 each person in the household, and r is the number of rooms 𝑖𝑖 excluding kitchen, bathroom and verandah.
ℎ 𝑟𝑟

Living Alone: Living Alone is a dummy variable, where 1= living alone, and 0=otherwise,

Age: This is a continuous variable, ranging from 15 to 99 years. Positive Affective Psychological Condition: Number of responses with regards to being hopeful, optimistic about the future and life generally. Physical Environment: This is the number of responses from people who indicated suffering landsides; property damage due to rains, flooding; soil erosion; Negative Affective Psychological Condition: Number of responses from a person on having loss a breadwinner and/or family member, loss of property, made redundancy, failure to meet household and other obligations. Income is proxied by total annual expenditure in Jamaican dollars 165

Findings: Demographic Characteristics of Sampled Population Table 7.1 examines the demographic characteristics of the sample. The sample was 3,770 men with a mean age of 40 years ± 17.9 years. Majority of the sample was never married (65%), 29.1% lived alone, 3.35 had private health insurance coverage, 17.3% reported an illness (i.e. dysfunction or health condition), 9% received retirement income, 60% per heads of households, while 735 had secondary or post-secondary level education. Of 40.3% of the Jamaican population that was classified in the two wealthy social hierarchies 45.1% was in the wealthy class and 54.9% in the wealthiest 20%. Of those who reported an illness, 5.7% responded to the typology of health conditions. The conditions were diarrhoea, 2.8%; respiratory diseases, 2.8%; diabetes mellitus, 5.6%; hypertension, 50%; arthritis, 22.2%, and unspecified conditions, 16.7%. A cross-tabulation between area of residence and social hierarchies revealed a significant statistical association - χ2 (df=2) =82.2, P < 0.0001. Fifty-nine percentage points of wealthy respondents dwelled in rural areas compared to 44% of those in the wealthiest social hierarchy. Concurrently, 14.4% of those in the wealthy hierarchy resided in urban areas compared to 19.8% of those in the wealthiest 20%. Table 7.2 highlights self-assessed health condition and age cohort of respondents. The findings revealed a positive statistical relationship between the two variables - χ2 (df=2) =187.7, P < 0.0001. Respondents ages 30 to 59 years were 1.3 times more likely to report illness compared to young respondents and elderly were 3.1 times more likely to indicate dysfunction with reference to young adults. 166

Table 7.3 represents self-assessed illness and social hierarchies of respondents. A crosstabulation between the two aforementioned variables revealed a significant statistical association - χ2 (df=1) =19.16, P = 0.02. The findings indicated that those in the wealthiest social hierarchy were 1.4 times more likely to report an illness than those in the wealthy social hierarchy. Table 7.4 examines the typology of reported health conditions by social hierarchy of respondents. Of the 17.3% of respondents (n=637) who indicated an illness, only 5.7% (n=36) responded in listing the health conditions. Acute health conditions were more a wealthy social class phenomenon while chronic conditions were more among the wealthiest class. Interestingly, none of those classified in the wealthy social hierarchy indicated diabetes mellitus compared to 9.5% of those in the wealthiest 20%. Multivariate Analysis Table 7.5 represents the use of logistic regression to test the hypothesis that self-assessed illness is a function of social, environmental and psychological conditions [i.e. Eq. (3)]. The final model (Eq. [4]) accounted for 29.4% of the variability in health conditions of men who are in the two wealthy social hierarchies. On examining the suitability of the data, it was revealed that 84.6% of the data was correctly classified: 99.9% of those who indicated that they had at least an ailment or injury over the last four weeks prior to the survey period and 21.8% of those who did not report a dysfunction. Limitation of the study The use of secondary data posed a fundamental problem for this study as we were unable to use explanatory variables that were test identified factors of other study. Hence, we were limited by the availability of the dataset. Another limitation to the study is health conditions are not constant 167

and so time being fluid and a critical was omitted as well as other lifestyle conditions. We recommend that modification to the model [Eq. (2)], which reads, α (t); where α parameter of time t. Discussion The present study revealed that 17 out of every 100 men in the two wealthy social hierarchies reported an illness compared to 13 in 100 of the population [5]. Self-assessed chronic health conditions were among those in men in the current respondents (77.8%) compared to that of the population (43.2%). Fifty percentage points of current sample had hypertension compared to 22.4% of the population; 22.2% had hypertension compared to 8.8% of the population; and 5.6% of the current respondents had diabetes mellitus compared to 12% of the population. Concurrently, age was positively correlated with health conditions and that elderly men were 3.1 times more likely to report illness compared to young adults. More men in the household, household heads, negative affective psychological conditions and consumption were positively correlated with increased health conditions. Rural men were more likely to report health condition than semi-urban wealthy men.

The World Health Organization [29-30] forwarded a position that there is a disparity between contracting many diseases and the gender constitution of an individual. One health psychologist, Rice [31], in concurring with WHO, argued that differences in death and illnesses are the result of differential risks acquired from functions, stress, life styles and ‘preventative health practices’ [31], suggesting income plays a role in health status. Although income is a predictor of health [27, 32-40] in almost all countries of the world women outlives men [41] even though their economic wellbeing is lower [33]; studies highlight that this is owing to 168

lifestyle practices. The current study concurs with the literature as we found that consumption of those in the two wealthy social hierarchies is positively associated with self-assessed health conditions, suggesting that their lifestyle practices expressed through consumption expenditure accounted for their self-related health conditions. Biomedical studies showed that there are gender specific diseases. The examples here are prostate cancer (affect only men) and cervical cancer (plague only women). Rice [31] believed that this health difference between the sexes is due to social support. According to Rice [31], Rodin & Ickovics [42] this can be explained by epidemiological trends. Lifestyle practices may justify the advantages that women enjoy compared in men concerning health status. However, a survey done by Rudkin found that women have lower levels of wellbeing (i.e. economic) than men [43]; but they outlive men owing to their preventative health-care behaviour. This finding is further sanctioned by Haveman et al [44] whose study reveal that retired men’s wellbeing was higher than that of their female counterparts, because men usually received more material resources, and more retired benefits compared to women ages 65 years and older. What about their health status? The issue extends beyond chronic illnesses as Courtenay [45] noted from research conducted by the Department of Health and Human Services [46] and Centers for Disease Control [47] 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 constitution [45,48], to which Courtenay [45] explained are due to behavioural practices of the sexes and goes to explain the fact that men are dying 6 years earlier than females [49]. 169

Females, on the other hand, have a high propensity than males to contract particular conditions such as depression, osteoporosis and osteoarthritis [29, 50]. Herzog [50] noted that “…it appears that older women are more likely to be impaired by their health problems, while older men are more likely to die from them.” A study that was conducted by Schoen et al. [51] on a group of adolescents reveals something different from that which was reported by WHO. They found that males are more likely than females to feel stressed ‘overwhelmed’ or ‘depressed’, and they attributed this to limitedness of men’s social networks. This is embedded in this study as we found that the more males in the household do the result in increased selfassessed health conditions, because men want to dominant and this is not possible if the individual is not the head. There is a paradox as if the individual is a head of household, other men in the household will result in continuous power struggles resulting in depression and other psychological conditions. Other research have agreed with Schoen et al that men in general tends to be more stressed and less healthy than females, and further argued that men can use denial, distraction, alcoholism and other social strategies to conceal their illness or disabilities [52-55] which is embedded in the current study that revealed a positive association between consumption and health conditions as well as the lower report on health conditions. On the other hand, Herzog [50] 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. Could suicide be used as a proxy for depression? Suicide is taken from death registers, which is likely to be underreported for the aged, since other illness are present, and may be substituted as the cause of mortality [50]. Herzog noted that data on suicide and depression yielded different results, and based on this fact, suicide cannot be used as an indicator for depression. Notwithstanding this 170

fact, the current study has found that negative affective psychological conditions is positive associated with self-rated conditions, and this speaks to the interpretation of the world in the mind of the rich and its influence on their health conditions. Based on demographic model from abridged Life Tables, mortality is different between the genders [56]. Generally, from the United Nations statistical databases, life expectancy for male is lower than of females. This is particular true for females in the old aged cohorts [57, 58]. Moore et al. [58] added, “Females’ life expectancies are likely to remain above that for males [56] for the foreseeable future, among both the population as a whole and the elderly” [58]. Among the justification for the differential between life expectancy the sexes is linked with the health consciousness of women and their approach to preventative care. Unlike women,

worldwide men has a reluctance to ‘seek health-care’ compared to their female counterpart. It follows in truth that women have bought themselves additional years in their younger years, and it is a practice that they continue throughout their life time which makes the gap in age differential what it is – which is approximately a 4-year difference in Jamaica. Studies have revealed that the classification of many diseases affect a particular gender. In that, for particular chronic viruses, the primary contributor to death is ischemic heart diseases that substantially are a man rather than a women’s disease. In a research conducted jointly by the University of Michigan in the United States and the Bureau of Health Promotion in Taiwan on elderly Taiwanese, between 1989 and 1993, of 4,049 people of 60 years and beyond, a number of socio-economic determinants were studied concerning mortality. From the findings, age is positively related to health conditions, with female, married people, primary level education and post-primary level graduands negatively related to health conditions [59]. 171

Embedded within Zimmer, Martin & Lin’s findings are the direct relationship between ageing and health conditions [60] – which are the case in this study. Refining the age variable, we found that 11.7% of the young adults (ages 15 to 30 years) reported a self-assessed health conditions and when age increases to 30 to 59 years, self-assessed health conditions increased by 3.1% and it increased by 21.4% for elderly over older adults. It is clear from the included socio-economic factors mentioned previously that males who are older than sixty-years have a higher propensity to be ill, which this study agrees with. Health conditions, therefore, is influenced by marital status (i.e. married people) which means that men’s health benefit more than that of females. This reality represents a situation, where married people are less likely to particular health condition than those who are in common-law, visiting relationships or single. From the various studies presented, within the socio-demographic reality of longer life for female, there is a paradox in that living longer implies that there is a higher probability of preventative and curative costs of care. The Planning of Jamaica & the Statistical Institute of Jamaica [61] have found that women visit health-care professional more than their male counterparts, and their knowledge of health, nutrition and preventative measure are higher than that of males which explains their willing to report dysfunctions as this is an indicator of the need for care. It should be noted here that a study conducted by Franzini et al. [62] on native Mexicans in Texas found that females had worse mental and self-assessed health than their male counterparts, but not physical health. Franzine et al’s work contravenes many findings on gender and health status. Another study on socioeconomic determinants of mortality in two Canadian provinces found that household income and education were significant (p ≤ 0.5) in predicting mortality. When gender was introduced within the model, the association dissipated [36].

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It is well established that area of residence influence health status [27,28, 32-33]; but we disagree with Bourne’s work that found elderly respondents who dwelled in the different regions of Jamaica experience no statistical difference in physical functional – using dysfunctions (p > 0.05). In this we found that there is no statistical difference between the self-assessed health conditions of men who are in the wealthiest two quintile and dwelling in Kingston Metropolitan Area and Rural Areas; whereas a statistical difference was observed between self-assessed health conditions of rich men and those who resided in Semi-urban with referent to those who lived in rural areas. On the matter of living alone it is well established in literature that this affects health conditions, health status, quality of life, wellbeing and life satisfaction; but we found that income is not a factor in determining the health conditions of men in the wealthiest per capita. The role of income in the current study is to provide a better physical milieu as well as open one access to a greater consumption. It is this consumption which is byproduct of more income result in increased health conditions. Contrary to the findings of Smith & Kington’s work as well as Marmot [35], consumption is detrimental to ‘good’ health for men in two wealthy social hierarchies in Jamaica. The rationale for this is tied to their lifestyle behavior. This indicates that income can buy commodities, but more of it destroys ones health status through the unhealthy choices that are made. Another issue that emerges here is fact that income does not mean knowledge or ‘better’ healthy-behavioural practices. More income, on the other hand, creates unavailability access that was previously restricted commodities as well as creating a particular social networking that was once nonexistence. The rich has a large access to social support and social networking which militates 173

against loneliness affecting their health status. The irony, nevertheless, it is working through their psychological state which is captured in negative affective psychological conditions, they are still vulnerable to negative conditions that affect the general populace. It should be noted here that this variable positively affects their health conditions. Conclusion In summary, we now have information on the factors that determine the self-assessed health status of those Jamaicans in the two wealthy social hierarchies (i.e. 40.1% of the population in 2002). Instead of institution policies that are guided by narratives, we will now be able to use explanation by way of this study to better understand the studied cohort of people and by so we will be able to effective plan for the healthy development of the populace. The current research has shown that their health condition is substantially influenced by age, negative affective psychological conditions and being head of a household. Men in the wealthy social hierarchies were not will to reveal the typology of illnesses that they had experienced or were experiencing in the period of the survey. Seventeen out of every 100 wealthy men were experiencing an ailment, but only 6 out of every 100 of those who reported an illness stated what the health conditions were. Of those who stated their health conditions, it is clear the chronic conditions accounted for most of the ailments (78%), with hypertension accounted for one half of the conditions and that these are greater than that for the population. These findings are germane as they provide us with insights into the health belief system of wealthy men in Jamaica; the difference is health behaviour based on area of residence as well as aid an understanding of how policy can be tailored to address their health behaviour. Conflicts of interest 174

There are no conflicts of interest to report by the author.

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.

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avoidance. Seattle: Hogrefe and Huber; 1993. 55. Sutkin L, Good G. Therapy with men in health-care settings. In: Scher M, Stevens M, Good G, Eichenfield GA, editors. Handbook of counseling and psychotherapy with men (pp. 372-387). Los Angeles: Sage Publications; 1987. 56. Elo IT. New African American life tables from 1935-1940 to 1985-1990. Demography. 2001; 38:97-114. 57. United Nations. Population, ageing and development. San Juan, Puerto Rico: UN. ECLAC; 2004. 58. Moore EG, Rosenberg MW, McGuinness D. 1997. Growing old in Canada: Demographic and geographic perspectives. Ontario: Nelson; 1997. 59. Zimmer Z, Martin LG, Lin H-S. Determinants of old-age mortality in Taiwan; 2003. [Updated 2006, March 21; cited 2006, March 21]. Available from http://www.popcouncil.org/pdfs/wp/181.pdf. 60. Erber J. Aging and older adulthood. New York: Waldsworth, Thomson Learning; 2005.

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Table 7.1 Demographic Characteristics of Sampled Population, n =3,770 n Age Group Young Adults (15 – 30 yrs) 1,262 Older Adults (31 – 59 yrs) 1,888 Elderly (ages 60+ yrs) 620 Marital Status Married 1,058 Never Married 2,370 Divorced 49 Separated 51 Widowed 116 Living Alone No 2,673 Yes 1,095 Ownership of Private Health Insurance No 3,462 Yes 118 Self-assessed Health Conditions None 3,038 At least one 637 Receiving Retirement Income No 3,426 Yes 339 Household Head No 1,505 Yes 2,261 Educational Attainment Primary and below 603 Secondary and post secondary 2,414 Tertiary 291 Social hierarchies Upper middle class (i.e. wealthy) 1,700 Affluent (i.e. wealthiest 20%) 2,070 Age Crowding

Percent 33.5 50.1 16.4 29.0 65.0 1.3 1.4 3.2 70.9 29.1 96.6 3.3 82.7 17.3 91.0 9.0 40.0 60.0 18.2 73.0 8.8 45.1 54.9

40.0 yrs (± 17.9 yrs); Range =84yrs.; 99-15 yrs. 1.2 person (±0.798 person); Range = 8: 0 -8 person

179

Table 7.2 Self-assessed Health Conditions of men in the Two social hierarchies by Age Group, n=3,675 Age group Variable Young Adults (ages 15 to 30 yrs). n (%) Self-assessed health condition None At least one Total, n χ2 (df=2) =187.7, P < 0.0001 1066 (88.3) 141 (11.7) 1207 1580 (85.2) 274 (14.8) 1854 392 (63.8) 222 (36.2) 614 3038 (82.7) 637 (17.3) 3675 Older Adults (ages 30 to 59 years) n (%) Elderly (ages 60 yrs. and over) n (%) Total n (%)

180

Table 7.3 Health Conditions of Men in Jamaica By Social hierarchies Variable Social hierarchy Wealthy n (%) Self-assessed illness None At least one Total, n χ2 (df=1) =19.16, P = 0.02 1413 (85.7) 236 (14.3) 1649 1625 (80.2) 401 (19.8) 2026 3038 (82.7) 637 (17.3) 3675 Wealthiest 20% n (%) Total n (%)

181

Table 7.4 Self-assessed diagnosed health condition by social hierarchy of respondents Social hierarchy Variable Wealthy Wealthiest 20% n (%) n (%)

Total n (%)

Self-assessed health condition Acute Influenza Diarrhoea Respiratory Chronic Diabetes mellitus Hypertension Arthritis Other Total, n

0 (0.0) 0 (0.0) 1 (6.7) 0 (0.0) 7 (46.7) 3 (20.0) 4 (26.7) 15

0 (0.0) 1 (4.8) 0 (0.0) 2 (9.5) 11 (52.4) 5 (23.8) 2 (9.5) 21

0 (0.0) 1 (2.8) 1 (2.8) 2 (5.6) 18 (50.0) 8 (22.2) 6 (16.7) 36

182

Table 7.5 Regression analysis: Health Conditions of those in the two wealthy social hierarchies By Some Explanatory Variables 95.0% C.I Std. Explanatory Variables OR Error Living Alone 0.147 1.269 0.951-1.692 Retirement Income 0.189 1.221 0.844-1.767 Logged consumption 0.237 1.833** 1.153-2.916 Physical Environment 0.150 0.877 0.653-1.178 Semi-urban 0.150 0.739* 0.551-.992 Urban 0.207 1.056 0.704-1.583 Referent group – Rural Area 1.000 Social Support 0.127 Crowding 0.108 Land Ownership 0.145 Negative Affective 0.021 Positive Affective 0.030 Logged income 0.199 Head Household 0.182 Age 0.004 Health Insurance Coverage 416.9 Number of male in 0.099 household Number of female in 0.118 household Nagelkere R-square = 0.294 -2 Log Likelihood = 1,669.04 Chi-Square (df = 17) = 434.425, P < 0.0001 **P<0.001, ***P<0.0001, *P<0.05 0.988 1.157 0.921 1.075** 0.984 0.844 1.876** 1.025*** 76735042.32 1.258* 1.081 0.770-1.267 0.937-1.430 0.693-1.223 1.032-1.120 0.927-1.043 0.571-1.247 1.313-2.681 1.016-1.034 0.000-. 1.036-1.528 0.858-1.364

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Chapter Eight

Determinants of self-reported health conditions of people in the lower socioeconomic strata, Jamaica
Paul A. Bourne

Introduction

Poverty is a phenomenon that affects developed as well as developing societies [1-5], but more widespread in the latter nations. The issue of poverty is much a reality as household crowding, income inequality, health inequality, social development, demographic transition, gender inequality, fertility, mortality, and mistrust as well as economic growth or healthy life expectancy. It influences people in many ways such as in-affordability of resources that can improve or retards socioeconomic development, nutrition, sanitation, and quality sociophysiological milieu, premature deaths and unhealthy life expectancy. Owing to incapacitation that poverty causes, it creates a ‘bad’ environment that accounts for a certain health status and in the process facilitates ill-health [6]. An extensive review of literature has shown that a ‘poor’ milieu contributes to ill-health [6-15], suggesting that insufficient money accommodates health hazards as the poor may not have money to spend on quality health care involving specialized surgery or preventative treatments. In 2002, statistics for Jamaica reveals that 50.4 per cent of the total consumption expenditure of those in the poorest quintile was spent on food and beverage, compared to 38.1 per cent for those in the wealthiest quintiles. In a paper titled Poverty and Health, Murray [16] argued that there is a clear interrelation between poverty and health. She noted that financial inadequacy prevents an individual from 184

accessing – food and good nutrition, potable water, proper sanitation, medicinal care, preventative care, adequate housing, knowledge of health practices – and attendance at particular educational institutions among other things, which concurs with previous research [2, 9-12, 15]. The issue of resource insufficiency affects the ability and capacity of the poor from accessing the quality of goods and services comparable to the rich who are better able to enjoy quality of life/ wellbeing. The World Health Organization (WHO) [10] found that 80% of chronic illnesses were in low and middle income countries, and 60% of global mortality is caused by chronic illness, thus suggesting that illness interfaces with poverty and explain premature mortality owing to material deprivation. The WHO stated that “In reality, low and middle income countries are at the centre of both old and new public health challenges” [10]. The high risk of death in low income countries is owing to food insecurity, low water quality, low sanitation coupled with inaccess to financial resources. Poverty makes it insurmountable for poor people to respond to illness unless health care services are free. Hence, the people who are poor will suffer from chronic diseases. The WHO captures this aptly “...People who are already poor are the most likely to suffer financially from chronic diseases, which often deepen poverty and damage long term economic prospects” [10]. Clearly, material deprivation, lack of or limited opportunities high levels of incapacities, unemployment excess, dietary deficiency, and psychological frustration among the poor, seems to be more life threatening among developing than developed nations. Based on statistics (Jamaica Survey of Living Conditions, (JSLC)), in 2006, 35.2 per cent of those in the poorest quintiles indicated that they were not able to seek health care services because of in-affordability compared to 16.7 per cent of those in the wealthiest quintile (Table 185

8.1). In the same year, the statistics revealed that 71 per cent of the poorest Jamaicans attended public health care services compared to 21.7% wealthiest Jamaicans whereas 73.9 per cent of the wealthiest visited private health care facilities compared to 24.3 per cent of the poorest Jamaicans. The reality is the poor spend on food, beverages, fuel, household supplies and household expenses (54 per cent in 2006) compared to those in the wealthiest quintiles (50 per cent). The reverse side of this reality means that the poor has less income to be used for health care, and for spending on safer milieus. It is argued that the environment has aided the increase of illnesses such as malaria, El Niňo, dengue fever, asthma and other respiratory diseases, and cholera [17]. Diseases like malaria and dengue are mostly attributable to poor living conditions, which speaks to the importance of a quality of life measurement that is comprehensive as against the biomedical model, which is an end product model. This point is further embodied in reason for the

resurgence of tuberculosis throughout the world even in affluent societies, despite the advancement of technology and medicine. Such matter is answered in the simple fact that poor sanitation, overcrowding in homes, inadequate nutrition are accounting for the rise in this ailment. The Organization of Eastern Caribbean States [18] in one of their reports writes that, “while material poverty affect a large number of households, the Report points to the impending dangers of more widespread and subtle forms of poverty that include poor health, inadequate levels of educational attainment; lack of economic assets or access to markets or jobs that could create the unsafe physical environment; and various forms of social exclusion.” According to Ranis and Stewart [19], healthier, better nourished, and more educated people contribute 186

significantly to economic growth than their otherwise counterparts. In an organization with highly trainable staff, very low absenteeism (not much sick leave) contributes to productivity. Marmot [9] posits that poverty means the inability to obtain the essentials of life. This is also reflected in a (i) ‘poor’ milieu; (ii) matter of low income which prevents them from accessing certain resources; and (iii) problem of social inequality. Those realities justify the inverse relationship found between the physical environment and health status [6-8]. Moreover, poverty explains the inadequacy in terms of material conditions. These are expressed through inability to afford basic needs, food, clothing, and particular quality environment. However limited resources interfere with the ability to acquire the essentials. Poverty can be seen as exclusion; the European Union defines the poor as persons whose resources (material culture and social) are so limited as to exclude them from the minimum acceptable way of life in the member state in which they live depending on benefits as equivalents as claiming social assistance”. Dalzell-Ward [20], commented that, “The deprivation of energy foods will result in excessive fatigue which will in turn diminish social and work performance and interfere with well-being.” This position clearly indicates a level of development. If an individual is unhealthy this would likely add to less working hours, and by extension reduce production in an organization and the country. This brings to mind, the view point of Adam Smith, that matters of this nature are an indication of reduced economic growth. If an individual is malnourished, this will adversely affect the health of the person, hence the possibility of mental and physical underdevelopment, lowered productivity, increased absenteeism, and reduce social and economic capital. Another school of thought concurred with Dalzell-Ward [20], when she said: 187

An extensive examination of the literature review has shown that poverty is directly associated with health conditions, and is inversely related to health status, thus suggesting that income is critical to health status of people. In all the reviews, the researcher came upon no study in Jamaica that sought to explore determinants of self-reported health status of those in the lower socioeconomic strata, the magnitude of those factors, and the probability of switching from ‘good’ health to ‘bad’ health. As a result, the current study examines determinants of selfreported health conditions of people in lower socioeconomic strata of Jamaica. This was in an effort to fill the gap in the present literature; and in the process provide public health practitioners with what are the predictors of self-reported health status of those who are in the poor quintile which will allow them to understand people’s perception as well as to address health issues relating to the population that may be generated from the actions (or inactions) of the poor.

Theoretical Framework
The theoretical framework that underpins the current study is modelled by Franc, Perronin and Pierre [1]. Using a Health, Health Care and Insurance Survey (ESPS) that was carried out between 1994 and 2004 in France, Franc, Perronnin, Pierre [1] sought to model health insurance demand. The survey sampled 20,000 insured respondents, who will be making the transition to retirement. They used probit analysis to estimate the probability of switching from private insurance to public providers or vice versa. The switching behaviour was controlled for sociodemographic characteristics in order to remove the effects that are not directly linked to the nature of the contract. This is embodied in the mathematical formula, (Eq. (1) : P (Yi = 1 / Zi, Xi, Δri) = α + β. Zi + γ. Xi + δ. Δri + ε ……………………Eq. (1) 188

where yi is a binary variable defined by yi = 1 if the individual switched and yi=0 otherwise, Zi represents the nature of the contract (compulsory, voluntary or individual); Xi and Δri represent controls variables: Xi is a vector of individual characteristics (education, age of retirement, retirement wave, type of provider, individual assessment of payments for specialist care, public fund, public co-payment exemption and vital risk) and Δri represents the variation of income: “same income”, “higher income after” and “lower income after”. The standard error ε is assumed to follow a cumulative normal distribution. In the current work, we will modify model 1, Eq. (1), to reflect a set of tested variables for Self-reported health conditions of Jamaicans who are the bottom quintiles – poorest and poor. Thus, we will build a model, Eq. (2), which allows us to estimate the individual probability, ‘P’, of switch from ‘good’ health to ‘bad’ health – Self-reported health conditions by the estimates of the parameters (α and β): 𝑁𝑁(Hi = 1/[1 + e −[Ai ,Yi ,MRi ,ARi ,EDi ,∑i=1 Pi , Xi ,Ci ]
2

= 𝛼𝛼 + 𝛽𝛽1 𝐴𝐴𝑖𝑖 + 𝛽𝛽2 Yi + β3 MRi + β4 ARi + β5 EDi + β6 Xi + β7 Ci + � βij Pijk + ε
i=1

2

where Hi is a binary variable defined by Hi = 1 if the individual Self-reported his/her health conditions and Hi=0 otherwise, Ai represents the age of individual i, Yi represents average income per person per household, MRi represents marital status –of an individual who is divorced, separated, or widowed with reference to someone who is single; or an individual i who is married with referent to person i who is single – ARi represents area of residence –of an individual who lived in Other Towns with reference to someone who dwelled in a Rural area; or an individual i who resided in Kingston Metropolitan Area with referent to person i who dwelled 189

in Rural Area – EDi represents educational level –of an individual who has a secondary level of education with reference to someone has primary and below education; or individual i who has tertiary level education with referent to person i who has primary or below education – Xi is gender of respondent i (with 1=male and 0=otherwise)- Ci is crime that is exposed to by person i; and where ∑2 βij Pijk is the summation of psychological state of person k, where i represents i=1

negative psychological state of person k and j denotes the positive psychological state of person k, and 𝛽𝛽1 to 𝛽𝛽7 represent the coefficient of variable 1 to variable 7 with βi denotes the coefficient for negative psychological state and βj represents the coefficient of the variable positive psychological state. Ergo the model that will be examined in the current study is expressed in the equation below; 𝑁𝑁(Hi = 1/[1 + e −[Ai ,Yi ,MRi ,ARi ,EDi ,∑i=1 Pi , Xi ,Ci ]
2

= 𝛼𝛼 + 𝛽𝛽1 𝐴𝐴𝑖𝑖 + 𝛽𝛽2 Yi + β3 MRi + β4 ARi + β5 EDi + β6 Xi + β7 Ci + � βij Pijk + ε
i=1

2

The current work is concerned about (i) the probability of predicting a person reporting a health condition, and (ii) the parameter of each factor and its interpretation. From Table 3, we will substitute the parameter with their appropriate coefficients:
2
2 𝑁𝑁

(Hi = 1/[1 + e−[Ai ,Yi ,MRi ,ARi ,EDi ,∑i=1 Pi , Xi ,Ci] = −3.938 + .043𝐴𝐴𝑖𝑖 + .000Yi + .252MRi − .394ARi + .366EDi − .768Xi + .013Ci + �. 064Pik + ε
i=1

It should be noted that MRi represents an individual who is married with referent to one who was never married; ARi represents person I who dwelled in Other Towns with reference to someone who resided in a rural area; EDi represent the educational level of an individual who 190

has had secondary or post-secondary education; where Xi=1 represents a male and 0=otherwise and Pi represents a negative psychological conditions of person k.
2
2 𝑁𝑁

(Hi = 1/[1 + e−�Ai ,Yi ,MRi ,ARi ,EDi ,∑i=1 Pi , Xi ,Ci � = −3.938 + .043 ∗ 30 + .000 ∗ $4,000 + .252 ∗ 1 + −.394 ∗ 1 + .366 ∗ 1 + −.768 𝑁𝑁(Hi = 1/[1 + e−[Ai ,Yi ,MRi ,ARi ,EDi ,∑i=1 Pi , Xi ,Ci ]
2 2

∗ 1 + .013 ∗ 5 + �. 064 ∗ 1
i=1 𝑁𝑁

(Hi = 1/[1 + e−[Ai ,Yi ,MRi ,ARi ,EDi ,∑i=1 Pi , Xi ,Ci ) = 8.547 𝑁𝑁(Hi = 1/[1.00194127] 𝑁𝑁(Hi) = 0.99806 𝑁𝑁(Hi = 1/[1 + e−8.547 𝑁𝑁(Hi = 1/[1 + 1.941266067 ∗ 10−4 ]

= −3.938 + 12.9 + 0 + .252 − .394 + .366 − .768 + .065 + 0.064

A probability value of 0.998 of Self-reported health conditions of poor Jamaicans indicates that we are 0.998 sure of what explains how the poor switched from no health conditions to at least one-health condition. The current study also seeks to examine the factors that determine ‘health conditions’ and their parameters as well as understanding each influential factor on health conditions.

Methods and Measures
Of the 9,931 respondents, who participated in this study, 48.3% were males and 51.7% females, who are in the bottom quintiles of per capita population (50.1% below the poverty line and 49.9% poor). The current study is a constituent of a prevalence survey that was carried by the Statistical Institute of Jamaica and the Planning Institute of Jamaica between June and October 191

2002 (Jamaica Survey of Living Conditions, JSLC). The JSLC is a variation of the World Bank’s Living Standard Measurement Study (LSMS) household survey. The JSLC focuses on and emphasizes policy impact which is the difference from the LSMS. Ever since 1988, the Statistical Institute of Jamaica (STATIN) in partnership with the Planning Institute of Jamaica (PIOJ) have been carrying out twelve-monthly surveys on living conditions of Jamaican populace. The JSLC’s design is that of a multi-module household survey with modules on health, consumption, education, house, anthropometric measurements and immunization data for all children 0-59 months, and demographic variables. JSLC is carried out with a selfadministered questionnaire by trained interviewers to responsible to household members. Participations are asked to recollect detailed information their consumption patterns over the last 30 days of the survey period as well as their health care expenditure in addition to the aforementioned variables. A self-administered questionnaire was used to collect data from Jamaicans on different facet of life. The fundamental structure of the instrument has remained the same over the years with some differences yearly to include module on social safety net, elderly, crime and victimization, physical environment, remittances and other components. Stratified random sample was used to drawn the respondents (N=25,018). The survey was weighted in order that it represents the population of Jamaica. Data were stored, retrieved, and analyzed using Statistical Package for Social Sciences (SPSS) for Windows, Version 16.0 (SPSS Inc; Chicago, IL, USA). For the current study, descriptive statistics was used to provide socio-demographic characteristics on the sampled population, and logistic regression was used to establish a model that reflects the health conditions of poor Jamaicans. The dependent variable is self-reported health conditions, with some predisposed explanatory variables (Measure). 192

For 2003 to 2006, the Jamaica Surveys of Living Conditions did not collect data on the health status of Jamaica. Data for 2008 to 2009 are not yet ready, at the time of writing this paper the researcher was not given access to the 2007 survey data and so the researcher had to resort to using 2002 survey data to conduct this research Measures Self-reported Health Conditions denote self-reported illnesses/injuries that were experienced by the individual in the 4-week of the survey period: This is a dummy variable, where 1=selfreported ailments, injuries or illnesses suffered in the last four weeks and 0 if did not report any illness/injury. Household crowding is the mean number of persons who dwelling in a household: Where 𝑥𝑥𝑖𝑖 represents each individual, and ∑𝑛𝑛 𝑥𝑥𝑖𝑖 is the summation of the all the 𝑖𝑖=1

individuals with the household, and ‘i’ denotes first person to the last person, n, and ∑𝑛𝑛 𝑓𝑓𝑖𝑖 is the 𝑖𝑖=1 summation of number of rooms in the house excluding kitchen, bathroom(s) and verandah.

Physical Environment: This is the number of responses from people who indicated suffering landsides; property damage due to rains, flooding; soil erosion; Negative Affective Psychological Condition: Number of responses from a person on having loss a breadwinner and/or family member, loss of property, made redundancy, failure to meet household and other obligations. Positive Affective Psychological Condition: Number of responses with regards to being hopeful, optimistic about the future and life generally.

193

Crime and victimization index (Crime Index) denotes the self-reported experiencing a crime or being a victim of any form crimes and this include if these crimes or victimization are against an individual family member of close associate.

Where ki represents the frequency with which an individual witnessed or experience 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. Ti 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 and a maximum of 51.

Findings: Demographic Characteristics of Sampled Population
The sampled population was 9,931 respondents, of which 48.3% (n=4,799) were males and 51.7% (N=5,129) females with mean age for the sample being 26.1 years (± 22.5 years). Moreover, most of the population were never married (71.3%, N=4,020), had secondary and post-secondary level education, (75.5%, N=3,885), did not report having a health condition (84.9%, N=8,268), with marginally more respondents owing property (58%, N=3,927). In addition, the average occupancy per room was 3 (± ≈ 2); Range =11 persons per room (Table 8.2). Of those who reported ill-health (15.1%), 1% indicated that this was cold; 4.2% diahorrea; 6.3% diabetes mellitus; 36.5% hypertension; 29.2% arthritis and 22.9% did not 194

specify the health condition. Fifty-five percent indicated that they purchased the prescribed medication compared to 3.3% who claimed that they did not buy the prescribed medication and 31.0% mentioned that none prescribed medication was required; and 5.1% purchased over the counter medication. Of those who answered the question on health care-seeking behaviour in the last 12 months (n=9,679), 34.7% indicated that they sought medical care compared to 65.3% who did not. Twenty percent (representing 22.2%) sought public medical care, 10.1% private and 2.4% said both. In response to the reason for not seeking medical care, 30.4% reported that they were unable to afford medical care costs and 70.4% claimed that they were unable to afford medications. Only 2.7% of the sample had health care insurance. The median expenditure on medical care was US $5.89 (US $1.00 = Ja. $50.97).

Findings: Multivariate Analysis
Using logistic regression, it was found that 85.2% of the data were corrected classified: 98.3% of those reported not having a health condition and 33.8% of those who reported at least one health condition (Table 8.3). This is an indication that the data is a good fit for the model, as 85% were correctly classified. Moreover, using the principle of parsimony only those factors that were statistically significant (p < 0.05; 95% Confidence Interval) will be used in the model and so those are the only ones that will be referred to in this study. We have found that 8 factors explained 39.6% health conditions of poor Jamaicans (Table 8.3). Of the 8 factors, the 5 most significant ones are age (OR = 1.04, 95% CI = 1.04 – 1.05), sex of respondents (OR = 0.46, 95% CI = 0.39 – 0.56), negative affective psychological conditions (OR = 1.07, 95% CI = 1.04 – 1.10), average income per household (OR = 1.00, 95% 195

CI = 1.00 – 1.00), and educational level (OR = 1.44, 95% CI = 1.15 – 1.81) (Table 8.3). Moreover, poor respondents have a lower Self-reported health conditions compared to their female counterparts (OR=0.39, 95%CI: 0.39, 0.56). Furthermore, a male is one-half less likely to report a health condition than a female. On the other hand, the old a respondent become he/she is 1.04 times (OR=1.04, 95%CI: 1.04, 1.05). Similarly, crime directly affects the Self-reported health conditions of poor respondents. An individual who has been influenced by more crime and victimization is 1.01 times more likely to report a health condition compared to another individual who is influenced by less crime and victimization. This positive association was also observed for income (OR=1.00, 95%CI: 1.00, 1.00), a married person with referent to a single individual (OR=1.29, 95%CI: 1.04, 1.59) which was the same for those who indicated a negative affective psychological condition (OR=1.07, 95%CI: 1.04, 1.10).

Discussion
The literature revealed that access to good health care is dependent on possessing money. [1, 2, 4, 9]. The findings of this study endorse the view point of the literature. Marmot [9] and Sen [2] argued that income directly influences good health, and explains why the poor’s health is poor and justified their high levels of health conditions and premature mortality. Unlike the other studies, this paper found that income for the poor was positively correlated with health conditions, suggesting that the more income that this cohorts receives, there is an increased probability that good health status will be reduced. Studies have highlighted that poor people are more likely to have ‘lower’ health status (dysfunctions), suggesting that more income should revert more health conditions. However, in this study income did not reduce but was associated with increased health conditions in poor Jamaicans. Embodied in this finding is the implied 196

relationship between greater income and risky lifestyle behaviour, which accounts for the rationale of more income explaining more self-reported health conditions. The increased income for this group is not spent on things that would account for better health status, but on clothing, entertainment, furniture and unhealthy foods. The argument of the maldistribution of poor income on particular items can be highlighted by some of the findings of the current work. This research found that 55 out of every 100 of the poor purchased the prescribed medication given to them by their medical practitioners, and 35 out of every 100 sought medical care. Comparatively, 64 out of every 100 Jamaicans sought medical care for the same period (2002) and the figure was 75 out of every 100 for the population that purchased the prescribed medication. The current finding revealed that only 3 out of every 100 were holders of health insurance coverage compared to 14 out of every 100 for the nation; while for this study 70 out of every 100 of those who did not purchase medication indicated inaffordability compared to 50 out of every 100 for the population. Embedded in this finding is the fact that low income and more of income at this low level is unable to afford positive effects on health to the point that it reduces poor health status (or illhealth). The fact is more income for the poor does not change their physical milieu, educational attainment, sanitation, nutrition or the social environment and therefore more money will be spent on things that will not transform their economic status as well as their mindset about good lifestyle choices. More income for this cohort explains the disparity, in particular health conditions compared to that of the population. The current study revealed that 15 out of every 100 poor Jamaican reported at least one health condition compared to 13 out of every 100 for the nation. 197

Some health conditions such as diabetes mellitus and hypertension are as a result of lifestyle practices, and 37 out of every 100 poor Jamaican reported hypertension compared to 22 out of every 100 for the population, while for diabetes mellitus it was 6 out of every 100 poor compared to 12 out of every 100 for the nation (in 2007). In 2002, twenty nine out of every 100 of the poor compared to 9 out of every 100 for Jamaicans (in 2007). Health literature has extensively examined the role of the physical milieu on health, landslides, flooding, and other ecological conditions. It is noted that these variables do affect the self-reported health status of poor Jamaicans. What can explain this seemingly paradox is maladjustment. When people live in a particular sociopolitical or physiological environment, they become more acceptable of the physical surrounding and this climatization allows for the readjustment (or maladjustment) of the mind to those external pollutants that may be health causing agents; but they are not recognized within their experiences as such conditions. On the other hand, the crime and victimization that is products of environmental health, impacts on the wellbeing of inner-city residence. One of the significant findings of this paper is the crucibility of ageing to self-reported health conditions of Jamaicans. It was pointed out that ageing is the single most influential predictor of health conditions of poor Jamaicans, suggesting that ageing comes with its health conditions and is consonant with general research on ageing and health [7], [8], and [10]. The rationale of the aged being the age cohort with the most use of prescription drug is as a result of the ageing process. The role that pharmaceutical drugs play in this experience is postulated. Cajanus found that 70% of individuals who were patients within different typologies of health services were senior citizens [21, 22]. Among the many issues that the research reported on, are 198

the six major causes of morbidity and mortality identified by the Caribbean Epidemiology Centre. These are of paramount importance to this discussion. Men are less likely to visit health services, and normally this is the last resort for many of them. The literature as established that females seek more health care than their male counterparts [7, 8], and this accounted for the greater incidence of them reporting health conditions. This does not indicate that they are less healthy than males. Using the life

expectancy, which is greater for females than males in many nations including Jamaica, longer life is associated with better health status. One Organization, in seeking to explain the health disparity between the gender, shares the view that the disparity between contracting many diseases are said to be due to the gender constitution of an individual [24]. Others argued that differences in death and illnesses are as a result of differential risks acquired from functions, stress, lifestyles and ‘preventative health practices’ [25]. This suggests that many of the diseases are based on social factors, as lifestyle practices (contributing to health status) may justify the advantages that women enjoy compared to men. Females, on the other hand, have a high propensity than males to experience certain conditions such as depression, osteoporosis and osteoarthritis [24, 26]. Herzog [26] noted that “…it appears that older women are more likely to be impaired by their health problems, while older men are more likely to die from them.” A study that was conducted by Schoen et al. [27] on a group of adolescents reveals something different from that which was reported by WHO. The authors found that males are more likely than females to feel stressed ‘overwhelmed’ or ‘depressed’, and they attributed this to limitedness of men’s social nerks. Schoen and colleagues when further to argue that men can use denial, distraction, alcoholism and other social strategies 199

to conceal their illness or disabilities, which is supported by other scholars as the rationale for women outliving their male counterparts[28-31]. Courtney and colleagues [32] like the World Health Organization attributed this biomedical condition to difference between the genders based on hormonal differentiations, social nerks and support, and cultural and lifestyle practices. This is captured in the life expectancy that reflects a greater value for females than males. Among the justifications for the differential between life expectancy, gender is linked with the health consciousness of women and their approach to preventative care. Unlike women, worldwide men has a reluctance to ‘seek health-care’ compared to their female counterpart. It follows in truth that women have bought themselves additional years in their younger years, and it is a practice that they continue throughout their life- time which makes the gap in age differential what it is – which is approximately a 4-year difference in Jamaica. Studies have shown that males benefit from their involvement in marriage where the insistence of their wives regarding the practice of healthy lifestyle is adhered to [7, 8, 33], 34]. Smith and Waitzman [35] pointed out that wives dissuade their husbands from risky behaviours such as the use of alcohol and drugs, bad eating habits and the maintaining of a strict medical regimen. . Ergo, the current study has concurred with the literature that married people have greater reporting health conditions compared to the other union status, which aids in the explaining of them seeking more health-care services compared to the other marital statuses. In Smith and Waitzman’s [35] literature review, they added that men’s gains from marriage was greater than that of women [36]. The question of education on matters of health and well-being has raised cause for concern. Education is a well established factor of health status and/or mortality [7, 8, 20, 37-43]; 200

and this was also the case in this study. This study disagreed not with education being the predictor of health status, but the level of education that determines health status. All the studies that were examined on the relationship between educational level and health status show that higher than lower level of education accounts for the disparity in health status [45-50]. In the current study, we found that there is no disparity in the health condition of someone with tertiary level education and that of primary level education. However, there is disparity between primary and secondary level education. The study also found, that for the poor, those with secondary level education were less likely to report unfavourable health conditions than those with primary education. Does this have anything to do with the psychological state of the poor at the primary level? One of the realities of poverty is its deprivation with sociopolitical and ecological conditions, and this accounts for a particular mindset of those who continuously have to live in this reality. This study is not putting forward a perspective that the poor has the worse mindset; instead, it is highlighting the position of continued deprivation which results from maldistribution of money, as well as money not being spent on those materials that contribute to positive lifestyle. It was noted in the literature that 50.4 per cent of the total consumption of those in the poorest 20% was spent on food and beverage compared to 38.1 per cent for those in the wealthiest quintiles [44]. If one were to include fuel and household supplies as well as housing and household expenses, this would account for 68.3 per cent of the total consumption of those in the poorest quintiles compared to only 10.3 per cent being spent on education. In this study, it is noted that self-reported health conditions are directly associated with negative affective psychological state of the individual, indicating how the socio-environment create a worsened state for the poor. This further goes to the inverse impact of negative affective 201

condition on the wellbeing and the direct influence of positive affective conditions on wellbeing [7, 8], which adds credence to the position that the health-care treatment of poor must not hold constant their socioeconomic and political environments as these are important in determining health status of this cohort of people.

Conclusion
In summary, public health practitioners in wanting to change some of the behavioural practices of poor people in regard to their health must understanding the factors that determine their health status and the quality of life enjoyed (or not), as this provides answers to some of the issues in relation to action (or inactions) of those individuals. It should be understood also that the milieu of the poor is a creation of income inequality, maldistribution of resources, lack of or limited opportunities. Therefore, in using infant mortality, life expectancy and mortality to proxy the health of a poor population, this would be omitting the psychological state that is a product of the deprivation. Life expectancy speaks of length of life and omits healthy life expectancy; thus, health education must incorporate for those realties with the findings of research if they are to effectively address some of the health concerns of the poor. It should be noted here that any inactions by government or public health specialists will result in increased health expenditure by the state to treat the poor when they seek medical care.

References
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4 United Nations Development Programme (UNDP). Human Development Report – Consumption for Human Development. New York: Oxford University Press; 1998. 5 UNDP. Human Development Report – Globalization with a Human Face. New York: Oxford University Press; 1999. 6 Pacione M. Urban environmental quality of human wellbeing–a social geographical perspective. Landscape and Urban Planning 65, (2003), pp. 19-30. 7 Bourne PA. Determinants of Wellbeing of the Jamaican Elderly. Unpublished Master Thesis, the University of the West Indies, Mona; 2007a. 8 Bourne PA. Using the biopsychological Model to evaluate the wellbeing of the Jamaican elderly. West Indian Medical J 56 (2007b) [Abstract]; (Suppl 3), pp. 39-40. 9 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 21 (2002), pp.31-46. 10 World Health Organization. Preventing Chronic Diseases a vital investment. Geneva: WHO; 2005. 11 Muller O, Krawinkel M. Malnutrition and health in developing countries. Canadian Medical Association Journal 173(2005):279-286. 12 Bloom DE, Canning D. The health and poverty of nations: From theory to practice. Journal of Human Development 4(2003):47-72. 13 Lynch JW, Kaplan GA, Shema SJ. Cumulative impact of sustained economic hardship on physical cognitive, psychological, and social functioning. New England Journal of Medicine 337(1997):1889–1895. 14 Menchik PL. Economic status as a determinant of mortality among black and white older men: Does poverty kill? Population Studies 47(1993):427–436. 15 Zick CD, Ken RS. Marital transitions, poverty and gender differences in mortality. Journal of Marriage and the Family 53(1991): 327–336 16 Murray S. Poverty and health. Canadian Medical Association Journal 174(2006):923923. 17 Barrett R, Kuzawa C, McDade W, Armelagos GJ. Emerging and re-emerging infectious diseases: The Third Epidemiologic Transition. Annual Reviews Anthropology 27(1998):247-71. 18 Organization of Eastern Caribbean States (OECS). Human development report. Trinidad and Tobago. SCRIP-J Printers; 2002. 19 Ranis G Stewart F. 2001. Growth and human development: Comparative Latin American Experience. The Developing Economies, XXXIX 4(2001): 333-65. Retrieved on October 12, 2006 from http://www.ide.go.jp/English/Publish/De/pdf/01_04_01.pdf. 20 Dalzell-Ward A. A textbook of health education. London: Tavistock Publications; 1974. 21 CAJANUS. Focus on the elderly. The Caribbean Food and Nutrition Institute Quarterly 32(1999):179-240. 22 Anthony BJ. Nutritional Assessment of the elderly. The Caribbean Food and Nutrition Institute Quarterly 32(1999):201-216. 23 Franc C, Perronnin M, Pierre A. Private supplementary health insurance: Retirees’ demand. Document de travail working paper No. 9. France; 2008. 24 World Bank. World development indicators. Washington, D.C.: IRDB; 2005 203

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26 Herzog AR. Physical and mental health in older women: Selected research issues and data sources. In Health and economic status of older women: Research Issues and Data Sources. Ed. J. A. Hendricks. New York: Baywood Publishing; 1989. 27 Schoen C, Davis K, DesRoches C, Shekhdar A. The health of adolescent boys: Commonwealth Fund survey findings. New York: Commonwealth Fund; 1998. 28 Friedman HS, ed. Hostility, coping, and health. Washington, DC: American Psychological Association; 1991. 29 Kopp MS., Skrabski A, Szedmak S. Why do women suffer more and live longer? Psychosomatic Medicine 60(1998):92-135. 30 Weidner G, Collins RL. Gender, coping, and health. In H.W. Krohne ed. Attention and avoidance. Seattle: Hogrefe and Huber; 1993. 31 Sutkin L, Good G. Therapy with men in health-care settings. In M. Scher, M. Stevens, G. Good, & G.A. Eichenfield eds. Handbook of counseling and psychotherapy with men (pp. 372-387). Los Angeles: Sage Publications; 1987. 32 Courtenay WH et al. Gender and ethnic differences in health beliefs and Behaviors. Journal of Health Psychology 7(2002):219-231. 33 Moore EG, Rosenberg MW, McGuinness D. Growing old in Canada: Demographic and geographic perspectives. Ontario: Nelson; 1997. 34 Koo J, Rie J, Park K. Age and gender differences in affect and subjective wellbeing. Geriatrics and Gerontology International, 4(2004):S268-S270. 35 Smith KR, Waitzman NJ. Double jeopardy: Interaction effects of martial and poverty status on the risk of mortality. Demography 31(1994):487-507. 36 Lillard LA, Panis CWA. 1996. Demography 33(1996):313-327. Marital status and mortality: The role of health.

37 Lusyne P, Page H, Lievens J. Mortality following conjugal bereavement, Belgium 199196: The unexpected effect of education. Population studies 55(2001):281-289. 38 Lynch SM. Cohort and life-course patterns in the relationship between education and health: A hierarchical approach. Demography 40 (2003):309-331. 39 Ross CE, Mirowsky J. Refining the association between education and health: The effects of quantity, credential, and selectivity. Demography 36(1999):445-460. 204

40 Winkleby MA., et al. 1992. Socioeconomic status and health: How education, income, and occupation contribute to risk factors for cardiovascular disease. American Journal of Public Health 82(1992): 816-820. 41 Smith JP, Kington R. Demographic and Economic Correlates of Health in Old Age. Demography 34(1997):159-170. 42 Grossman M. The demand for health- a theoretical and empirical investigation. New York: National Bureau of Economic Research; 1972. 43 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 17(2005):342-352. 44 Planning Institute of Jamaica (PIOJ) and Statistical Institute of Jamaica (STATIN). Jamaica Survey of Living Conditions, 2002-2007. Kingston: PIOJ, STATIN; 2003-2008. 45 WHO. The Social Determinants of Health; 2008. Available at http://www.who.int/social_determinants/en/ (accessed April 28, 2009). 46 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. 47 Wilkinson RG, Marmot M. Social Determinants of Health. The Solid Facts, 2nd ed. Copenhagen: World Health Organization; 2003. 48 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). 49 Graham H. Social Determinants and their Unequal Distribution Clarifying Policy Understanding The Milbank Quarterly 2004; 82 (1), 101-124. 50 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.

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Table 8.1. Reason for Not Seeking Health Care and Public/Private Health Care Utilization by Income Quintile Could not afford it Quintile Poorest 20% 2 3 4 5 35.2 19.2 19.5 14.6 16.7 71.0 51.1 50.6 27.5 21.7 24.3 42.3 42.9 65.4 73.9 Public Private

Source: Planning Institute of Jamaica and the Statistical Institute of Jamaica. Jamaica Survey of Living conditions, 2006. PIOJ and STATIN; 2007.

206

Table 8.2. Socio-demographic Characteristics of Sample, n = 9,931 Details Gender Male Female Marital Status Married Never married Divorced Separated Widowed Self-reported Health Conditions None At least one condition Educational Level Primary and below education Secondary and post-secondary Tertiary Property (i.e. land) ownership No Yes Crowding Age 4,799 5,129 48.3 51.7 Number Percent

1,255 4,020 19 51 326

21.7 71.3 0.3 0.9 5.8

8,268 1,475

84.9 15.1

1,197 3,885 66

23.3 75.5 1.3

2,849 3,927

42.0 58.0

2.6 ±1.6 person per room; Range = 11, 1 to 12 persons 26.1 ± 22.5 years; Range = 99 years, 0 to 99 yrs.

207

Table 8.3. Logistic Regression: Self-reported Health Conditions of those in the lower socioeconomic strata by some explanatory variable Odds Ratio 95.0% C.I. Age Loneliness Averaged income Physical environment Separated, Divorced, & Widowed Married Referent group (never married) Other towns Urban areas Referent group (rural) Secondary Tertiary Referent group (primary or below) Social Support Crowding Negative affective Positive affective Health insurance Retirement income Sex (1= male) Crime index
Nagelkerke R-squared = 0.396 -2 Log Likelihood = 3,389.1 Model χ2 (df = 19) = 1,365.5, P = 0.001 *P < 0.05, **P < 0.01, ***P < 0.001

1.04 0.88 1.00 1.04 1.19 1.29 1.00 0.67 0.89 1.00 1.44 1.25 1.00 1.17 0.98 1.07 1.00 8.23 1.26 0.46 1.01

1.04 – 1.05*** 0.69 – 1.13 1.00 – 1.00** 0.87 – 1.25 0.87 – 1.63 1.04 -1.59* 0.52 – 0.87** 0.64 – 1.22

1.15 – 1.81** 0.54 – 2.87

0.98 – 1.40 0.91 – 1.06 1.05 – 1.10*** 0.96 – 1.03 0.00 0.92 – 1.71 0.39 – 0.56*** 1.00 – 1.02**

208

Chapter Nine

Paradoxities in self-evaluated health data in a developing country
Paul A. Bourne

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. 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 209

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 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 210

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?

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%. 211

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 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 212

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 [2237], 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. 213

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 (i.e. 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, It ; 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 (i.e. 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, 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 214

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. Medical care-seeking behaviour therefore was coded as a binary measure where 1=Yes and 0= otherwise. 215 (3) (4)

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 9.1). 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 9.2).

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Table 9.3 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 9.4). 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 9.5). The model is a very good fit for the data – χ2 = 33.7, P < 0.001, Hosmer and Lemeshow Test P = 0.766 (Table 9.5).

Discussion

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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 218

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 219

paradox can be unraveled in the definition of health and socialization of males in Jamaica. 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 220

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 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

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ratios as for 2000 to 2004, which implies that gender is creating a noise when collecting data on men’s health in Jamaica. 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

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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 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 223

49% of the sample being males, it follows that paradoxities identified in the current study highlights the difficulties in interpreting health data in Jamaica.

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.

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.

References
1. Planning Institute of Jamaica (PIOJ), Statistical Institute of Jamaica (STATIN). Jamaica Survey of Living Conditions, 1988-2007. Kingston: PIOJ, STATIN; 1989-2008. 2. STATIN. Demographic statistics, 2005-2007. Kingston: STATIN; 2006-2008. 224

3. Hutchinson G, Simeon DT, Bain BC, Wyatt GE, Tucker MB, LeFranc E. 2004. Social and Health determinants of well-being and life satisfaction in Jamaica. Int J of Soci Psychiatry. 50:43-53. 4. Bourne PA. Socio-demographic determinants of health care-seeking behaviour, selfreported illness and self-evaluated health status in Jamaica. Int J of Collaborative Research on Internal Med and Public Health 2009;1:101-130. 5. Bourne PA, Rhule J. Good Health Status of Rural Women in the Reproductive Ages. International Journal of Collaborative Research on Internal Medicine & Public Health, 1(5):132-155. 6. Bourne PA. Medical sociology: Modelling well-being for elderly people in Jamaica. West Indian Med J 2008;57:596-604. 7. PIOJ. Economic and Social Survey Jamaica, 1980-2008. Kingston: PIOJ; 1981-2009. 8. Bourne PA. A theoretical framework of good health status of Jamaicans: using econometric analysis to model good health status over the life course. North American Journal of Medical Sciences. 2009;1: 86-95. 9. Bourne PA, McGrowder DA, Crawford TV. Decomposing mortality rates and examining health status of the elderly in Jamaica. The Open Geriatric Med J 2009 2:34-43. 10. Abel WA, Bourne PA, Hamil HK, Thompson EM, Martin JS, Gibson RC, Hickling FW. A public health and suicide risk in Jamaica from 2002 to 2006. North American Journal of Medical Sciences 2009;1:142-147. 11. Bourne PA. Childhood Health in Jamaica: changing patterns in health conditions of children 0-14 years. North American Journal of Medical Sciences. 2009;1:160-168. 12. Bourne PA. Demographic shifts in health conditions of adolescents 10-19 years, Jamaica: using cross-sectional data for 2002 and 2007. North American Journal of Medical Sciences. 2009;1:125-133. 13. 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. 14. World Bank, Development Research Group, Poverty and human resources. Jamaica Survey of Living Conditions (LSLC) 1988-2000: Basic Information. Washington DC; 2002. Retrieved on August 14, 2009, from, http://www.siteresources.worldbank.org/INTLSMS/Resources/.../binfo2000.pdf 15. Cohen L, Holliday M. Statistics for Social Sciences. London: Harper & Row; 1982. 16. Cohen J, Cohen P. Applied regression/correlation analysis for the behavioral sciences, 2nd ed. New Jersey: Lawrence Erlbaum Associates; 1983. 17. Hair JF, Black B, Babin BJ, Anderson RE, Tatham RL. Multivariate data analysis, 6th ed. New Jersey: Prentice Hall; 2005. 18. Mamingi N. Theoretical and empirical exercises in econometrics. Kingston: University of the West Indies Press; 2005. 19. Zar JH. Biostatistical analysis, 4th ed. New Jersey: Prentice Hall; 1999. 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. 225

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. 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. 226

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 9.1. 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 9.2. Socio-demographic characteristic of sample by educational level
Characteristic
Primary Secondary

Educational level
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

< 0.05 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) 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 9.3. Socio-demographic characteristic of sample by self-reported illness
Self-reported illness P

Yes %

No %

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 Health insurance coverage None Private coverage Public coverage Total Age Mean (SD) in years Medical Expenditure1 Mean (SD) in US$
1

>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 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 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 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) 79.8 12.5 7.7 6503 < 0.05 <0.05

Rate in 2007:US$1.00 = Ja$80.47

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Table 9.4. Stepwise Logistic Regression: Good self-rated health status by sociodemographic, economic and biological variables R-squared Variable SE P Odds ratio 95.0% C.I. Self-reported illness Medical care-seeking Age Income 0.48 0.18 0.01 0.00 0.002 0.000 0.000 0.007 0.000 0.23 0.51 0.97 1.00 16.03 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 9.5. 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 Ten Self-reported health and health care utilization of older people

Paul A. Bourne1 , Christopher A.D. Charles2, Cynthia G. Francis1 & Stan Warren
Department of Community Health and Psychiatry, Faculty of Medical Sciences University of the West Indies, Mona, Kingston, Jamaica
2 1

King Graduate School, Monroe College, 2375 Jerome Avenue, Bronx, New York 10468 And Center for Victim Support, Harlem Hospital Center, New York
3

Department of Sociology, Psychology and Social Work, Faculty of Social Sciences University of the West Indies, Mona, Kingston, Jamaica

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.
1

Corresponding author: Paul A. Bourne, Research Fellow and Biostatistician, Dept of Community Health and Psychiatry, UWI, Mona, Jamaica. Email: paulbourne1@yahoo.com. 876 457-6990 (mobile).

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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]. Based on Figures 10.1 and 10.2, 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

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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 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 (i.e. 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 235

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 (i.e. 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. 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 236

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.
E l d e r l y 25 20 15 10 5 0 60+ 65+ 80+ 1950 6.9 4.5 0.5 1975 8.1 5.4 0.7 60+ 2000 9.9 6.9 1.4 65+ 80+ 2025 16.1 11.1 2.3 2050 23.8 18 5.1

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

Figure 10.1. Caribbean Elderly population as a percentage of total population

( % )

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30 E l 25 d 20 e % 15 r 10 l y 5 ( ) 0 60+ 65+ 80+ 1950 5.8 3.9 0.2 1975 8.5 5.8 0.8 60+ 65+ 2000 9.6 7.2 1.8 80+ 2025 14.5 9.9 2.1 2050 24 18.1 4.8

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

Figure 10.2. Jamaica Elderly population as a percentage of total population

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 238

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 (i.e. LFS) was selected for the JSLC. The sample was weighted to 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. 239

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.

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Table 10.0. 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

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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 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 10.1). Fortyfour 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 10.1, 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% 242

in arthritic cases (Table 10.1). 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 percentage 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%). Based on Table 10.2, 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 10.3). Table 10.4 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 was 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. 243

A cross-tabulation between health status and sex of respondents revealed no significant statistical correlation (χ2 (df = 4) = 3.867, P > 0.05) (Table 10.5). 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 10.6). Table 10.6 indicated that the poorest 20% had a very good 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 10.7). Based on Table 10.8, 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 244

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 10.9). 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 10.10). 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 expenditure, with those who recorded very poor health status spent more than those with a poor health status. Table 10.11 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 10.11). Based on Table 10.11, 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 10.12). 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) = 245

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. Based on Figure 10.3, 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%).
50 45 P e r c e n t 40 35 30 25 20 15 10 5 0 2002 2007 Poorest 20% 0.8 21.4 Poor 0.90 33.30 2002 Middle 2.9 27.7 2007 Wealthy 3 22.2 Wealthiest 20% 7.8 43.5

Figure 10.3. Percentage of population 80+ years with health insurance coverage, 2002 and 2007 246

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. 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 247

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, 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 248

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+ year olds in Newcastle (i.e. 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 249

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 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. 250

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 (i.e. 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 251

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%. 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 252

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 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 careseeking 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 253

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 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. 254

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 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 255

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 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 self256

reported 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.

References
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Table 10.1. 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

262

Table 10.2. Diagnosed health conditions by area of residence
Variable 20021 20072

Diagnosed Health conditions Cold Diarrhoea Asthma Diabetes Hypertension Arthritis Other No
1 2

Rural

Semi-urban

Urban

Rural

Semi-urban

Urban

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

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

2 2

263

Table 10.3. Health status by area of residence
Variable 20021 20072

Health status Very good Good Moderate Poor Very poor
1

Rural NI NI NI NI NI

Semi-urban NI NI NI NI NI

Urban NI NI NI NI NI

Rural 6.4 31.9 38.3 21.3 2.1

Semi-urban 6.1 18.2 33.3 30.3 12.1

Urban 6.5 10.4 44.2 28.6 10.4

2 2

NI χ (df = 8) = 11.899, P > 0.05

NI No information available

264

Table 10.4. 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

265

Table 10.5. 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

266

Table 10.6. 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

267

Table 10.7. 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

268

Table 10.8. 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

269

Table 10.9. Diagnosed health conditions by health care seeking behaviour
Variable 20021 Health care-seeking behaviour 20072 Health care-seeking behaviour

Diagnosed Health conditions Cold Diarrhoea Asthma Diabetes Hypertension Arthritis Other No
1 2 2 2

Yes

No

Yes

No

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

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

270

Table 10.10. Health status by Annual total expenditure, 2007 Descriptive statistics 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

95% Confidence Interv

305,535.97 - 2,588,5 438,146.81 - 865,2 341,591.79 - 543,3 339,847.05 - 606,6 372,800.66 - 631,8 461,261.72 - 655,3

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

271

Table 10.11. Self-reported health conditions by total expenditure, 2002 and 2007 20021

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

95% Confidence Mean Lower Bound Up . . . 132,665.90 70,773.02 45,436.40 142,452.01

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

4

272

Table 10.12. 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% C

Lower

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

273

Chapter Eleven Health of females in Jamaica: using two cross-sectional surveys
Paul A. Bourne

Introduction
Life expectancy is among the objective indexes for measuring health for a person, society, or population. In 1880-1882, life expectancy at birth for females in Jamaica was 39.8 years which was 2.79 years more than that for males. One hundred and twenty-two years later, health disparity increased to 5.81 years: in 2002-2004, life expectancy at birth for females was 77.07 years [1]. For the world, the difference in life expectancy for the sexes was 4.2 years more for females than males: for 2000-2005, life expectancy at birth for females was 68.1 years [2]. Within the expanded conceptual framework offered by the World Health Organization (WHO) in the late 1940s, health is more than the absence of morbidity as it includes social, psychological and physiological wellbeing [3]. Some scholars [4] opined that using the opposite of ill-health to measure health is a negative approach as health is more than this biomedical approach. Brannon and Feist [4] forwarded a positive approach which is in keeping with the ‘Biopsychosocial’ framework developed by Engel. Engel coined the term Biopsychosocial when he forwarded the perspective that patient care must integrate the mind, body and social environment [5-8]. He believed that mentally patient care is not merely about the illness, as other factors equally influence the health of the patient. Although this was not new because the WHO had already stated this, it was the application which was different from the traditional biomedical approach to the study and 274

treatment of ill patients. Embedded in Engel’s works were wellbeing, wellness and quality of life and not merely the removal of the illness, which psychologists like Brannon and Feist called the positive approach to the study and treatment of health. Recognizing the limitation of life expectancy, WHO therefore developed DALE – Disability Adjusted Life Expectancy – which discounted life expectancy by number of years spent in illness. The emphasis in the 21st Century therefore was healthy life and not length of life (ie life expectancy) [9]. DALE is the years in ill health which is weighted according to severity, which is then subtracted from the expected overall life expectancy to give the equivalent healthy years of life. Using healthy years, statistics revealed that the health disparity between the sexes in Jamaica was 5 years in 2007 [10], indicating that self-rated health status of females on average in Jamaica is better than that for males. This is not atypical to Jamaica as females in many nations had a greater healthy life expectancy than males. The discipline of public health is concerned with more than accepting the health disparity as indicated by life expectancy or healthy life expectancy, as it seeks to improve the quality of life of the populace and the various subgroups that are within a particular geographical border. In order for this mandate to be attained, we cannot exclude the study of females’ health merely because they are living longer than males and accept this as a given; and that there is not need therefore to examine their self-rated health status. Many empirical studies that have examined health of Caribbean nationals were on the population [11-15]; elderly [16-25]; children [26, 27]; adolescents [28-30] and females have been omitted from the discourse. A comprehensive search of health literature in Caribbean in particular Jamaica revealed no studies. The values for the healthy life expectancy cannot be 275

enough to indicate the self-rated health status of females neither can we use self-rated health status of population, children, elderly and adolescents to measure that of females. WHO [31] forwarded a position that there is a disparity between contracting many diseases and the gender constitution of an individual, suggesting that population health cannot be used to measure female health. Females have a high propensity than males to contract particular conditions such as depression, osteoporosis and osteoarthritis [31]. A study conducted by McDonough and Walters [32] revealed that women had a 23 percent higher distress score than men and were more likely to report chronic diseases compared to males (30%). It was found that men believed their health was better (2% higher) than that self-reported by females. McDonough and Walters used data from a longitudinal study named Canadian National Population Health Survey (NPHS). Those aforementioned realities justify a study on female health in Jamaica. The current study fills the gap in the health literature by investigating health of females in Jamaica. The objectives of the current study are 1) to examine the health conditions; 2) provide an epidemiological profile of changing health conditions in the last one half decade (2002-2007); 3) evaluate whether self-reported illness is a good measure of self-rated health status; 4) compute the mean age of females having particular health conditions; 5) calculate the mean age of being ill compared with those who are not ill; and 6) assess the correlation between self-rated health status and income quintile.

Materials and methods
Sample 276

The current study extracted subsample of females from two secondary cross-sectional data collected by the Planning Institute of Jamaica and the Statistical Institute of Jamaica [33, 34]. In 2002, a subsample of 12,675 females was extracted from the sample of 25,018 respondents and for 2007; a subsample of 3,479 females was extracted from 6,783 respondents. The survey is called the Jamaica Survey of Living Conditions (JSLC) which began in 1989. The JSLC is modification of the World Bank’s Living Standards Measurement Study (LSMS) household survey. A self-administered questionnaire is used to collect the data from Jamaicans. Trained data collectors are used to gather the data; and these individuals are trained by the Statistical Institute of 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 (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 (i.e. LFS) was selected for the JSLC. The sample was weighted to reflect the population of the nation. The non-response rate for the survey for 2007 was 26.2% and 27.7%. Measures

277

Self-reported illness (or Health conditions): 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 (self-rated health status): “How is your health in general?” And the options were very good; good; fair; poor and very poor. The first time this was collected for Jamaicans, using the JSLC, was in 2007. 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). 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 socio-demographic variables of the sample. Cross Tabulations were employed to examine correlations between nonmetric variables and Analysis of Variance (ANOVA) were utilized to examine statistical associations between a metric and non-metric variable. The level of significance used in this research was 5% (ie 95% confidence interval).

278

Bryman and Cramer [35] correlation coefficient values were used to determine, the strength of a relation between (or among) variables: 0.19 and below, very low; 0.20 to 0.39, low; 0.40 to 0.69, moderate; 0.70 to 0.89, high (strong); and 0.90 to 1 is very high (very strong).

Results
Demographic characteristic of sample In 2002, 14.7% of sample reported an illness and this increased by 19.1% in 2007. Over the same period, health insurance coverage increased by 81.0% (to 21.0% in 2007); those seeking medical care increased to 67.6% (from 66.0%); the mean age in 2007 was 30.6±21.9 years which marginal increased from 29.4 ± 22.3 years; diabetic cases exponentially increased by 227.7% (in 2007, 15.4%); hypertension decline by 45.5% (to 24.8% in 2007) and arthritic cases fell by 66.1% (to 9.4% in 2007). Urbanization was evident between 2007 and 2002 as the number of females who resided in urban areas increased by 114.7% (to 30.4% in 2007), with a corresponding decline of 19.4% in females zones. Table 11.1 revealed that the increase in self-reported illness was substantially accounted for by increased cases in the rural sample (from 12.9% in 2002 to 20.0% in 2007). The drastic increase in health insurance coverage in 2007 was due to public establishment of public health insurance coverage. The greatest increase was observed in semi-urban areas 17.8%) followed by urban (9.6%) and rural (7.8%) Table 11.1. The increases in self-reported illness can be accounted for by diabetes mellitus, asthma and other dysfunctions. Concurrently, most of the increased cases were diabetic in semi-urban zones (17.1%); other health conditions in semi-urban areas (12.4%) and asthma in urban zones (12.0%) (Table 11.1). 279

Bivariate analyses There was a significant statistical correlation between self-rated health status and self-reported illness - χ2 (df = 4) = 700.633, P < 0.001; with there being a negative moderate relation between the variables – correlation coefficient = - 0.412 (Table 11.2). Based on Table 11.2, 10.7% of those who reported an illness had had very good self-rated health status compared to 40.2% of those who did not indicate an illness. On the other hand, 2.5% of those who did not report a dysfunction had at least poor self-rated health status compared to 19.8% of those who indicated having an illness. Even after controlling self-rated health status and self-reported illness by age, marital status and per capita annual expenditure, a moderate negative correlation was found – correlation coefficient = - 0.362. On further examination of the self-reported illness by age, it was found that in 2002 the mean age of individual who reported an illness was 43.97 ± 26.81 years compared to 27.05 ± 20.41 years for who without an illness – t-test = 30.818, P < 0.001. In 2007, the mean age of reporting an illness was 42.83 ± 26.53 years compared to 28.16 ± 19.95 years for those who did not report an ailment – t-test = 15.263, P < 0.001. Based on Figure 11.1, there is an increase in the mean age of females being diagnosed with diarrhoea (32.00 ± 36.2 years) and asthma (21.73 ± 20.51 years). However, there is reduction in the mean age of females reported being diagnosed with chronic illness such as diabetes mellitus (60.54 ± 17.14 years); hypertension (60.85 ± 16.93 years) and arthritis 59.72 ± 15.41 years). The greatest decline in mean age of chronically ill diagnosed females was in arthritic cases (by 7.41 years). Concurrently, the mean age of females with unspecified health conditions fell by (33%, from 54.62 ± 21.77 years in 2002 to 36.42 ± 23.69 years in 2007).

280

A cross tabulation between self-rated health status and income quintile revealed a significant statistical correlation - χ2 (df = 16) = 54.044, P < 0.001; with the relationship being a very weak one – correlation coefficient = 0.126 (Table 11.3). Based on Table 3, the wealthy reported the greatest self-rated health status (ie very good) compared to the wealthiest 20% (36.7%); with the poorest 20% recorded the least very good self-rated health status. No significant statistical correlation was found between diagnosed self-reported illness and income quintile - χ2 (df = 28) = 36.161, P > 0.001 (Table 11.4).

Discussion
Self-rated health status of female Jamaicans can be measured using self-reported illness. The current study found a moderate significant correlation between the two aforementioned variables, suggesting that self-reported illness is a relatively good measure of female’s health. In this study it was revealed that 60 out of every 100 who reported an illness had at most fair self-rated health status, with 20 out every 100 indicated a least poor health. It is evident from the findings that self-rated health status is wider than illness, which concurs with the literature [35, 36], which is keeping with the propositions of the WHO that health must be more than the absence of illness. Self-rated health status is people’s self-rated perspective on their general self-rated health status [35], which includes a percentage of poor health (or ill-health). The other components of this status include life satisfaction, happiness, and psychosocial wellbeing. Using a sample of elderly Barbadians, Hambleton et al [37] found 33.5% of explanatory power of self-rated health status is accounted for by illness. There is a disparity between the current study and that of Hambleton et al’s work as more of self-rated health status of the elderly is explained by current illness with this 281

being less for females in Jamaica. Concomitantly, there is an epidemiological shift in the typology of illnesses affecting females as the change is towards diabetes mellitus. In 2007 over 2002, the 15 out of every 100 females reported being diagnosed with diabetes mellitus compared to 5 in 100 in 2002 indicating the negative effects of life behaviour of female’s self-rated health status. Another important finding of the current study is that diagnosed illnesses are not significantly different based on income quintile in which a female is categorized. However, the self-rated health status of females in different social standing (measured using income quintile) is different. Embedded in this finding is the role of income plays in improving self-rated health status [38]. Like Marmot [38], this study found that income is able to buy some improvement in self-rated health status; but this work goes further as it found that income does not reduce the typology in health conditions affecting females. Before this discussion can proceed, the discourse must address the biases in subjective indexes which are found in studies like this one. Any study on subjective indexes in the measurement of health (for example, happiness, life satisfaction; self-rated health status, selfreported illness) needs to address the challenges of biases that are found in self-reported data in particular self-reported health data. The discourse of subjective wellbeing using survey data cannot deny that it is based on the person’s judgement, and must be prone to systematic and nonsystematic biases [40]. Diener [36] argued that the subjective measure seemed to contain substantial amounts of valid variance, suggesting that there is validity to the use of this approach in the measurement of health (or wellbeing) like the objective indexes such as life expectancy, mortality or diagnosed morbidity. A study by Finnas et al [41] opined that there are some methodological issues surrounding the use of self-reported (or self-rated) health and that these may result in incorrect inference; but that this measure is useful in understanding health, 282

morbidity and mortality. Using life expectancy and self-reported illness data for Jamaicans, Bourne [42] found a strong significant correlation between the two variables (correlation coefficient, R = - 0.731), and that self-reported illness accounted for 54% of the variance in life expectancy. When Bourne [42] disaggregated the life expectancy and self-reported illness data by sexes, he found a strong correlation between males’ health (correlation coefficient, R = 0.796) than for females (correlation coefficient, R = 0.684). Self-reported data therefore do have some biases; but that it is good measure for health in Jamaica and more so for males. In spite of this fact, the current research recognized some of the problems in using self-reported health data (read Finnas et al. [41] for more information), while providing empirical findings using people’s perception on their health. Now that the discourse on objective and subjective indexes is out of the way, the next issue of concern is the reduced aged of reported illness and age of being diagnosed with particular chronic illness. In 2002, the mean age recorded for those who self-reported an illness was 44 years and this fell by 1 year in 2007, indicating that on average females are becoming diagnosed with an illness on average 2 months earlier. When self-reported illness was

disaggregated into acute and chronic health conditions, it was revealed that on average females were being diagnosed 7.41 years earlier with arthritis in 2007 over 2002; 4.95 years earlier with hypertension and 1.13 years earlier with diabetes mellitus.

Conclusion

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The current study revealed that rural females recorded the highest percentage of self-reported illness. Concurrently, in 2007, 20 out of every 100 females in rural Jamaica reported an ailment which is a 3.7% increase over 2002 compared to a 3.1% increase in urban and 2.2% increase in semi-urban females. Furthermore, poverty was greatest for rural females. In 2002, poverty among rural females was 2.2 times more than urban poverty; and this increased to 3.3 times in 2007. In addition to the aforementioned issues, there is a shift in chronic illnesses occurring in females in Jamaica. Hypertension and arthritis have seen a decline in 2007 over 2002; however, there were noticeable increases in diabetes mellitus over the same period. The greatest increase in cases of diabetes mellitus occurred in semi-urban females followed by urban and rural females. In summing, the current study has revealed that, although healthy life expectancy for females at birth in Jamaica is 66 years, improvements in their self-rated health status cannot be neglected as there are shifts in health conditions (to diabetes mellitus) as well as the decline in ages at which females are being diagnosed with particular chronic illnesses. There is an issue which emerged from the current finding, the increasing cases of unspecified illness among females and this must be examined as to classification in order that public health practitioners will be able to address it before it unfolds into a public health challenge in the future.

References
1. Statistical Institute of Jamaica, (STATIN). Demographic statistics, 2005. Kingston: STATIN; 2006. 2. Department of Economic and Social Affairs Population Division, United Nations, (UN). World population ageing 19590-2050. New York: United Nations; 2002.

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3. World Health Organization, (WHO). 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: WHO, 1948. 4. Brannon L, Feist J. Health psychology. An introduction to behavior and health 6th ed. Los Angeles: Thomson Wadsworth; 2007. 5. Engel G. 1960. A unified concept of health and disease. Perspectives in Biology and Medicine 1960;3:459-485. 6. Engel G. The care of the patient: art or science? Johns Hopkins Medical Journal 1977;140:222-232. 7. Engel G. The need for a new medical model: A challenge for biomedicine. Science 1977;196:129-136. 8. Engel G . The biopsychosocial model and the education of health professionals. Annals of the New York Academy of Sciences 1978;310: 169-181. 9 WHO. WHO Issues New Healthy Life Expectancy Rankings: Japan Number One in New ‘Healthy Life’ System. Washington & Switzerland: WHO; 2000. 10. WHO. World health statistics, 2009. Geneva: WHO; 2009. 11. Bourne, P.A. (2009). A theoretical framework of good health status of Jamaicans: using econometric analysis to model good health status over the life course. North American Journal of Medical Sciences, 1(2): 86-95. 12. Bourne PA. Socio-demographic determinants of Health care-seeking behaviour, selfreported illness and Self-evaluated Health status in Jamaica. International Journal of Collaborative Research on Internal Medicine & Public Health, 2009, 1 (4):101-130. 13. Bourne PA. Health Determinants: Using Secondary Data to Model Predictors of Wellbeing of Jamaicans. West Indian Med J. 2008; 57:476-81. 14. Hutchinson G, Simeon DT, Bain BC, Wyatt GE, Tucker MB, LeFranc E. 2004. Social and Health determinants of well-being and life satisfaction in Jamaica. Int J of Soci Psychiatry. 2004;50:43-53. 15. Asnani MR, Reid ME, Ali SB, Lipps G, Williams-Green. Quality of life in patients with sickle cell disease in Jamaica: rural-urban differences. J of Rural and Remote health 2008;8:890. 285

16. 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. 17: 342-352. 17. Brathwaite FS. The elderly in the Commonwealth Caribbean: A review of research findings. Ageing and Society 1989;9:297-304. 18. Brathwaite FS. The elderly in Barbados: problem and policies. Bulletin of the Pan American Health Organization 1990;23:314-29. 19.Eldemire D. The Jamaican elderly: A socioeconomic perspective and policy implications. Social and Economic Studies 1997;46: 175-193. 20.Eldemire D. Older women: A situational analysis, Jamaica 1996. New York: United Nations Division for the Advancement of Women; 1996. 21. Palloni A, Pinto-Aguirre G, Pelaez M. Demographic and health conditions of ageing in Latin America and the Caribbean. Int J of Epidemiology 2002;31:762-771. 22. Eldemire D. The elderly and the family: The Jamaican experience. Caribbean Affairs 1994;19:31-46. Bulletin of Eastern

23. Bourne PA, McGrowder DA, Crawford TV. Decomposing Mortality Rates and Examining Health Status of the Elderly in Jamaica. The Open Geriatric Med J. 2009; 2:34-44. 24. 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. 25. Bourne PA. 2008. Medical Sociology: Modelling Well-being for elderly People in Jamaica. West Indian Med J 57:596-04. 26. Walker S. Nutrition and child health development. In: Morgan W, editor. Health issues in the Caribbean. Kingston: Ian Randle; 2005: p. 15-25. 27. Samms-Vaughn M, Jackson M, Ashley D. School achievement and behaviour in Jamaican children. In: Morgan W, editor. Health issues in the Caribbean. Kingston: Ian Randle; 2005: p. 26-37. 28. Frederick J, Hamilton P, Jackson J, Frederick C, Wynter S, DaCosta V, Wynter H. Issues affecting reproductive health in the Caribbean. In: Morgan W, editor. Health issues in the Caribbean. Kingston: Ian Randle; 2005: p. 41-50. 29. Bourne PA. Demographic shifts in health conditions of adolescents 10-19 years, Jamaica: Using cross-sectional data for 2002 and 2007. North American Journal of Medical Sciences 286

2009; 1:125-133. 30. Blum RW, Halcon L, Beuhring T, Pate E, Campbell-Forrester S, Venema A. Adolescent heath in the Caribbean: Risk and protective factors. American Journal of Public Health 2003; 93: 456-460. 31. WHO. Ageing and health, epidemiology. Regional Office in Africa: WHO; 2005. 32. McDonough P, Walters V. Gender and health: reassessing patterns and explanations. Social Science and Medicine 2001; 52:547-559. 33. 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. 34.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. 35. Bryman A, Cramer D. Quantitative data analysis with SPSS 12 and 13: a guide for social scientists. London and New York: Routledge; 2005: p. 214-219. 35. Kahneman D, Riis J. Living, and thinking about it, two perspectives. In: Huppert FA, Kaverne B, Baylis N, editors. The science of well-being: Integrating neurobiology, psychology, and social science. London: Oxford University Press; 2005. p. 285-304. 36. Diener E. Subjective well-being. Psychological Bulletin, 1984;95:542–75 37. Hambleton IR, Clarke K, Broome HL, Fraser HS, Brathwaite F, Hennis, A.J. Historical and current predictors of self-reported health status among elderly persons in Barbados. Revista Panamericana de salud Públic 2005; 17, 342-352. 38. 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, pp.31-46. 40. Schwarz N, Strack F. Reports of subjective well-being: judgmental processes and their methodological implications. In: Kahneman D, Diener E, Schwarz N, editors. Well-being: The Foundations of Hedonic Psychology. Russell Sage Foundation: New York; 1999;pp 61-84. 41. Finnas F, Nyqvist F, Saarela J. Some methodological remarks on self-rated health. The Open Public Health J 2008;1:32-39.

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42. Bourne P. Is self-reported health a good measure of objective health? North American J of Medical Sciences. In print.

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Table 11.1. Sociodemographic characteristics of sample by area of residence, 2002 and 2007
2002 Variable Rural Marital status Married Never married Divorced Separated Widowed Income quintile Poorest 20% Poor Middle Wealthy Wealthiest 20% Health conditions Diagnosed Acute: Cold Diarrhoea Asthma Diagnosed Chronic: Diabetes mellitus Hypertension Arthritis Other Non-diagnosed Self-reported illness Yes No Health care-seekers Yes No Health insurance Yes, Private Yes, Public No Age Mean (SD) in yrs SemiUrban 568 (25.7) 1452 (65.7) 16 (0.7) 27 (1.2) 147 (6.7) Urban Rural SemiUrban 111 (21.0) 362 (68.6) 16 (3.0) 5 (0.9) 34 (6.4) Urban 2007

1232 (25.7) 3033 (63.3) 25 (0.5) 51 (1.1) 453 (9.4)

243 (19.3) 907 (71.9) 18 (1.4) 22 (1.7) 71 (5.6)

262 (23.9) 723 (65.9) 11 (1.0) 12 (1.1) 89 (8.1)

161 (21.2) 523 (68.9) 16 (2.1) 8 (1.1) 51 (6.7)

1864 (24.8) 1867 (24.8) 1559 (20.7) 1340 (17.8) 894 (11.9)

450 (13.5) 511 (15.3) 652 (19.2) 759 (22.7) 965 (28.9)

206 (11.4) 231 (12.7) 331 (18.2) 441 (24.3) 605 (33.4)

498 (29.9) 437 (26.2) 342 (20.5) 237 (14.2) 154 (9.2)

77 (10.2) 146 (19.4) 161 (21.4) 183 (24.3) 185 (75.2)

97 (9.2) 131 (12.4) 212 (20.0) 265 (25.0) 354 (33.4)

1 (0.7) 3 (2.2) 1 (0.7) 8 (6.0) 57 (42.5) 38 (28.4) 26 (19.4) 1181 (16.3) 6051 (83.7)

0 (0.0) 1 (3.0) 2 (6.1) 0 (0.0) 20 (60.6) 8 (24.2) 2 (6.1) 384 (12.0) 2811 (88.0)

0 (0.0) 0 (0.0) 0 (0.0) 1 (4.2) 10 (41.7) 7 (29.2) 6 (25.0) 228 (12.9) 1540 (87.1)

13 (7.8) 2 (1.2) 20 (12.0) 23 (13.8) 33 (19.8) 9 (5.4) 45 (26.9) 22 (13.2) 324 (20.0) 1298 (80.0)

21 (20.0) 2 (1.9) 6 (5.7) 18 (17.1) 29 (27.6) 7 (6.7) 13 (12.4) 9 (8.6) 104 (14.2) 627 (85.8)

13 (7.8) 2 (1.2) 20 (12.0) 23 (13.8) 33 (19.8) 9 (5.4) 45 (26.9) 22 (13.2) 164 (16.0) 864 (84.0)

791 (66.0) 407 (34.0)

261 (66.8) 130 (33.2)

145 (64.7) 79 (35.3)

215 (65.5) 113 (34.5)

65 (63.1) 38 (36.9)

125 (74.4) 43 (25.6)

540 (7.4) 6723 (92.6) 29.5 (23.0)

539 (16.7) 2690 (83.3) 28.6 (21.2)

341 (19.3) 1430 (80.7) 30.0 (21.0)

114 (7.1) 126 (7.8) 1361 (85.0) 29.9 (22.3)

117 (16.3) 56 (17.8) 547 (76.0) 30.6 (21.1)

191 (18.7) 98 (9.6) 735 (71.8) 31.6 (22.0)

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Table 11.2. Self-rated health status by self-reported illness, 2007 Self-rated health status Yes Very good 63 (10.7) Good 176 (29.8) Fair 234 (39.7) Poor 104 (17.6) Very poor 13 (2.2) Total 590 χ2 (df = 4) = 700.633, P < 0.001, correlation coefficient = - 0.412 Self-reported Illness No 1114 (40.2) 1305 (47.1) 281 (10.2) 55 (2.0) 13 (0.5) 2768

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Figure 11.1. Mean scores for self-reported diagnosed health conditions, 2002 and 2007

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Table 11.3. Self-rated health status by income quintile, 2007 Income Quintile Self-rated health status Poorest 20% 2.00 3.00 4.00 Very good 196 (30.2) 237 (34.0) 225 (32.4) 282 (42.4)

Wealthiest 20% 243 (36.7)

Good

287 (44.2)

320 (45.9)

326 (46.9)

268 (40.3)

284 (42.8)

Fair (moderate)

105 (16.2)

110 (15.8)

107 (15.4)

87 (13.1)

108 (16.3)

Poor

56 (8.6)

23 (3.3)

30 (4.3)

24 (3.6)

26 (3.9)

Very poor

6 (0.9) 650

7 (1.0) 697

7 (1.0) 695

4 (0.6) 665

2 (0.3) 663

Total

χ2 (df = 16) = 54.044, P < 0.001, correlation coefficient = 0.126

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Table 11.4. Self-reported diagnosed health condition by per capita income Income Quintile Diagnosed health condition Poorest 20% 2.00 3.00 4.00 Yes, Cold 14 (11.4) 20 (17.5) 21 (15.8) 13 (11.8)

Wealthiest 20% 12 (10.3)

Yes, Diarrhoea

2 (1.6)

5 (4.4)

6 (4.5)

1 (0.9)

2 (1.7)

Yes, Asthma

12 (9.8)

9 (7.9)

11 (8.3)

3 (2.7)

13 (11.1)

Yes, Diabetes

17 (13.8)

14 (12.3)

12 (9.0) 26 (23.6)

23 (19.7)

Yes, Hypertension

35 (28.5)

27 (23.7)

38 (28.6) 24 (21.8)

24 (20.5)

Yes, Arthritis

11 (8.9)

5 (4.4)

6 (4.5)

5 (4.5)

5 (4.3)

Yes, Unspecified

25 (20.3)

27 (23.7)

26 (19.5) 29 (26.4)

25 (21.4)

No Total χ2 (df = 28) = 36.161, P < 0.001

7 (5.7) 123

7 (6.1) 114

13 (9.8) 133

9 (8.2) 110

13 (11.1) 117

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Chapter Twelve
Self-rated health of the educated and uneducated classes in Jamaica
Paul A. Bourne

Introduction
Health is imperative for socio-economic and political development of people, a society and a nation. It is within this context that a study of health is critical as it relates to the wider society. Traditionally, the concept of health is measured using life expectancy, mortality, and diagnosed illness. In the social sciences, researchers have used self-rated health status [1-9]; and selfreported illness [10-17] to measure health. Apart from those terminologies, other synonyms such as self-assessed health; self-reported health; perceived health; self assessment of health; global health status and health status have all been used to speak about health. It follows from the aforementioned perspective that all those terms imply the same measurement of health or health status. Self-rated health status is among the subjective indexes used to measure health; and some scholars argue that they are not a good assessment of health like life expectancy, per capita income or mortality [18-20]. The subjective/objective indexes of measuring health emerged as scholars sought to ensure that the measurement of health was a reliable and valid one. Some scholars opined that the self-assessment of one’s health status was more comprehensive than objective assessment [3, 5, 21] as it included one’s health and general life satisfaction. Studies have shown that subjective indexes are a good measurement for mortality [2, 22-24], and life expectancy [25]. Concurrently, a recently conducted study by Bourne [25] found that self-assessed illness was not a good measure of mortality; however it was a good one for life expectancy in Jamaica. 294

The subjective indexes in measuring health open itself to systematic and unsystematic biases [26]. People’s perception can be biased as they may inflate or deflate their status in an interview or on a self-administered instrument (ie questionnaire). Another aspect of biasness in subjective evaluation of health is the matter of recall. It is well established in research literature that as people age, their mental faculties decline [27-32], suggesting that some people will have difficulties recalling experiences which have passed. Within the context of the time recall biasness can occur in subjective indexes, Kahneman [33] devised a procedure of integrating and reducing the subjective biases when he found that instantaneous subjective evaluations are more reliable than assessments of recall of experiences. Contrary to Kahmeman’s work, Bourne [25] found that self-assessed health for a 4-week period is a good measure of life expectancy (objective index). In spite of the fact that subjective indexes is a good measure of objective health, the former still contains biases; which Diener [34] opined still have valid variance. It is well established in health research that there is a correlation between or among different socio-demographic, psychologic and economic variables [4, 6-17, 20] and self-rated health status. The correlates include education; marital status; area of residence; education; income; psychological conditions (ie positive and negative psychological affective conditions); and other variables. Freedman & Martin [35], using data from 1984 and 1993 panel survey of Income and Program Participation, noted that there was an association between educational level and physical functioning of people over 65 years. Another study by Koo, Rie & Park [36], using multivariate regression, concluded that education was a predictor of increased subjective wellbeing (t [2523] = 7.83, P<0.001], which means that education was more than associated with health. Concomitantly, another research found that the number of years of school (i.e. The

295

Quantity Theory) was a crucial predictor of health status of an individual [37] which indicates that tertiary level graduants are more likely to be healthier than non-tertiary people. While education opens choices, opportunities, access to resources and is associated with increased likelihood of higher income, does it hold true in developing nations like Jamaica that the educated class has greater self-rated health status than the uneducated classes? A paucity of information (research literature) exist in Jamaica on the educated and uneducated classes and their self-rated health status, self-reported illness (es); area in which educated and uneducated classes reside; health care-seeking behaviour among the different educational classification and the self-rated health status of Jamaicans and its correlates. The current study is important as it used a statistical technique which accommodates the all items in self-rated health status categorization as against dichotomizing self-rated health. Dichotomizing self-rated health status in good and poor health means that some of the original information will be lost; and this explains why some researchers argued for the maintenance of the Likert nature of the measure and not dichotomization [38-40]. Secondly, the study is significant as it included more variables. These included (1) educational levels and area of residence; (2) educational levels and health care-seeking behaviour; (3) health insurance coverage and educational levels; (4) self-reported illness (es) and educational levels; (5) social standing and educational levels. The objectives of the current study therefore are to (1) identify the socio-demographic and economic correlates of self-rated health status of Jamaicans; (2) examine the effects of these variables; (3) explore self-rated health status and self-reported diagnosed recurring illness among the educated and uneducated classes; (4) calculate the mean age of respondents in the different educational categorization; (5) compute mean income among 296

the different educational types; and (6) determine whether a significant statistical correlation exists between the different educational cohorts.

Materials and methods
Data A survey on the living conditions of Jamaicans was conducted between May and August of 2007 jointly by the Planning Institute of Jamaica (PIOJ) and the Statistical Institute of Jamaica (STATIN) [41]. The survey is called the Jamaica Survey of Living Conditions (JSLC) which began in 1988. It is yearly survey. The JSLC is a modification of the World Bank’s Living Standards Measurement Study (LSMS), which is a household survey [42]. The current study used the JSLC’s dataset for 2007 in order to carry out the analyses of data [43]. It had a sample size of 6,783 respondents. The non-response rate was 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

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turn provided the sampling frame for the labour force. One third of the Labour Force Survey (i.e. LFS) was selected for the JSLC. The sample was weighted to reflect the population of the nation. Instrument A self-administered instrument (ie questionnaire) 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 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.

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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 and Holliday [44] and Cohen and Cohen [45], low (weak) correlation ranges from 0.0 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. 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 [46-51]. Another approach in addressing and/or reducing autocorrelation, is all variables that were identified from the literature review were included in the model with the exception of those with which the percentage of missing cases were in excess of 30%. The current study used the ordinal nature of the dependent variable (self-rated health status or self-rated health) which denotes that none of the original data will be lost as is the case in dichotomizing self-rated health. Ordered regression model is written as Pr(𝑌𝑌 = 𝑦𝑦𝑠𝑠 I 𝐱𝐱 =
∑k exp (αl + ∅i β′ 𝐱𝐱) l=1 (exp (αs + ∅s β′ 𝐱𝐱)

, s = 1, …k,

(1)

Where, x is the vector of covariates with coefficient to be estimated; k is the number of cut-points for the dependent variable; α s , α l stand for the intercepts in the regression models. Anderson [52] opined that ø 1 =1 and ø k, and that other constraint are possible. In the current study, the researcher set ø 1 =1 and 0= ø 1 < ø 2 < …< ø k =1 correspond to the levels from very good to very poor, and other levels of health are relative to “very good”. Based on Anderson arguments, the monotone increasing ø’s are dealt with by varying the sign for β. Within this context, a positive estimation of coefficient denotes that those with this characteristic would be 299

negatively associated with good health status and those without would positively associated with good health status (or self-rated health status). Simply put, positive estimation of coefficients means poor health and negative estimation of coefficients denotes better self-reported health status. Measurement of variables Dependent variable Self-rated health status (ie self-rated health) 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]. Independent variables Self-reported illness was derived from the question, “Have you had any illnesses other than injury? For example a 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 recoded a binary value, 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, header, or pharmacist being visited in the last 4 weeks?’ with there being two options Yes or No.

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Medical care-seeking behaviour therefore was coded as a binary measure where 1=Yes and 0= otherwise. Crowding is the average number of person (s) per room excluding kitchen, bathroom and verandah (ie. total number of people in household divided by the total number of rooms excluding kitchen, bathroom and verandah). 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 and bivariate analyses The sample was 6,783 respondents: 48.7% males and 51.3% females. Eighty-two percent of respondents rated their health status as at least good compared to 4.9% who rated it as poor. Fifteen percent of respondents reported some form of illness within the last 4 weeks. Of those who recorded an ailment, 89% reported that the dysfunction was a diagnosed recurring one. The most frequently recurring illness was unspecified conditions (23.4%) followed by hypertension (20.6%); cold (14.9%); diabetes mellitus (12.3%), and others (Table 12.1). The median age of the sample was 29.9 years (range = 99 years). The median annual income was US $7,050.66 (rate in 2007:1US$= Ja$80.47; range = US $4,406.20), and median crowding was 4.0 persons per room (range= 16 persons). A cross-tabulation between educational level and area of residence revealed a significant statistical correlation – χ2(df = 40 = 78.02, P < 0.001 (Table 12.2). Based on Table 12.2, 0.8% of 301

rural respondents had tertiary level education and 5.4 times more urban residents had tertiary level education compared to rural respondents. No significant statistical correlation existed between educational level and sex of respondents – χ2 (df = 2) = 5.61, P > 0.05 (Table 12.3). Similarly no significant statistical association was found between purchased prescribed medication and educational levels of respondents - χ2 (df = 10) = 11.9, P > 0.05. A significant statistical difference was found between mean age of respondents who are at different educational levels – F statistic [2, 6589] = 214.64, P < 0.001. The mean age of primary and below respondents was 32.0 years (SD = 22.6, 95% CI = 31.4-32.6) compared to 14.6 years (SD = 1.7, 95% CI = 14.5-14.8) for those with secondary level and 26.4 years (SD = 10.6, 95% CI = 24.6-28.2) for those with tertiary level education. A cross-tabulation between self-reported illness and educational level revealed a significant statistical association - χ2 (df = 2) = 61.33, P < 0.001. Primary or below educational level respondents recorded the greatest percent of people with illness (es) (16.2%) followed in descending order by tertiary level (9.2%) and secondary level respondents (5.4%). The statistical correlation was a weak one – correlation coefficient = 0.10. A significant statistical correlation existed between self-reported diagnosed recurring illness and educational level – χ2 (df = 14) = 42.56, P < 0.001 (Table 12.4). Respondents with secondary level education (37.5%) had the highest percent of unspecified health conditions followed in descending order by tertiary (33.3%) and primary level respondents (22.7%). Hypertension was substantially a primary phenomenon; 21.6% compared to 8.3% of tertiary level individuals. Similarly, diabetes mellitus (12.8%) was more prevalent among primary level respondents compared to 5.0% of secondary level respondents. On the other hand, asthma was 302

the greatest among tertiary level respondents (33.3%) compared to secondary level (22.5%) and primary level respondents (8.7%). Respondents with tertiary level education were most likely to be classified in the wealthiest 20% (53.4%) compared to those with secondary education who were more likely to be in the middle class and those with primary level education were either in the poorest 20% (20.3%) or in the wealthiest 20% (20.3) (Table 12.4) – χ2 (df = 8) = 124.53, P < 0.001. Of the 20.2% of respondents who had health insurance coverage, tertiary level people were more likely to have private coverage (35.9%) followed by primary or below (12.0%) and secondary level individuals (11.6%) – χ2 (df = 4) = 76.95, P < 0.001 (Table 12.4). Concurrently, a significant statistical difference existed between the mean age among the different educational levels in which respondents were categorized (Table 12.4) – F statistic [2, 6589] = 214.6, P < 0.001: mean age for those with at most primary level education was 32.0 years (SD = 22.6) compared to a mean age of 26.4 years (SD = 10.6) for those with tertiary level education. When educational level of respondents was disaggregated into no formal, basic, primary to tertiary, the mean age of respondents with no formal education was 42.7 years (SD = 18.0); 2.7 years (SD = 1.9) for basic school level respondents and 9.0 years (SD = 2.2) for those who have primary level education – F statistic [4,6587] = 2207.9, P < 0.001 Multivariate analysis Self-rated health statuses of respondents are correlated with (1) age; (2) income; (3) crowding; (4) sex; (5) marital status; (6) area of residence, and (7) self-reported illness (es) – χ2= 1,568.4, P < 0.001; and that the data is a good fit for the model - LL = 9,218.0. The 7 socio-demographic and economic correlates accounted for 33% of the variability in self-rated health status (Table 12.5). Based on the Table, the older the respondents get, the more likely they are to rate their 303

health status as poor and this was the same for crowding and those who report an illness (health condition). Urban residents are more likely to report poor self-rated health status than rural residents. However, there was no statistical difference between self-rated health status for rural and semi-urban residents. Married people are more likely to report better self-rated health status than widowed people; people with more income are more likely to report better health status and so are males in comparison to females. However, no significant statistical difference was found between self-rated health status among the educated and uneducated cohorts.

Discussion
The current study concurs with the literature that self-reported illness has the most influence on self-rated health status of people [8]. In a study of elderly Barbadians (ages 60+ years), Hambleton et al. [8] found that current illness accounted for 87.7% of the variance in self-rated health status. In another study on married people in Jamaica, Bourne and Francis [53] found that 73% of self-reported illnesses explains the variability in self-reported health status. Embedded in the current finding is whether self-rated health is examined on elderly or married people. Current self-reported illnesses accounted for a critical proportion of self-rated health and can be used to measure health. Within this context, self-reported illness is a good measure of self-rated health, and this has been established by other studies [10-17, 25]. A recently conducted research found that self-reported illness accounted for 54% (r-square) of the variance in life expectancy of Jamaicans [25]; and this increased to 63% for males. Subjective indexes such as self-rated health and self-reported illness and be used to measure health; but the latter is a better measure and this must be taken into consideration in the interpretation of findings using this measurement. The challenges noted by some researchers in using self-rated health are (1) biasness and (2) the dichotomization of the measure. While biasness is synonymous with subjective 304

assessment or evaluation of any construct, the validity of using the measure is high. Diener [34] noted in 1984 that there are still some valid variances, which was validated in a recent study by Bourne [25]. Health literature has long established that subjective indexes such as self-rated health, happiness, and life satisfaction are good measures of health as they are more comprehensive (including social activities and relationships; psychological conditions; emotions, spirituality, life satisfaction); while still incorporating the objective component [3, 21, 34]. This is justified by studies that found strong statistical correlation between subjective health and objective indexes such as life expectancy [25] and mortality [2, 22-24]. It should be noted here that subjective index (ie self-reported illness) and mortality are lowly correlated in Jamaica [25] which suggests that health literature among regions have revealed different findings. This denotes that the wholesale use of what is obtained in one nation cannot be applied to another without understanding socio-demographic characteristics. However, Jamaica like other nations can use subjective indexes to assess health status of its people and by extension population. The issue of the dichotomization of self-rated health, because some of the original values will be lost, is now resolved by this study as self-rated health was dichotomized and findings were similar to those who had dichotomized the dependent variable (ie self-rated health status). What are the similarities and dissimilarities between the two statistical approaches in operationalizing subjective health? Studies in the Caribbean found that age, marital status, crowding, sex of respondents, area of residence, income and illnesses were statistically correlated with subjective health [8, 1017, 53], which is validated by the current study. Even some non-Caribbean studies have found the aforementioned variables to be statistically associated with subjective health [7, 9], indicating 305

that dichotomizing self-rated health status does not fundamentally change most of the sociodemographic, economic and biological variables. Examining data on married people by way of dichotomizing self-rated health status, Bourne [25] found that men had a greater self-reported health status than women, and in the current study (non-dichotomization of self-rated health status), males had a higher health status than females. On the other hand, in Bourne’s work [25], he found in descending order selfreported illnesses, age, income and sex to be the only factors of self-reported good health while in the non-dichotomized study more variables accounted for health status. Nevertheless, ranking of the correlates were similar in both studies as in the current. The factors in descending order were self-reported illness, age, crowding, income, sex and the others, indicating the closeness of the statistical approaches. Married people are a component of the general populace and they have different socio-demographic and economic experiences which are different from some unmarried people. The literature showed that income is strongly correlated with self-rated health; however, in Jamaica this is clearly not the case. In Jamaica, income plays a secondary role to illness and age and when self-rated health is non-dichotomized, it becomes even a weaker variable. Although income affords one particular choices (or lack of), the educated class in Jamaica received more income than uneducated classes; however, the former class is not healthier than the latter. This finding is contrary to the literature that showed the association between higher education and health [7-9]. Education influences social standing and income; but it does not directly influence good health status in Jamaica. Concurrently, the current work found that education is positively correlated with more health insurance coverage; however, health 306

insurance coverage is not significantly associated with better health status. Embedded here is the fact that health insurance coverage in Jamaica is not an indicator of health care-seeking behaviour but a product that is purchased for the eventuality on the onset of illness as it will lower out of pocket medical care expenditure. Education provides its recipients with knowledge, access to knowledge, access to income and other empowerment; but it does not mean that educated classes are more concerned about their health which can be measured using health care-seeking behaviour and knowledge about the illness that are affecting the individual. The current paper found that 25 out of every 100 educated Jamaican are aware of their health condition(s), and this is greater than that for uneducated classes. Jamaicans with the least level of education were most cognizant of their ailments and sought medical care equally as educated Jamaicans. Education therefore does not denote empowerment to seek medical care, which is embedded in the culture in particular for men. Education is still unable to break the bondages of socialization which purports that health is weakness, and that to display weakness as a man removes his masculinity. This continues to shackle Jamaicans, particularly men who still subscribe to the traditional notion that illness is correlated to weakness and that men should not display weakness. It is this cultural perspective that barrs many men from visiting health care facilities, except on cases of severe illness or being married [25]. Hence, the mortality being greater for men is not surprising [54] as many men will die prematurely because of the time in which they visit health care institutions. This reluctance to seek medical care is not limited to males, as since 1988 when Jamaica began collection data on the living conditions of its people, as females sought more medical care than males but the disparity ranged between -2 to 6%. In 2007, 68% of females sought medical care compared to

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63% of males which means that higher education which is substantially a female phenomenon in Jamaica is not fundamentally improving the health status of females or even males. Educated Jamaicans are more likely to live in urban areas and those with primary or below education more likely to live in semi-urban zones. The current findings found that semiurban respondents were more likely to have better health status, although they are more likely to have at most primary level education. In 2007, statistics revealed that 15.3% of Jamaicans in rural areas were below the poverty line compared to 4% of semi-urban and 6.2% of urban Jamaicans [41], indicating that poverty is more synonymous with rural areas, yet there is no significant statistical difference between the self-rated health status of rural and urban Jamaicans. Income makes a difference in health as those with more can access more and greater resources including health care, but clearly income beyond a certain amount is retarding the health status of Jamaicans. This study cannot stipulate a baseline income that people should receive in order to prevent a decline in health status; however, clearly there is a state of contentment among the poor and very poor who were equally healthy as the wealthy. The health disparity between them and the educated showed no significant statistical difference and this emphasizes that wealth does not automatically transfer itself into health. Another issue which is evident in the data is the variability in measure of health among the social classes as the poorest 20% reported less illness than the wealthiest 20% [41], yet still the former group dwell in slums, inner-city neighbours, violent communities and have lower levels of education. Despite Diener’s findings [34] that the variance is minimal, Bourne’s work showed a strong association between subjective health (ie self-reported illness) and life expectancy - a correlation coefficient between 50 and 60% for a single variable is strong. However, this highlights that there are still some challenges embedded in the use of self-rated health status. 308

Conclusion
While the dichotomization of self-rated health status loses some of the original data, when selfrated health is non-dichotomized, socio-demographic and biological variables accounted for 33% of the explanation of the variance and this was 44% using dichotomization for married Jamaica, suggesting dichotomization of health status still holds some validity. Another critical finding that emerged from the current work is that education is not improving the health status Jamaicans. However it is correlated with better social standing and higher income. Income is significantly associated with better health status and it played a secondary role to self-reported illness and age of respondents. Education is associated with more health insurance coverage, but that health insurance coverage cannot be used to measure health care seeking behaviour or measure better health status of Jamaicans. In summing, there is a need for a public health care campaign that is specifically geared towards the educated classes as their educational achievement is not translating itself into better health care seeking behaviour and health status than the uneducated which suggests that socialization is barring Jamaicans from better health status choices.

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

Acknowledgement 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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Table 12.1. Demographic characteristic of sample, n=6,783 Characteristic Sex Male Female Marital status Married Never married Divorced Separated Widowed Social standing Poorest 20% Poor Middle Wealthy Wealthiest 20% Area of residence Urban Semi-urban Rural Self-reported illness Yes No Self-reported diagnosed recurring illness Cold Diarrhoea Asthma Diabetes mellitus Hypertension Arthritis Unspecified Not reported as diagnosed Health care-seeking behaviour Yes No Self-rated health status Very good Good Moderate Poor Very poor

n 3303 3479 1056 3136 77 41 224 1343 1354 1351 1352 1382 2002 1458 3322 980 5609 149 27 95 123 206 56 234 109 658 347 2430 2967 848 270 50

% 48.7 51.3 23.3 69.2 1.7 0.9 4.9 19.8 20.0 19.9 19.9 20.4 29.5 21.5 49.0 14.9 85.1 14.9 2.7 9.5 12.3 20.6 5.6 23.4 10.9 65.5 34.5 37.0 45.2 12.9 4.1 0.8

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Table 12.2. Educational level by area of residence, n = 6,592 Characteristic Area of residence Total Educational level Urban Semi-urban Rural % % % % Primary and below 84.8 89.0 88.0 87.3 Secondary 10.9 9.6 11.2 10.8 Tertiary 4.3 1.5 0.8 2.0 Total 1952 1421 3219 6592 Chi-square (df = 4) = 78.02, P < 0.001, cc = 0.11

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Table 12.3. Education level by sex of respondents, n = 6,592 Characteristic Male % Educational level Primary and below Secondary Tertiary Total Chi-square (df = 2) = 5.61, P > 0.05 87.9 10.5 1.6 3207 Sex Female % 86.6 11.0 2.4 3385 Total % 87.3 10.8 2.0 6592

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Table 12.4. Self-reported diagnosed recurring illness and social standing by educational level Educational Level Total Characteristic Primary or Secondary Tertiary below % % % % Self-reported diagnosed recurring illness1 Cold 15.0 17.5 0.0 14.9 Diarrhoea 2.9 0.0 0.0 2.7 Asthma 8.7 22.5 33.3 9.5 Diabetes mellitus 12.8 5.0 0.0 12.3 Hypertension 21.6 0.0 8.3 20.6 Arthritis 5.9 0.0 0.0 5.6 Unspecified condition 22.7 37.5 33.3 23.4 Not diagnosed 10.5 17.5 25.0 10.9 Total 947 40 12 999 2 Social standing (income quintile) Poorest 20% 20.3 19.7 3.8 19.9 Poor 20.0 21.7 7.6 20.0 Middle 19.4 24.5 16.0 19.9 Wealthy 19.9 20.3 19.1 19.9 Wealthiest 20% 20.3 13.7 53.4 20.2 Total 5752 709 131 6592 Health Insurance coverage3 No 79.8 83.7 57.8 79.8 Private 12.0 11.6 35.9 12.5 Public 8.1 4.6 6.3 7.7 Total 5682 689 128 6499 Age4 Mean (SD) in years 32.0 (22.6) 14.6 (1.7) 26.4 (10.6) 30.0 (21.8) Health care-seeking behaviour5 Yes 65.7 60.0 66.7 65.5 No 34.3 40.0 33.3 34.5 Total 953 40 12 1005 Income6 Mean (SD) in US$7 8,381.88 9,580.20 14,071.67 8,623.84 (6,641.28) (7,712.81) (9,31.10) (6,874.54) 1 Chi-square (df = 14) = 42.56, P < 0.001, cc=0.20 2 Chi-square (df = 8) = 124.53, P < 0.001, cc=0.14 3 Chi-square (df = 4) = 76.95, P < 0.001, cc=0.11 4 F statistic [2,6589] = 214.6, P < 0.001 5 Chi-square (df = 2) = 0.6, P > 0.05 6 F statistic [2,6589] = 52.4, P < 0.001 7 Rate in 2007:1US$= Ja$80.47

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Table 12.5. Ordinal logistic regression: Sociodemographic and biological differentials of selfrated health status of Jamaicans
Characteristic
Excellent self-rated health Good self-rated health (ø 1 ) Fair self-rated health (ø 2 ) Poor self-rated (ø 3 ) Very poor (ø4) Age Income Crowding Primary or below Secondary Tertiary (=0) Sex (female=0) Married Never married Divorced Separated Widowed (=0) Poorest 20% Poor Middle Wealthy Wealthiest 20% (=0) Urban Semi-urban Rural (=0) Private insurance Public insurance Public insurance – other No insurance coverage (=0) Illness

Estimate
0.0 0.540 3.504 5.935 8.659 0.045 -3.79E-007 0.083 -0.187 0.042 -0.221 -0.554 -0.352 -0.469 -0.109 0.203 0.013 0.028 -0.238 0.217 0.008 -0.175 0.026 0.387

Std. Error
0.0 0.345 0.625 0.985 1.425 0.008 0.000 0.025 0.252 0.267 0.077 0.200 0.192 0.319 0.369 0.163 0.140 0.126 0.122 0.090 0.085 0.110 0.149 0.209

95% CI Wald
2.456 31.465 36.327 36.909 34.055 10.636 11.130 0.553 0.025 8.290 7.704 3.342 2.171 0.087 1.554 0.009 0.048 3.782 5.789 0.008 2.542 0.032 3.433

P
0.117 0.000 0.000 0.000 0.000 0.001 0.001 0.457 0.874 0.004 0.006 0.068 0.141 0.768 0.213 0.925 0.826 0.052 0.016 0.927 0.111 0.859 0.064

Upper
-0.135 2.279 4.005 5.865 0.030 -6.06E-007 0.034 -0.681 -0.481 -0.372 -0.945 -0.729 -1.094 -0.832 -0.116 -0.262 -0.219 -0.477 0.040 -0.159 -0.389 -0.265 -0.022

Lower
1.216 4.728 7.865 11.452 0.060 -1.51E-007 0.132 0.307 0.566 -0.071 -0.163 0.025 0.155 0.615 0.523 0.288 0.274 0.002 0.395 0.174 0.040 0.318 0.796

2.377

0.401

35.152

0.000

1.591

3.163

Nagelkerke r-square = 0.33 Chi-square = 1,568.4, P < 0.001 LL = 9,218.0 n=4,433

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Chapter Thirteen Dichotomising poor self-reported health status: Using secondary cross-sectional survey data for Jamaica
Paul A. Bourne

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 (i.e., 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 and operationalisation of a measure, as this is not a scientific enough rationale for the use of a particular measure. 318

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 self-reported 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 has examined the validity of dichotomisation of self-reported health status. The same was also found 319

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 (i.e., marital status, age cohort, social class); and 4) examine the odds of reporting poor or moderate-to-very poor self-reported 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 320

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 (i.e., very poor or poor

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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. 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. 322

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 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 1a and 1b. Figures 1a and 1b 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 323

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 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 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 13.1). 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. 324

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 13.2). 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. Generally, using the odds ratio, males benefited more by being married (Table 13.3) than females (Table 13.3). 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 13.3 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 (i.e., 75+ years) increased exponentially over very poor-to-poor self-reported health status.

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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, 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 13.4).

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 326

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 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 (i.e., 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 327

that stopping the study at age 64 would have excluded a critical proportion of those who are likely to be reporting poor health status. Among the social determinants of health are social class and area of residence [1-6, 31-33]. 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

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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 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 (i.e., including moderate health status) for those of 75+ years fell 329

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 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 agedependent, 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 330

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 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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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: 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.

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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 13.1. 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 13.2. 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 19.6 22.4 28.1 33.3 25 54.6 59.7 65.6 100 100 Poorest20% Poor Middle Wealthy Wealthiest20% Total n 20.7 18.0 18.6 12.0 266 29.4 24.2 22.0 16.4 207 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 42.9 30.3 33.3 20.1 156 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 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 43 336 46.7 47.0 52.0 40.7 266 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 58.8 61.3 62.7 54.5 207 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 81.0 66.7 73.3 50.0 156 79.8 60.0 59.7 72.4 77.4 80.6 68.5 75.0 77.1 69.6 71.0 58.1 172 100.0 71.4 87.5 25.0 97 79.2 59.3 56.3 71.4 75.0 0.0 70.0 77.8 71.4 62.5 80.0 60.0 119 100.0 83.3 85.7 33.3 23 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

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

Table 13.3. 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
4654yrs 5564yrs 6574yrs 7584yrs 85+yrs

Self-reported illness Yes 7.7 No 1 Area of residence Urban 0.5 Semi-urban 0.9 Rural 1 Marital status Married 0.9 Not 1 Social class Poorest20% 1.8 Poor 1.9 Middle 1.6 Wealthy 1.7 Wealthiest20% 1 Total n 266 Self-reported illness Yes 3.3 No 1 Area of residence Urban 0.3 Semi-urban 0.5 Rural 1 Marital status Married 1.0 Not 1 Social class Poorest20% 3.7 Poor 2.2 Middle 2.2 Wealthy 2.1 Wealthiest20% 1 Total n 284

Men 1.9 1 0.8 3.5 1 0.6 1

4654yrs

5564yrs

6574yrs

7584yrs

85+yrs

5.7 1 0.5 1.1 1 0.7 1 1.5 2.1 1.6 1.4 1 207 3.4 1 0.3 0.3 1 1.0 1 3.0 1.8 1.6 1.7 1 216

6.5 1 0.5 1.1 1 0.9 1 1.6 3.0 1.7 2.0 1 156 3.3 1 0.3 0.4 1 1.4 1 5.3 2.0 2.4 2.3 1 172

3.2 1 0.5 1.8 1 0.9 1

9.6 1 1.0 0.9 1 0.7 1 1.8 1.3 1.3 1.6 1 266 4.3 1 0.6 0.6 1 1.0 1 2.2 2.1 1.5 1.9 1 284

10.5 1 1.2 1.4 1 0.8 1 1.2 1.2 1.3 1.4 1 207 4.2 1 0.7 0.7 1 1.3 1 2.0 2.5 1.4 1.9 1 216

16.8 1 0.4 1.6 1 0.7 1 1.9 4.3 2.0 2.7 1 156 2.6 1 0.4 0.8 1 1.9 1 2.2 2.4 1.7 1.8 1 172

7.7 1 0.1 1.8 1 0.2 1 large large 7.5 21.0 1 97 2.6 1 0.4 0.8 1 0.0 1 2.3 1.1 1.1 2.7 1 119

4.1 1 0.7 3.9 1 0.1 1 large large 10.0 12.0 1 23 2.6 1 0.3 1.0 1 0.0 1 2.0 1.4 1.0 3.2 1 43

1.5 1.5 3.0 2.2 1.3 1.1 3.0 5.9 1 1 97 23 Women 3.2 1 0.7 0.8 1 0.0 1 2.0 1.6 1.8 4.0 1 119 4.3 1 0.6 0.8 1 0.0 1 1.4 1.3 2.2 3.5 1 43 337

Table 13.4. 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 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 0.004 1 0.020 1 0.046 1 0.167 1 0.228 1

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Chapter Fourteen Retesting and refining theories on the association between illness, chronic illness and poverty: Are there other disparities?
Paul A. Bourne

Introduction
Empirically there are many studies which have found and established a statistical association between poverty and illness [1-8]. Some research showed that those in the lower socioeconomic status are less healthier than those who in the wealthy socioeconomic groups [9,10]. A study by van Agt et al. [8] found that poverty was greater among the chronically ill that non-chronically ill people, and the WHO [4] concurred with Van Agt et al. [8] when it opined that 80% of chronic illnesses were in low and middle income countries. Poverty is not only associated with illness and ill-health, but also greater mortality. According to 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; (3) and other socio-political incapacity [3, 8, 11]. Sen [11] encapsulated this well when he opined that high levels of unemployment in the economy is associated with higher levels of capabilities, suggesting money and other incapacities of those who are likely to be unemployed in the society. The poor is therefore more likely to be unemployed, ill, suffering from more chronic illness, have insufficient money, low level of educational attainment, have greater percent of infant and other mortality and live inadequate physical environment than those in the wealthy social hierarchies. 339

Using objective indexes such as infant mortality and life expectancy to measure health of a population, studies on the Latin America and the Caribbean concurs with the aforementioned research. Cass et al. [12] found that infant mortality in Peru for those in the poorest quintile (i.e. poorest 20%) was almost 5 times more than that for those in the wealthiest quintile (i.e. wealthiest 20%). Another study revealed that out of pocket medical expenditure accounts for some people become poor and that a greater percent of these people do not have health insurance coverage [2]. One study highlighted 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 is illness is longstanding, and the Director of the Pan American Health Organization in 2001 wrote that it is still evident in contemporary societies [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 level of illness (i.e. psychopathology). Clearly is well established for centuries that poverty is associated with illness, and that it affects those therein by the constricting their capacity which further affects their health. The poor have lower access to money and other resources than the wealthy, and are also deprived in the future from good health outcome. A study by Mayer et al. [15] provided evident that there is a strong relationship between health and future economic growth, suggesting that current poverty contract future health and economic prosperity. Mayer et al.’s work provide pertinent insight into the retardation of poverty, but also gives an understanding of how poverty affects health, production, productivity and it being a present and future problem for public health policy makers. How is this of concern to public health policy makers in Jamaica?

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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 like other nations. If poverty is associated with unemployment, not seeking medical care, and not seeking medical care is related with illness, it appears to be a non-issue to retest the established theory of poverty and illness and poverty and chronic illnesses in Jamaica. All of the aforementioned studies that have examined poverty and illness have not used self-reported data to test the poverty and illness, and poverty and chronic illness phenomena. The aims of the current study to investigate (1) poverty and illness, (2) poverty and chronic illness, and (3) other sociodemographic characteristics in order to provide understanding of existing disparities as well as concur 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 policy guidelines for Jamaica. The cross-sectional survey was conducted between May and August 2002 from the 14 parishes across Jamaica and included 25,018 people of all ages [20]. The JSLC used stratified random probability sampling 341

technique to draw the original sample of respondents, with a non-response rate for 26.2%. The sample was weighted to reflect the population. Study instrument The JSLC used an administered questionnaire where respondents are asked to recall detailed information on particular activities. The questionnaire was modelled from the World Bank’s Living Standards Measurement Study (LSMS) household survey. The questionnaire covers demographic variables, health, education, daily expenses, non-food consumption expenditure, and other variables. Interviewers are trained to collect the data from household members. 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 statistical significance of a metric and non-dichotomous variable. Logistic regression analyses examined the 1) 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 packages 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 342

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. To retain or exclude a variable from the model, this 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, injuries or illnesses [29-31]. While self-reported ill-health is not an ideal indicator of actual health conditions because people may underreport, 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 in a Likert scale matter ranging from excellent to poor. Medical care-seeking behaviour was taken from the question ‘Has a health care practitioner, header, or pharmacist being 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.

343

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 denote 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 and a maximum of 51.

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-weeks, 63.9%; primary or below level education, 20.9; secondary level education, 73.1%, and mean age of 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 14.1 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 (i.e. poorest 20%) was substantially a rural 344

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 4weeks 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 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: Mean age of rural residents was 29.1 years (± 22.6 years); semiurban’s residents mean age 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 practitioner in the last 4-weeks was 1.7 (± 1.4). The was a significant statistical difference between the mean number of visits to health care practitioner and area of residence: Mean number of visits by rural residents was 1.6 (± 1.2) compared to 1.6 (± 1.2) for semi-urban dwellers and 2.0 (± 2.5) for urban dwellers. 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 crime and 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 14.2 examines visits to health care facilities, health insurance coverage, educational level and crime by social hierarchy. 345

When self-reported illness and social hierarchy was disaggregated by area of residences, 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 14.3 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 mean length of 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 social hierarchy were accounted for by poorest 20% and wealthy (P = 0.011) and 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, arthritis; and other chronic illness (unspecified) was 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 illness 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 10,000 346

for females. Seventy-two percent of those who indicated that they had a chronic illness sought medical care in the last 4-week compared to 78.9% who do not have chronic illness that 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 those 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.

Multivariate analyses

Table 14.4 shows information on particular variables and their correlation (or not) with selfreported illness. Of the 17 variables identified from the literature and available in for this study, 5 emerged as being statistical significant correlates of self-reported illness of Jamaicans (i.e. social hierarchy, medical expenditure, sex, age and income) - Model χ2 (17) =56.45, P < 0.001. The statistical significant correlates accounted for 14.8% of the variability in self-reported illness.

Table 14.5 examines social hierarchy and sex and their influence (or not) on self-reported chronic illness. One sex emerged as being statistical significant correlates of self-reported chronic illness in Jamaica - Model χ2 (3) =6.42, P < 0.001.

Discussion
The current study revealed that 13 in every 100 Jamaican 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 that former 347

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 illness 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 the 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 rural residents had the least percent of people with tertiary level education, had 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 indexes such as life expectancy, infant mortality and general mortality, it is well established that poverty is associated with illness and those with more chronic illness are more likely to be poor. The current study, using self-reported illnesses, has concurred with the literature that poor reported more illness and are more likely to have more chronic illness than those in the upper class. This study, however, found than 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 the married people are healthier than other marital cohorts [34-38] as the findings showed no statistical association between marital status and self-reported illness. 348

However, the findings revealed that almost 45% of those with chronic illnesses were married compared to those who were never married, widowed, separated, and divorced people. Lillard and Panis [39] contradicted many of the traditional findings that married people are healthier and reported 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 that enter marriage at an early age, which suggest that these men do so because of health reasons [39]. This then would support the current research of married people indicating more chronic illness than non-married people. Concurringly, married people do not report more illness, but more chronic illness 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 (ie. 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 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 (i.e. insufficient money) that accounts for the poor inability to (1) access higher level education; (2) access greater and the best health care treatment; (3) poor physical milieu; (4) higher levels of infant mortality; (5) poor material conditions; (6) clean water and nutrition; and (7) social position deprivation. It follows that poverty incapitates the individual and this extends 349

into the future if he/she is not assisted by external sources. Does money really makes 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 utilise 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 was owing to insufficient funds compared to 9 out of every 100 of those in the wealthiest 20%. Furthermore findings from the present research found that people who spent 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 seek medical care compared to the wealthy. This insufficient financial resource is hampering 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] 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 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,

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and illnesses can lead to poverty and future constraint on capabilities and limiting opportunities to create a better life for themselves. If those in poorest 20% group experienced illness and visited medical practitioner more than those in the upper class, it follows that poverty is explaining (1) most of prevalence of illness, (2) severity of illness, and (3) more chronic illness, then 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 comprehensively knowledge of relationship between poverty and illness as well as the other health inequalities, will aid physicians in understanding the reasons for the disproportionately more poor visiting them and having particular chronic illnesses. Health is also a social phenomenon, and so physicians need training in 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 of money provides some insights into the plight of those therein. It is critical to understand this group and where they live like Kiefer said that poverty was “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 which is nutritional deficiency, as some people belief that so as long as they have some to eat or a ‘full tummy’ is enough to delay illness. The image of a ‘full tummy’ 351

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 nutritional value in food intake. Household in low-income groups are substantially 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 an 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 ingredient in good health [45], but do residents of low-income rural area as well as low-income urban areas know that deficient intake of calcium, iron, magnesium, zinc, folate, vitamin A, vitamin B 6 , vitamin C is responsible for some of their illness. 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 indexes such as life expectancy, infant mortality and 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 indexes of the past. While those people in the poor social 352

hierarchies were more likely to report more illness and self-reported chronic illness than those in the wealthy group, there is no difference between those in the poor group and the middle class. Those with chronic illness 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 will have hypertension, and the least probable to utilise health care facilities than the upper class. In sum, subjective index such as self-reported illness or self-reported diagnosed health conditions can be used to measure health as the traditional infant mortality, general mortality and life expectancy. Poverty indeed is still continuing to influence ill-health, and those with chronic illness are more probable to be poor than in the upper class, but that other demographic characteristics provide more information on the poor and those with chronic illnesses. In sum, much investment has been made on health and these clearly have not reduced the inequalities and disparities between and among the difference 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 be used to guide policies, framed interventions and focus future research in Jamaica.

The way forward
Subjective indexes 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 353

health inequalities and disparities in society, programmes are need that will address issues in rural areas, gender, income inequalities, and the health disparities between public and private health care services offerings to the all. Another area which must be addressed is 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 negative life events on people and their effects on the crime problem in the Caribbean. Another issue which must be investigated is the quality of care offered to the poor from the perceptive of the individuals (i.e. a survey research). This would provide pertinent information as to whether those people who are poor perceived themselves to receiving the worst health, and to devise a method that will objective assess service 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 a 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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20. 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]; 2002. 21. Cohen L, Holliday M. Statistics for Social Sciences. London: Harper & Row; 1982. 22. Hair JF, Black B, Babin BJ, Anderson RE, Tatham RL. Multivariate data analysis, 6th ed. New Jersey: Prentice Hall; 2005. 23. Mamingi N. Theoretical and empirical exercises in econometrics. Kingston: University of the West Indies Press; 2005. 24. Zar JH. Biostatistical analysis, 4th ed. New Jersey: Prentice Hall; 1999. 25. Hamilton JD. Time series analysis. New Jersey: Princeton University Press; 1994. 26. Kleinbaum DG, Kupper LL, Muller KE. Applied regression analysis and other multivariable methods. Boston: PWS-Kent Publishing; 1988. 27. Cohen J, Cohen P. Applied regression/correlation analysis for the behavioral sciences, 2nd ed. New Jersey: Lawrence Erlbaum Associates; 1983. 28. Koutsoyiannis A. Theory of econometrics, 2nd ed. New York: MacMillan Publishing; 1977. 29. Bourne PA. Socio-demographic Correlates of Health care-seeking behaviour, selfreported illness and Self-evaluated Health status in Jamaica. International Journal of Collaborative Research on Internal Medicine & Public Health 2009; 1(4), 101-130. 30. Bourne PA, Rhule J. Good Health Status of Rural Women in the Reproductive Ages. International Journal of Collaborative Research on Internal Medicine & Public Health 2009; 1(5):132-155. 31. Finnas F, Nyqvist F, Saarela J. Some methodological remarks on self-rated health. The Open Public Health Journal 2008; 1: 32-39. 32. 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. 33. Idler EL, Kasl S. Self-ratings of health: Do they also predict change in functional ability? Journal of Gerontology 1995; 50B (6): S344-S353. 34. Bourne PA. Medical Sociology: Modelling Well-being for elderly People in Jamaica. West Indian Medical Journal 2008; 57: 596-04. 35. Bourne PA. Health determinants: Using secondary data to model predictors of well-being of Jamaicans. West Indian Medical Journal 2008;57: 476-480 36. Smith KR, Waitzman NJ. Double jeopardy: Interaction effects of martial and poverty status on the risk of mortality. Demography 1994; 31:487-507. 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. 356

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 14.1: 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 14.2. Particular variable by social hierarchy, 2002 Characteristic Sex Male Female Marital status Married Never married Divorced Separated Widowed Visits to health care institutions (for last visit) Public hospitals Private hospitals Public health care centre Private health care centre Health insurance ownership Yes No Educational level Primary and below Secondary Tertiary Crime and victimization index mean ± SD Age mean ± SD Crowding mean ± SD Total medical expenditure mean ± SD (in USD)† †USD 1.00 = Jamaican $50.97 Poorest 20% 2454(49.3) 2520(50.7) 569(21.1) 1926(71.3) 14(0.5) 30(1.1) 162(6.0) 166(49.3) 14(4.2) 107(31.7) 76(22.6) 84(1.7) 4745(98.3) Poor Social hierarchy Middle Wealthy P Wealthiest 20% 0.002 2345(47.3) 2609(52.7) 656(22.3) 2094(71.2) 5(0.2) 21(0.7) 164(5.6) 135(38.5) 29(8.3) 102(29.1) 120(34.1) 172(3.6) 4651(96.4) 2440(49.0) 2542(51.0) 742(23.3) 2229(69.9) 16(0.5) 30(0.9) 173(5.4) 164(42.7) 19(5.0) 75(19.6) 137(35.6) 270(5.6) 4574(94.4) 2482(49.4) 2540(50.6) 860(25.4) 2303(67.9) 26(0.8) 31(0.9) 172(5.1) 175(42.1) 40(9.7) 64(15.5) 176(42.2) 655(13.5) 4204(86.5) 2611(51.4) 2464(48.6) < 0.0001 1223(31.7) 2261(58.7) 62(1.6) 73(1.9) 234(6.1) 137(30.6) 52(11.7) 34(7.6) 258(57.2) 1490(30.7) 3370(69.3) < 0.0001 609(24.6) 588(22.0) 628(22.7) 604(20.1) 568(16.5) 1837(74.3) 2048(76.5) 2114(75.3) 2249(75.0) 2292(66.4) 25(1.0) 41(1.5) 57(2.0) 146(4.9) 591(17.1) 2.4±10.2 1.5±4.9 2.0±7.2 2.2±8.5 2.4±8.2 25.5±22.7 26.8±22.2 28.3±21.9 29.6±21.3 33.8±20.9 3.0±1.8 2.3±1.3 2.0±1.2 1.6±0.9 1.2±0.8 15.22±28.91 21.67±37.99 22.54±42.87 33.11±70.35 45.53±79.52 < 0.0001 < 0.0001 < 0.0001 < 0.0001 < 0.0001

< 0.0001 < 0.0001 < 0.0001

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Table 14.3. 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 (17) =56.45, P < 0.001 -2 Log likelihood = 368.58 Nagelkerke R2 =0.148

Table 14.4. Logistic regression: Self-reported illness by particular variables Std. Odds Variable Wald Coefficient error P ratio statistic 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 0.44 0.77 0.17 0.13 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 Upper 1.52 4.09 1.21 0.98 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 14.5. Logistic regression: Self-reported chronic illness by some variable Std. error 0.66 0.58 Wald statistic 0.26 0.31 Odds ratio 0.72 0.72 1.00 0.31 95.0% C.I. Lower 0.20 0.23 Upper 2.62 2.26

Variable Middle Two wealthy quintiles †Two poor quintiles
Model χ2 (3) =6.42, P < 0.001 -2 Log likelihood = 368.58 Nagelkerke R2 =0.06

Coefficient -0.34 -0.33

P 0.61 0.58

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 Fifteen Child Health Disparities in an English-Speaking Caribbean nation: Using parents’ views from a national survey
Paul A. Bourne, Paul A. Bourne, Cynthia Grace Francis & Elaine Edwards

Introduction

In 1946, the World Health Organisation1 (WHO) joined the discussion on health which resulted in a conceptual definition that expanded on the popular absence of diseases. The WHO theorized that health must incorporate social, economic and psychological variables and not merely the absence of diseases. This was documented in the preamble to its Constitution1 in 1948. Engel2-6 who was a physician later became involved in the discourse and added a conceptual model. He opined that the treatment of mentally ill-patient must include the physical, social and psychological conditions. He called this conceptual framework, a biopsychosocial model. Despite the efforts of WHO and Engel to broaden the biomedical model (ie diseases causing pathogens), scholars such as Bok7 argued that the WHO’s conceptual definition of health is too broad and by extension elusive to operationally measure. He therefore cited that the difficulty with measuring the WHO’s conceptual definition of health is such that it should not be used by researchers. Bok’s perspective did not include a suggestion to replace this but speaks to the dominance of traditional approach to the measurement of health. The traditional approaches such

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as mortality, diagnosed illness and life expectancy have objectively measurable outcomes which are among the rationales offered for justifications of their usages. Using mortality or morbidity to measure health is a narrow approach. This on the other hand is on the opposite extreme of the health pendulum as health is more than not having dysfunctions or death.8 Death is the outcome of some morbidities, accidents, injuries, suicide and other conditions. Those aforementioned issues omit the role that social determinants play on people health. These social determinants include poverty, income, marital status, crime and violence, culture, and much more.9-27 Poverty is empirically established as strongly correlated with poor health.25-27 It affects the quality of the physical environment, nutrition, choices, psychological state of the individual as well as socio-political choices. The deprivation which results from poverty may influence ones physical illness, but there are social issues surrounding poverty that may not result in injuries or even diseases. We can argue within the reality of contemporary societies that all peoples have equal access to health and other material resources, which would result in the same health outcome. If we assume this position, it would be highly flawed as the WHO28 opined that 80% of chronic illnesses were in low and middle income countries. This undoubtedly suggests that illness interfaces with poverty and other socioeconomic challenges. Poverty does not only impact on illness, it causes pre-mature deaths, lower quality of life, lower life and unhealthy life expectancy, low development and other social ills such as crime, high pregnancy rates, and social degradation of the community. Using two decades worth of data on Jamaica, Bourne29 found that there was a positive correlation between poverty and unemployment; poverty and illness; and crime and unemployment as well as a negative correlation between poverty and not seeking medical care.

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Illness therefore is an outcome of a plethora of conditions which include biological, social, economic and psychological issues. Many studies in the English-Speaking Caribbean as well as Cuba that have examined health status of children have substantially only examined mortality, birth, morbidity and to a lesser extent nutrition.30-37 Those studies are once again highlighting the strength of the biomedical model in contemporary Caribbean nations, and to a lesser extent not recognize the value of the social determinants in health and health care. The WHO and any other scholars have joined the discourse in the value of social determinants since the 2000 and this has seen many publications on the matter.16-19,21 Although the WHO opined that health research and by extension health must include the social determinants,21 subconsciously the dominance of the biomedical approach is so engrained in psyche that in 2009 WHO published a document entitled ‘World Health Statistics’ and the social determinants were omitted from the section on health indicators. The document examined mortality, morbidity, typologies of dysfunctions, burden of diseases, immunization, sanitation, healthy life expectancies, health expenditure, health care-utilization and omitted critical social determinants such as poverty, marital status, education, and so on. Like WHO, Caribbean scholars are so focused on the objective health measures (such as life expectancy, mortality and diagnosed morbidity) that their work lack policy invention strategy that include critical social determinants. Humans are multi-dimensional animals, suggesting that omitting social determinants are excluding critical tenets that can enhance policy formulation in improving health and guide political actions.18 In 2007, poverty rates in rural Jamaica was twice that of urban poverty39 and within the context of empirical findings the health status of children in the former areas cannot be the same as those in the latter areas. Poverty therefore affects the choices, physical environment, nutrients intakes, health care utilization, and 365

the quality of life of parents as well as their children. Having identified the weaknesses of many of the previous studies and the role of social determinant in health and health intervention, the current study will fill this gap by examining child health from the perspective of social determinants (including area of residence). In addition to the identified weakness of many studies that have examined health in children, the current study using Casas et al.’s40 work recognize that health disparity in Latin America and the Caribbean is accounting for some of the inequalities in health outcomes. Casas et al cited that the region demonstrated the greatest disparities in income and other social determinants, indicating a justification for the disparity in infant mortality between poor and developed countries.26 The aims of the present work are to evaluate the general health of children from the perspective of their parents’ views in an English-Speaking Caribbean nation as well as the typology of dysfunctions, health disparities, social determinants of selfevaluated health of children, and provide policy formulators as well as health researchers with pertinent information that can be used to formulate health intervention programmes and guide the focus of future research.

Materials and Methods
The Jamaica Survey of Living Conditions (JSLC) was commissioned by the Planning Institute of Jamaica (PIOJ) and the Statistical Institute of Jamaica (STATIN) in 1988.39 These two organizations are responsible for planning, data collection and policy guideline for Jamaica, and have been conducting the JSLC annually since 1989.39 The JSLC is a administered questionnaire where respondents are asked to recall detailed information on particular activities. The questionnaire was modelled from the World Bank’s Living Standards Measurement Study (LSMS) household survey.41 There are some modifications to the LSMS, as JSLC is more 366

focused on policy impacts.

The questionnaire covers demographic variables, health,

immunization of children 0–59 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. The current study extracted a sub-sample of 2,642 respondents 18 years and below from a larger nationally cross-sectional survey of 6,782 Jamaicans. This study used the dataset of the JSLC for 2007.42 Measures

Table 15.1 shows the operational definitions of some of the explanatory variables used in this study. An explanation of some of the variables in the model is provided here.

Statistical analysis

Statistical analyses were performed using the Statistical Packages for the Social Sciences v 16.0 (SPSS Inc; Chicago, IL, USA) for Widows. 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 nonmetric variables, and an Analysis of Variance (ANOVA) was used to test the equality of means among non-dichotomous categorical variables. Logistic regression examined the relationship between the dichotomous binary dependent variable and some predisposed independent (explanatory) variables (dependent variable was 1 if reported good health status and 0 if poor health). A pvalue < 0.05 was selected to established statistical significance. The final model was

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based on those variables that were statistically significant (p < 0.05). Categorical variables were coded using the ‘dummy coding’ scheme.

The predictive power of the model was tested using the ‘omnibus test of model’ and Hosmer and Lemeshow’s43 technique was used to examine the model’s goodness of fit. The correlation matrix was examined in order to ascertain whether autocorrelation (or multicollinearity) existed between variables. Cohen and Holliday44 stated that correlation can be low/weak (0–0.39); moderate (0.4–0.69), or strong (0.7–1). This was used in the present study to exclude (or allow) a variable. 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. Finally, forward stepwise technique in logistic regression was used to identify variables as well as determine the magnitude (or contribution) of each statistically significant variable, and the odds ratio (OR) for interpreting each of the significant variable.

Results
Demographic Characteristic The current study had a sample of 2, 642 respondents (ages 0 to 18 years): 50.9% males and 49.1% females. Forty-eight percentage of the sample was poor with 25% in the poorest 20% compared to 33% in the wealthy social hierarchies (including 14% in the wealthiest 20%). Fiftytwo percent of the sample resided in rural areas compared to 28% in urban and 20% in periurban areas. Eleven percent of the sample reported an illness in the last 4-weeks. Of those who indicated an illness, 16.5% claimed that their illness were non-diagnosed by medical 368

practitioners. Self-reported diagnosed illness were 58.2% acute conditions (including 34.7% influenza, 4.5% diarrhoea and 19.2% respiratory diseases), 1% chronic (i.e. diabetes mellitus) and 24.1% unspecified conditions. Of the sample 11.1% answered the question “Have you sought medical care in the last 4-weeks? Of those who responded to the medical care-seeking question, 58.4% claimed yes. When the respondents were asked “Why did you not seek medical care?” 17.8% said that they could not afford it, 50.8% was not ill enough and 19.5% used home remedy. Concurrently, 91.4% of the sample indicated at least good self-evaluated health status (including 45.1% excellent health status) with 0.2% claimed that their health status was very poor. There was a significant statistical difference between the mean age of respondents and self-reported diagnosed health conditions – F statistic = 8.4, P < 0.0001. The mean age of child being diagnosed with particular illness was 6.5 years (SD = 5.1; 95% CI = 5.5-7.1). The mean age of children with particular health conditions in sample was 4.8 years (SD = 4.5, influenza); 3.5 years (SD = 2.7, diarrhoea); 7.4 years (SD = 4.4, respiratory disease); 12.3 years (SD = 5.9 diabetes mellitus) and 8.4 years (SD = 5.9; other – unspecified conditions). Table 15.2 highlights particular social, economic and biological variables by area of residence. Three times more children in rural areas were from households in the poorest 20% compared to urban area. Rural children were 3.3 times more likely to experience illness over a longer period than urban children compared to 2 times more than peri-urban children. The identified cases of chronic condition (i.e. diabetes mellitus) were a rural matter (1.8%). Table 15.3 shows self-reported diagnosed health conditions by particular demographic characteristics. Rural children were highly likely to indicate most of the health conditions 369

compared to other children from other geographical zones. However, urban children were most likely to be diagnosed with respiratory diseases (35.7%) compared to peri-urban children with influenza (27.7%) and rural children with diarrhoea (92.3%). All the reported cases of diabetes mellitus were from rural zones (100.0%). Table 15.4 presents information between health care-seeking behaviour and particular demographic variables. A child who received medical care in the last 4 weeks was 1.8 times more likely to have health insurance coverage and 3.9 times more likely to report poor health status. No significant statistical association was found between health care-seeking behaviour and social hierarchy (P = 0.866), health care-seeking behaviour and age (P = 0.503) and health care-seeking behaviour and sex of respondents (P = 0.356). Multivariate analysis Table 15.5 highlights the explanatory social determinants of good health status of children in Jamaica. Six explanatory determinants were found explain good health status: age (OR = 0.95, 95% CI = 0.90-1.00); health care-seeking behaviour (OR = 0.29, 95% CI = 0.150.56); middle class (OR = 5.00, 95% CI = 1.75-14.28); length of illness (OR = 1.00, 95% CI = 1.00-1.00); medical expenditure (OR = 1.00-1.00) and area of residence (urban – OR = 2.75, 95% CI = 1.36 – 5.57; peri-urban – OR = 3.37, 95% CI = 1.42 – 7.99). The data were also a good fit for the model – model chi-square = 46.4, P < 0.0001.

Discussion
The current study highlighted that 89 out of every 100 children in Jamaica did not have an illness in 4-week period of a survey. Instead of using diseases to measure health, 91 out of every 100 370

reported at least good health status (including 45 out of every 100 very good self-evaluated health statuses). Using health conditions and mortality of children 0 – 18 years, the Pan American Organization (PAHO) concluded that most of Jamaica’s children were in good health.45 This finding is concurred by the current study, but this does not provide a holistic understanding of the health disparities in child health in the nation. The current findings revealed that 36 out of every 100 rural children were living in household in the poorest 20% compared to 14 out of every 100 in peri-urban households and 11 out of every 100 in urban households. Does this account for any health disparity in child health in the country? Concurrently, the present work showed that the length of illness experienced by child in rural households was 3.4 times more than for those in urban households and 1.9 times more than that for those in peri-urban households. This health disparity that did not emerge in the PAHO’s findings or other studies that have examined infant mortality or maternal deaths and/or births. The child health disparity continues as the only cases of chronic illness (ie diabetes mellitus) were found in rural children. Another notable health disparity was found in health insurance coverage of children in particular households. The current research highlighted that 11 out of every 100 children in rural household had health coverage compared to 22 out of every 100 in urban households and 16 in every 100 in peri-urban dwellings. Health disparities were also observed between typology of illnesses and social hierarchy in which children are in. Comparing the poorest 20% and the wealthiest 20%, the findings revealed that none of the children in wealthiest 20% households had diabetes mellitus compared to 1.8% children in households with the poorest 20%. Interestingly it was noted that children in urban households were 2.8 times more likely to claim good health with reference to rural children and ratio was 3.4 times more for peri-urban children with reference to rural children. 371

Chronic illness in Jamaica is clearly not limited to adults as the current study found that those with diabetes mellitus were rural females. The mean ages of rural female children being diagnosed with diabetes mellitus was 12.3 years, suggesting that chronic conditions begin to early in rural females. The number of cases in diabetes mellitus was spread equally among the poorest 20%, poor and the wealthy (33.3% respectively). This denotes that Jamaican females will be living longer with chronic illness, and this has implications for policy intervention, health care expenditure, public health care utilization and gerontological care in the future. An issue which is embedded in the present study that begs for some clarification is the rationale why urban and boys did not indicate any cases of diabetes. Morrison46 in an article entitled ‘Diabetes and hypertension: Twin Trouble’ established that diabetes mellitus and hypertension have now become two problems for Jamaicans and the wider Caribbean. This situation was equally collaborated by Callender47 at the 6th International Diabetes and Hypertension Conference. They opined that there was a positive association between diabetic and hypertensive patients - 50% of individuals with diabetes had a history of hypertension, suggesting that those who current had diabetes mellitus are highly likely to develop hypertension in the future. Embedded here is the immediate need to commence public health campaign geared towards parents as well as children who currently have diabetes about the likeliness of developing hypertension and how their lifestyle choices will become critical in lowering this probability. Another issue which emerged from the data is the correlation between health care-seeking behaviour and good health status. This work found that children who seek care are 71% less likely to declare good health status.

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Since 1988 data published in the Jamaica Survey of Living Conditions39 has been showing that females seek more medical care than males. The current study provides us with some understanding of role of socialization in this health disparity. This research revealed that there is no statistical association between health care-seeking behaviour and age of children as well as health care-seeking behaviour and sex of children, suggesting that it is not early socialization that accounts for males’ unwillingness to utilize health care services. Hence, this study rules out the role of parents in accounting for males’ actions (or inactions) on health careseeking in Jamaica. This denotes that the peer group, school, and political agents are among the socializing institutions responsible for males’ lower choice in medical care-seeking behaviour compared to females. One of the social determinants of health that is empirically established in health research as influencing health is education.9-21 The current work concurs with the empirical findings as children from middle class households were 5 times more likely to experience good selfevaluated health status with reference to those in poor social hierarchies. It follows that health disparity this current as highlighted by this study denotes that education (or the lack of) is explaining more of the health disparity experienced by children instead of money. Health inequalities among children of particular households in Jamaica is embedded in the educational achievement (or lack) of their parents. In Jamaica, the educated class is more likely to be teachers, doctors, nurses, public health practitioners and university graduants who are more informed about many issues including health options than the poorer social classes and this is translated into better health choices. A study on twins in USA found that more years in schooling (i.e. education) was associated with healthier patterns of behaviour. It is this value that accommodates for the higher health of the middle class over the poor and other social 373

hierarchies. The current study highlighted yet another health disparity which is difficult to explain ‘Why the children in the wealthy-to-wealthiest social hierarchies do not have a better good self-evaluated health compared to those in the poor-to-poorest households. This work revealed that children in poor and wealthy social hierarchies experience the same good health status. A part of the explanation for the comparable quality of life between the two aforementioned groups lies in the quality of public health care facilities and public health in the country. With the government health care policy which has removed user fees from public hospitals for children less than 18 years, access to health care is equally opened to all social classes. Although access does not represents utilization, within the Jamaican context, children who are taken to public health facilities are provided with a high level of care. Statistics from the Planning Institute of Jamaica and the Statistical Institute of Jamaica showed that private health care is pro-wealthy and public pro-poor, suggesting that for the wealthy and children of those social hierarchies to experience comparable self-evaluated health status, the quality of public health care is high in Jamaica. Another issue which holds some of the justifications is public health. It follows that in Jamaica, water supply, sewerage and food hygiene, and public education are of a high quality. Even though there are substantial inequalities between the public health for the wealthy compared to the poor, the physical environment, lower nutrition and diet are not such that they erode the quality of public health care and general public health and these are reducing some of the health outcome between the poor and the wealthy. Health therefore cannot be bought as was forwarded by Smith & Kington15 it is supported by other social determinants such as education, choices made by parents and health care system in the nation which when coalesce produce healthier people. Health care can be purchased, but this does not translate into better quality of life for those who are able to access those services. This is equally supporting 374

the perspectives of Casas et al.40 which forwarded that improvement in health in the Latin America and the Caribbean do not correspond to the economic development levels or the economic resources within countries as well as possessed by individuals. Addressing health disparities in children cannot omit the inequality between the lengths of time spent by children in rural households compared to children of other households. The current study revealed that there is no significant statistical relationship between self-reported illness and area of residence, yet children within rural households were 3.4 times more likely to experience longer time in illness compared to children of urban households and 1.9 times more than those in peri-urban households. A part of the answer lies in the culture, operational definition of health, choices on experiencing illness and health inequality among the parents within the different geographic areas. One of every two child who was ill was not taken to see a health care practitioner because parents’ reported that they were not ill enough. This highlights not only the cultural biases which are embedded in many parents and by extension Jamaicans about when one should visit medical practitioners. From this bias another is the number of parents who prefer to use home remedy as a first option instead of taking the child immediately to the medical practitioner. For one in every 5 children, the parent used home remedy compared to 9 in every 50 who claimed that affordability was the reasons for not taking the ill-child to a medical doctor. Education in Jamaica is a pro-urban and pro-peri-urban phenomenon making children in rural household more likely to have parents who are less educated compared to urban and periurban counterparts. With more than fifty percentages of the Jamaican children residing with parents of rural households, the benefits of education that include the decision to make healthier 375

choices because of information would be missing from those households. Many rural parents will be taking decision on health care choices based on their socialization, which includes home remedy and wait and see when a medical practitioner is needed by the ill-child. This delay of rural parents to take their ill-children to medical practitioners initially offers an explanation for them spending longer time with the illness as well as accounting for increased mortality among these children. The health inequality that exists in Jamaica on the health status of children can be explained more so by the retardation of culture, low education and tradition than on income. Although government policy has resulted in the removal of health care user fees for children (0 – 18 years) in Jamaica, open access does not denote equality in access. Health care institutions in urban and peri-urban areas are in easy access to residents, with this not being the case for rural residents, addressing cost of care is not putting care in the hand of all. The terrain in rural Jamaica means that public health care choices are not easily accessed by some residents and the distance is such that unless the conditions is severe many parents will prefer to treat the child at home or use the traditional healer (i.e. untrained physician). It is this cultural belief that retard many rural parents from purchasing health insurance coverage, and accounting for the high number of cases with diarrhoea. Hence, the association between poverty and ill-health is operating through education. Poverty leads to increased lower levels of education, and education reduces poor health status. Using statistics for 2007 on Jamaica, 71% of poverty was in rural areas49. Poverty is not only a rural phenomenon in Jamaica, but it also denotes material deprivation, social exclusion nutritional deficiency, increases chronic diseases and premature mortality27, 50-53 Poverty means that the individual will be unable to afford particular necessities, and good physical milieu, and 376

these deprivations will be such that food becomes important and the not dietary requirements. The poor will eat (or eat sometimes), but their physical milieu will be low and survival becomes so pronounced that choice in food is never the case. The nutritional deficiency will affect the parents and moreso the foetus.54 According to Martin-Gronert and Ozanne54 fetal overgrowth can transport glucose and other nutrients from the mother suffering from diabetes mellitus to the unborn child, and means that the fetal intra-uterine milieu will become susceptible to chronic diseases for the child in later life. Money therefore offers choices in a particular physical environment, social arrangement, food selection and health demand that is not available to someone who does not have it. According to Smith and Kington15, money buys health. This perspective assumes that health is a transferrable product and clearly it is not, but money really open access to things. This is justification for the lower health of those in the lower socioeconomic strata compared to those in the upper income group. Van et al53 found that those with chronic health conditions were more likely to be in the lower income group, and this is somewhat concurred by the current study. Clearly, poverty, low education, poor physical environment, nutritional deficiency, puberty and other sedentary and unhealthy lifestyle practices are justifying young rural female prevalence of diabetes mellitus54,55. Here the health disparity in health outcomes of children in particular socioeconomic strata and area of residence are clearly explained by social determinants of health16-19 and justify a rationale for lifestyle behaviour modifications that are needed to bring about greater responsibility of parents and children in Jamaica. According to Marvicsin56, type I diabetes has been increasing in Western industrialized countries over the past 2 decades, and that its occurrence appears during puberty (ages 10 to 12 377

years). She stated that 1 in every 400 to 500 children and adolescents had type I diabetes in United States. The present study revealed that 9 to every 500 children and adolescents had diabetes in Jamaica, indicating the extent of this chronic illness in an English-Speaking Caribbean nation. Statistics from Jamaica revealed that diabetes mellitus was almost 2 times more for females than males49. Within the context of the aforementioned findings, it can be extrapolated from the information that the rationale for no male-child having diabetes are embedded in (1) this appears earlier for females, (2) puberty, (3) obesity, (4) insulin resistance and (5) nutritional deficiency. The present findings highlight that females are more insulin resistant than males which is concurring to research by Murphy et al.57 The early inception of females with diabetes are owing to the fact that females enter puberty before males58 and that they are more likely to be overweight than boy59 which increases their risk of having diabetes. Within the general setting, there is a need for chronic diseases management in Jamaica so as to address the current and future challenges, which is only reinforcing a call made by Swaby et al in 200160. Another potent issue which accounts of the wide health disparity in chronic illness between males and females is owing to what Choudhary et al61 termed under-nutrition of girls (ages 10 – 12 years). The findings of Choudhary et al’s work61 showed that 7 of every 10 adolescent females were under weight (BMI < 18.5), which adds another dimension to the lifestyle management that is needed for parents, children, and in particular females, in order to rectify some of the future health problems which are accounting for lower health status of women compared to men in Jamaica. Khetarpal and Kochar62 also argued that diet and nutrition among rural women affect morbidity and clinical status of these women, which emphasize the importance of a normal balanced diet in health and wellbeing and not the mere consumption of food. They also concur with previous 378

studies which found an association between income, individual preference, belief, cultural traditions, physical milieu and morbidity in rural women. These all add a further dimension to the present study about the role of money, cultural sociophysical milieu in the infection of diseases and how these influence unhealthy (or healthy) lifestyle choices. The nutritional deficiency in rural women in Jamaica account for the prevalence of diabetes in females 10-12 years as these individual become infected with this chronic condition on the premise that they enter puberty before males, and that it is likely that rural males show later signs of infection after 18 years. Khetarpal and Kochar62 provide insights into the prevalence of diabetes in rural females, when they found that 6 out of every 10 rural women (ages 25-45 years) in a rural district in Yamunanagar (Haryana, India) were anemic owing to their low iron, B complex vitamins and vitamin C intake. This information provides an understanding of the present nutritional deficiency of rural women and that this is accounted for by material and income deprivation, and how this transmitted to rural female children.

Conclusions
In summary, although health indicators such as life expectancy, infant mortality, illnesses, and nutrition as well as socio-economic determinants such as poverty and education have improved exponentially in the Jamaica as well as in the Wider Latin America and the Caribbean, child health disparities still exist within Jamaica. Among the findings that emerged which account for these are: cultural biases, policy intervention, health care choices disparities and lack of education. The very young age at which rural females were diagnosed with diabetes mellitus speaks to unhealthy and sedentary lifestyle practices of their mothers during pregnancy, and how this is affecting their female offspring. The findings are far reaching and can be used to aid 379

policy formulation and guide future research. Clearly there is a need for rural Jamaicans to understand and ensure that they are having a balanced diet (with nuts, seeds, grains, vegetables and fruits) as otherwise this will affect not only them, but their children. The challenge of this being materialized will be linked to reduced material and income deprivations in rural Jamaica, coupled with a health-building understanding of what you eat, how it affects your health and how this influences morbidity in later life and increase the risk of chronic diseases in children.

Policy and Research Recommendations
In the 1990s, in seeking to lower health inequalities in the Jamaica, government policies focused on poor people. The policies have been able to reduce poverty, but health inequality and child health disparities are present in contemporary Jamaica. While poverty plays a role in the immunology of an individual, the quality of the physical and social environments, lowered access to material resources and utilization of particular health care services, many of the health inequalities which government policies should have addressed since the 1990s are still evident in child health. The issues of fairness in the distribution of health care choices and utilization are not resulting in removal of child health disparities in Jamaica. The findings which emerged from this work provide us with an understanding of some of the health disparities and clearly highlight that policy focus needs an overhaul for the future. In order to reduce some of the child health disparities in contemporary Jamaica, policy intervention must tackle education, cultural biases on health, health care definitions, timing in seeking health care, focus on accessibility of rural people to health care, and a direct intensive education campaign towards rural and indigenous populations on their perception of illness as well as utilizing medical practitioners as the first 380

option. Another issue is an immediate and extensive health campaign on chronic disease. This programme must to geared toward how to identify early symptoms of chronic illness in children, where to seek care, how to live with chronic illness from in childhood onwards, preventative as against curative care, and an intervention progrmme for public health practitioners. Public health practitioners need to be sensitized on the earliest of children in particular rural female being diagnosed with chronic illnesses which would see medical practitioners testing children on the appearance of particular symptoms and not assume that they are too young. In order to reach rural residents, a new approach is needed that will be established geared towards medical practitioners. The new thrust must include taking medical practitioners to the residents such as in schools, churches, house visits, mobile clinics, and remove the emphasis of tackling health of poor people as this bottom up approach has not addressed the health inequalities. Consequently, research should begin focusing on premature mortality in rural children, medical practitioners’ biases in working in rural areas, cultural and target rural residents in their communities in order to understand their perception of health care and/or health care utilization as well as health outcome after the new intervention is implemented in rural areas. Another way forward for researchers is to commence studying health disadvantage, health gaps and health gradients in Jamaica with a policy implementation approach.

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and obesity at age 15 by gender. OECD; 2009. Available at www.oecd.org/els/social/family/database (retrieved January 20, 2010). 60. Swaby P, Wilson E, Swaby S, Sue-Ho R, Pierre R. Chronic disease management in the Jamaican setting: HOPE worldwide Jamaica’s experience. PNP Med J 2001; 44:171-175. 61. Choudhary S, Mishra CP, Shukla KP. Correlates of nutritional status of adolescents girls in the rural area of Varanasi. The Internet J of Nutrition and Wellness 2009;7:1-16. 62. Khetarpal A, Kochar G. Health and well-being of rural women. The Internet Journal of Nutrition and Wellness 2007;3.

385

Table 15.1: Operational definitions of particular variables Variable Operational definition Coding Self-evaluated Parents’ evaluation of their 1= moderate-to-very good health status, 0 = health status (or children’s health status. otherwise health status) This is taken from the question “In general, would you say your health is excellent, good, moderate, poor or very poor?” Age group Age group is classified into 4 categories. 1 = children ages < 5 years old 2 = children ages 5 – 9 years old 3 = adolescents ages 10 – 14 years old 4 = adolescents ages 15 – 18 years old Number of people who live Total number of people in household divided by in a room total number of room excluding kitchen, bathroom and verandah Income quintiles were used Low = poorest 20% to poor; middle = middle to measure social class, and quintile and upper = wealthy to wealthiest 20% these range from quintile 1 (poorest 20%) to 5 (wealthiest 20%) Items owned by household Summation of durable goods members excluding property (or land) Visits to pharmacies, 1=Visits to health care professionals, medical practitioners, 0=otherwise nurses,

Crowding

Social hierarchy

Durable good

Health careseeking behaviour (health seeking behaviour) Income Self-reported illness

Income is measured by consumption Have you had any illness or injury during the past four weeks? For example, have you had a cold, diarrhoea, asthma, diabetes, hypertension, arthritis or other?

386

Table 15.2: Demographic characteristic of sample, n = 2, 642 Area of residence Variable Urban Peri-Urban Rural (%) (%) (%) Age group Children < 5 years old 24.3 23.5 Children 5 – 9 years old 25.2 27.0 Adolescents: 10 – 14 years old 26.9 29.3 Adolescents: 15 – 18 years old 23.6 20.2 Health Seeking-behaviour No 66.7 57.7 Yes 33.3 42.3 Health insurance coverage No 77.8 83.6 Yes 22.2 16.4 Self-reported illness None 10.4 10.0 Yes 89.6 90.0 Self-reported diagnosed health conditions Acute Influenza 22.7 53.8 Diarrhoea 0.0 1.9 Respiratory diseases 26.7 15.4 Chronic Diabetes mellitus 0.0 0.0 Other 25.3 15.4 Self-evaluated health status Very good 42.3 47.1 Good 46.8 49.6 Moderate 9.4 2.9 Poor 1.4 0.4 Very poor 0.0 0.0 Sex Male 49.1 50.7 Female 50.9 49.3 Social hierarchy Poorest 20% 11.1 13.7 Poor 14.5 23.1 Middle 21.0 22.5 Wealthy Wealthiest 20% Length of illness mean (SD) 26.6 26.9 7.7 (8.1) 23.6 17.1 13.6 (51.0)

P 0.112 22.6 28.7 30.0 18.7 0.224 54.8 45.2 <0.0001 88.9 11.1 0.315 12.1 87.9 0.002 34.1 7.3 17.1 1.8 26.2 <0.0001 45.7 44.7 6.7 2.5 0.4 0.684 51.1 48.9 <0.0001 36.4 27.0 18.2

12.7 5.6 25.8 (125)

0.045

387

Table 15.3: Self-reported health conditions by particular social variables Health conditions Acute conditions Chronic Influenza Diarrhoea Respiratory Diabetes mellitus % % % % 46.5 53.5 19.8 21.8 27.7 17.8 12.9 59.4 18.8 17.8 4.0 41.0 59.0 16.8 27.7 55.4 1.2 (0.4) 30.8 69.2 15.4 53.8 23.1 7.7 0.0 69.2 30.8 0.0 0.0 53.8 46.2 0.0 7.7 92.3 1.1 (0.4) 50.0 50.0 21.4 19.6 21.4 14.3 23.2 30.4 41.1 19.6 8.9 64.3 35.7 35.7 14.3 50.0 1.4 (1.0) 0.0 100.0 33.3 33.3 0.0 33.4 0.0 0.0 0.0 100.0 0.0 66.7 33.3 0.0 0.0 100.0 1.0 (0.0) Other P % 0.112 44.3 55.7 0.352 28.6 20.0 17.1 17.1 17.1 <0.0001 31.4 22.9 22.9 22.9 0.002 65.7 34.3 0.004 27.1 11.4 61.4 1.3 (0.5)

Variable

Sex Male Female Social hierarchy Poorest 20% Poor Middle class Wealthy Wealthiest 20% Age group Children: ages less than 5 years Children: 5 – 9 years Adolescents: 10 – 14 years Adolescents: 15 – 18 years Health care-seeking behaviour Yes No Area of residence Urban Peri-urban Rural Number of visits to health care practitioner Mean (SD)

0.393

388

Table 15.4: Health care-seeking behaviour by particular social variables Health care-seeking Variable Yes No % % Age group Children < 5 years old 44.4 Children 5 – 9 years old 28.1 Adolescents: 10 – 14 years old 17.0 Adolescents: 15 – 18 years old 10.5 Health insurance coverage No 76.6 Yes 23.4 Self-reported illness None 3.5 Yes 96.5 Health conditions Acute Influenza 31.1 Diarrhoea 5.3 Respiratory diseases 27.3 Chronic Diabetes mellitus 1.5 Other (unspecified) 34.8 Self-evaluated health status Very good Good Moderate Poor Very poor Sex Male Female Social hierarchy Poorest 20% Poor Middle Wealthy Wealthiest 20%

P 0.503 39.3 25.4 23.8 11.5 0.027 86.9 13.1 0.138 0.8 99.2 0.012 53.6 5.5 18.2 0.9 21.8 0.006

18.2 45.3 22.9 12.9 0.6 48.5 51.5 18.1 19.9 22.8 20.5 18.7

32.2 45.5 19.0 3.3 0.0 0.866 47.5 52.5 0.356 24.6 23.8 23.0 16.4 12.3

389

Table 15.5: Logistic regression: Explanatory social determinants of good health status of children Odds Explanatory variable Std. Error P ratio 95% C.I.
Age Health care-seeking behaviour Middle class †Poor classes Length of illness Medical expenditure Urban area Peri-urban area †Rural area
Hosmer and Lemeshow goodness of fit χ2 = 6.8 (8), P = 0.6 -2LL = 305.3 Nagelkerke R2 =0.196 †Reference group

R2
0.019 0.032 0.040

0.027 0.331 0.535 0.001 0.000 0.361 0.440

0.034 0.000 0.003 0.046 0.044 0.005 0.006

0.95 0.29 5.00 1.00 1.00 1.00 2.75 3.37 1.00

0.90-1.00 0.15-0.56 1.75-14.28 0.99-1.00 1.00-1.00 1.36-5.57 1.42-7.99

0.020 0.026 0.035 0.024

390

Chapter Sixteen Disparities in self-rated health, health care utilization, illness, chronic illness and other socioeconomic characteristics of the Insured and Uninsured
Paul A. Bourne

Introduction This study examines self-rated health status, health care utilization, income distribution, and health insurance status of Jamaicans, and the disparity between the insured and uninsured. It also models self-rated health status, health care utilization, income distribution, and how these differ between the insured and uninsured. The current findings revealed that 20.2% of Jamaicans had health insurance coverage (i.e. 2,140,316 Jamaicans are uninsured, using end of year population for 2007), suggesting that a large percent of the population are having to use out of pocket payment or government’s assistance to pay their medical bills. The health of individuals within a society goes beyond the individual to the socioeconomic development, standard of living, production and productivity of the nation. Individuals’ health is therefore the crux of human’s development, survivability and explains the rationale as to why people seek medical care on the onset of ill-health. In seeking to preserve life, people demand and utilize health care services. Western societies are structured that people meet health care utilization with a combination of approaches. These approaches can be any combination of out of pocket payment, health insurance coverage, government assistance and families’ aid. In Latin America and the Caribbean, health care is substantially an out of pocket expenditure aided by health insurance policy and government’s health care policy. Within the context of the realities in those nations, the health of the populace is primarily based on the 391

choices, decisions, responsibility and burden on the individual. Survival in developing nations are distinct from Developed Western Nations as Latin America and Caribbean peoples’ willingness, frequency, and demand for health care as well as health choices are based on affordability. Affordability of health care is assisted by health insurance coverage; as the provisions of care offered by the governmental policies mean that the public health care system will be required to meet the needs of many people. Those people will be mostly children, elderly and other vulnerable groups. The public health care system in many societies often time involve long queues, long waiting times, frustrated patients and poor people who are dependent on the service. In order to circumvent the public health care system, people purchase health insurance policies as a means of reducing futuristic health care cost as well as an avoidance of the utilization of public health care. Uninsurance in any society means a dependency on the public health care system, premature mortality and oftentimes public humiliation. The insured on the other hand are able to circumvent many of the experiences of the poor, elderly, children and other vulnerable cohorts who rely on public health care system. Insurance in developing nations, and in particular Jamaica, is private system between the individual and a private insurance company. Because of the nature of health insurance and insurance, people buy into a pool which is usually accommodated through employment. Such a reality excludes retired elderly, unemployed, unemployable, and children of those cohorts. In seeking to understand health care non-utilization and high mortality in developing nations, insurance coverage (or lack of) becomes crucial in any health discourse. There is high proportion of uninsured in the United States and this is equally the reality in many developing nations, particularly in Jamaica [1-6]. According to the World Health 392

Organization (WHO), 80% of chronic illnesses were in low and middle income countries, and 60% of
global mortality is caused by chronic illnesses [7]. It can be extrapolated from the WHO’s findings that

uninsurance is critical in answering some of the health disparities within and among groups and the sexes in the society. The realities of the health inequalities between the poor and the wealthy and the sexes in a society and those in the lower income strata having more illnesses and in particular chronic conditions [7-12] is embedded in financial deprivation. The WHO stated that “In reality, low and middle income countries are at the centre of both old and new public health challenges” [7]. The high risk of death in low income countries is owing to food insecurity, low water quality, low sanitation coupled with in access to financial resources [11, 13]. Poverty makes it insurmountable for poor people to respond to illness unless health care services are free. Hence, the people who are poor will suffer even more so from chronic diseases. The WHO captures this aptly “...People who are already poor are the most likely to suffer financially from chronic diseases, which often deepens poverty and damage long term economic prospects” [7]. This goes back to the inverse correlation between poverty and higher level education, poverty and non-access to financial resources, and now poverty and illness. According to the WHO [7], “In Jamaica 59% of people with chronic diseases experienced financial difficulties because of their illnesses...” and emphasize the importance of health insurance coverage and the public health care system for vulnerable groups. Previous studies showed that health insurance coverage is associated with health care utilization [1-6], and this provides some understanding of health care demand (or the lack of) in developing countries. Studies have been conducted on the general health of the insured and/or uninsured, health care utilization and other health related issues [1-6] have used a piecemeal approach, which means that there is a gap in the literature that could provides more insight into 393

the insured and uninsured. While the current body of health literature provide pertinent information on health and health care utilization and how these differ based on the insured and uninsured, health choices are complex and requires more than piecemeal inquiry.

Materials and methods

Data methods This study is based on data from the 2007 Jamaica Survey of Living Conditions (JSLC), conducted by the Planning Institute of Jamaica (PIOJ) and the Statistical Institute of Jamaica (STATIN). The JSLC is an annual and nationally representative cross-sectional survey that collects information on consumption, education, health status, health conditions, health care utilization, health insurance coverage, non-food consumption expenditure, housing conditions, inventory of durable goods, social assistance, demographic characteristics and other issues [14]. The information is from the civilian and non-institutionalized population of Jamaica. It is a modification of the World Bank’s Living Standards Measurement Study (LSMS) household survey [15]. Overall, the response rate for the 2007 JSLC was 73.8%. Over 1994 households of individuals nationwide are included in the entire database of all ages [16]. A total of 620 households were interviewed from urban areas, 439 from other towns and 935 from rural areas. This sample represents 6,783 non-institutionalized civilians living in Jamaica at the time of the survey. The JSLC used complex sampling design, and it is also weighted to reflect the population of Jamaica.

Statistical analysis 394

Statistical analyses were performed using the Statistical Packages for the Social Sciences v 16.0 (SPSS Inc; Chicago, IL, USA) for Windows. 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 nonmetric variables, and an Analysis of Variance (ANOVA) was used to test the equality of means among non-dichotomous categorical variables. Means and frequency distribution were considered significant at P < 0.05 using chi-square, independent sample t-test, and analysis of variance f test, multiple logistic and linear regressions.

Analytic Models

Cross-sectional analyses of the 2007 JSLC were performed to compare within and between subpopulations and frequencies. Logistic regression examined the relationship between the dichotomous binary dependent variable and some predisposed independent (explanatory) variables. A pvalue < 0.05 was selected to established statistical significance.

Analytic models, using multiple logistic and linear regressions, were used to ascertain factors which are associated with (1) self-rated health status, (2) health care utilization, (3) selfreported illness, (4) self-reported diagnosed chronic illness, and income. For the regressions, design or dummy variables were for all categorical variables (using the reference group listed last). Overall model fit was determined using log likelihood ratio statistic, odds ration and rsquared. Stepwise regressions were used to determine the contribution of each significant variable. All confidence interval (CIs) for odds rations (ORs) were calculated at 95%.

Results 395

Demographic characteristic of sample The sample was 6,783 respondents (48.7% males and 51.3% females). Children constituted 31.3%; other aged adults, 31.3%; young adults, 25.9%; and elderly, 11.9%. The elderly comprised 7.7% young-old, 3.2% old-old and 1.0% oldest-old. Majority of the sample had no formal education (61.8%); primary, 25.5%; secondary, 10.8% and tertiary, 2.0%. Two-thirds of the sample sought health in the last 4-weeks; 69.2% were never married; 23.3% married; 1.7% divorced; 0.9% separated and 4.9% were widowed respondents. Almost 15% reported an illness in the last 4-weeks (43.3% had chronic conditions, 30.4% had acute conditions and 26.3% did not specify the condition). Of those who reported an illness in the last 4- weeks, 87.9% provided information on the typology of conditions: cold, 16.7%; diarrhea, 3.0%; asthma, 10.7%; diabetes mellitus, 13.8%; hypertension, 23.1%; arthritis, 6.3%; and specified conditions, 26.3%. Marginal more people were in the upper class (40.3%) compared to the lower socioeconomic strata (39.8%). Only 20.2% of respondents had health insurance coverage (private, 12.4%; NI Gold, public, 5.3%; other public, 2.4%). Majority of health insurance was owned by those in the upper class (65%) and 19% by those in the lower socioeconomic strata. Bivariate analyses Sixty-one percent of those with chronic conditions were elderly compared to 16.6% of those with other conditions (including acute ailments). Only 39% of those with chronic conditions were non-elderly compared to 83.4% of those with other conditions – (χ2 = 187.32, P < 0.0001). Thirty-three percent of those with chronic illnesses had health insurance coverage compared to 17.8% of those with acute and other conditions - (χ2 = 26.65, P < 0.0001). 396

Furthermore examination of self-reported health conditions by health insurance status revealed that diabetics recorded the greatest percent of health insurance coverage (43.9%) compared to hypertensive, (28.2%); arthritic (25.5%); acute conditions’ patients (17.0%) and other health conditions respondents (18.8%). Sixty-seven percent of respondents who reported being diagnosed with chronic conditions sought medical care in the last 4-weeks compared to 60.4% of those with acute and other conditions (χ2 = 4.12, P < 0.042). Those with primary or below education were more likely to have chronic illnesses (45.0%) compared to secondary level (6.1%) and tertiary level graduants (11.1%) - (χ2 = 23.50, P < 0.0001). There was no

statistical association between typology of illness and social class - (χ2 = 0.63, P = 0.730): upper class, 44.6%; middle class, 41.1% and lower class, 43.0%. This study found significant statistical association between health insurance status and (1) educational level (χ2 = 45.06, P < 0.0001), (2) social class (χ2 = 441.50, P < 0.0001), and (3) age cohort (χ2 = 83.13, P < 0.0001). Forty-two percent of those with at most primary level education had health insurance coverage compared to 16.3% of secondary level and 42.2% of tertiary level respondents. Thirty-three percent of upper class respondents had health insurance coverage compared to 16.7% of those in the middle class and 9.4% of those in the lower socioeconomic strata. Almost 33% of the oldest-old had health insurance coverage compared to 15.1% of children; 18.4% of young adults; 23.6% of other aged- adults; 28.6% of young-old and 24.9% of old-old. A significant statistical association was found between health insurance status and area of residence (χ2 = 138.80, P < 0.0001). Twenty-eight percent of urban dwellers had health insurance coverage compared to 22.1% of semi-urban respondents and 14.5% of rural residents. Furthermore, similarly a significant relationship existed between health care seeking behaviour and health insurance status (χ2 = 33.61, P < 0.0001). Fourteen percent of those with health 397

insurance sought medical care in the last 4-weeks compared to 9.0% of those who did not have health insurance coverage. Likewise a statistical association was found between health insurance status and typology of illness (χ2 = 26.65, P < 0.0001). Fifty-eight percent of those with insurance coverage had chronic illnesses compared to 38.3% of those without health insurance. Concurringly, 42% of those with insurance coverage had acute or other conditions compared to 62% of those who did not have health insurance coverage. Further examination revealed that other public health insurance was mostly had by those with chronic illnesses (76%) compared to NI Gold (public, 65%) and 44% private health coverage (χ2 = 42.62, P < 0.0001). Private health coverage was most had by those with non-chronic illnesses (56%) compared to 35% with NI Gold (public) and 25% other public coverage. No significant statistical difference was found between the average medical expenditure of those who had insurance coverage and non-insured (t = 0.365, P = 0.715) – mean average medical expenditure of those without health insurance was USD 10.68 (SD = 33.94) and insured respondents’ mean average medical expenditure was USD 9.93 (SD = 18.07) - (Ja. $80.47 = US $1.00 at the time of the survey). There was no significant statistical relationship between health care utilization (publicprivate health care visits) and health conditions (acute or chronic illnesses) – χ2 = 0.001, P = 0.975. 49.2% of those who had chronic illnesses used public health care facilities compared to 49.3% of those with acute conditions. There is a statistical difference between the mean age of respondents with non-chronic and chronic illnesses (t = - 23.1, P < 0.0001). The mean age of some with chronic illnesses was 62.3 years (SD = 16.2) compared to 29.3 years (SD = 26.1) for those with non-chronic illnesses. Furthermore, the mean age of insured respondents with chronic illnesses was 63.8 years (SD = 398

15.8) compared to 32.5 years for those with non-chronic conditions. Concurringly, uninsured chronically ill respondents’ mean age was 61.5 years (SD = 16.5) compared to 28.6 years (SD = 25.9) for those with non-chronic illnesses. Table16.1 examines information on crowding index, total annual food expenditure, annual non-food expenditure, income, age, time in household, length of marriage, length of illness and number of visits made to medical practitioner by health insurance status. Self-rated health status, health care seeking behaviour, illness, educational level, social class, area of residence, and health conditions, health care utilization by health insurance status are presented in Table 16.2. Table 16.3 presents information on age cohort of respondents by diagnosed health conditions. A significant statistical association was found between the two variables χ2 = 436.8, P < 0.0001. Table 16.4 examines illness by age of respondents controlled for by health insurance status. There existed a significant statistical relationship between illness and age of respondents, but none between the uninsured and insured, P = 0.410. Table 16.5 presents information on the age cohort by diagnosed health conditions, and diagnosed health conditions controlled by health status. There is a statistical difference between the mean age of respondents and the typology of self-reported illnesses (F = 99.9, P < 0.0001). Those with cold, 19.2 years (SD = 23.9); diarrhoea, 30.3 years (SD = 31.4); asthma, 22.9 years (SD = 22.1); diabetes mellitus, 60.9 years (SD = 16.0); hypertension, 62.5 years (SD = 16.8); arthritis, 64.3 years (SD = 14.5), and other conditions, 38.3 years (SD = 25.3). Analytic Models 399

Nine variables account for (Table 16.6), 32.8% of the variance in moderate-to-very good selfrated health status of Jamaicans The variables are medical expenditure, health insurance status, area of residence, household head, age, crowding index, total food expenditure, health care utilization and illness. Self-reported illnesses accounted for 62.2% of the explained variability of moderate-to-very good health status. Table 16.7 shows information on the explanatory factors of self-reported illnesses. Seven factors accounted for 66.5% of the variability in self-reported illnesses. Ninety-two percent of the variability in self-reported illnesses was accounted for by health care utilization (health care seeking behaviour). Three variables emerged as statistically significant correlates of health care utilization. They accounted for 71.9% of the variance in health care utilization. Most of the variability can be explained by self-reported illnesses (71.2%, Table 16.8). Self-reported diagnosed chronic illnesses can be explained by 5 variables (gender, marital status, health insurance status, age and length of illness), and they accounted for 27.7% of the variance in self-reported diagnosed chronic illness (Table 16.9). Sixty-two percent of the variability in income can be explained by crowding index, social class, household head, health insurance status, self-rated health status, health care utilization, area of residence and marital status). Most of the variability in income can be explained by social class (Table 16.10). Table 16.11 presents information on the explanatory variables which account for health insurance coverage. Six variables emerged as significant determinants of health insurance coverage (age, income, chronic illness, health care utilization, marital status and upper 400

socioeconomic class). The explanatory variables accounted for 19.4% of the variability in health insurance coverage. Income was the most significant determinant of health insurance coverage (explained 43% of the explained variance, 19.4%).

Discussion The current study revealed that 15 out of every 100 Jamaicans reported having an illness in the last 4-weeks, and 57% of those with an illness had chronic conditions. Sixty-one out of every 100 of those with chronic illnesses were 60+ years; 67% of the chronically ill sought medical care when compared to 66% of the population. Most of the chronically ill respondents were uninsured (67%). The chronically ill had mostly primary level education, and there was no statistical association between typology of illness and social class. Almost 2 in every 100 chronically ill Jamaicans were children (less than 19 years), and most of them were uninsured. Nine percent more of the chronically ill who the other aged adult cohort did not have health insurance coverage. Insured respondents were 1.5 times more likely to rate their health as moderate-to-very good compared to the uninsured, and they were 1.9 times more likely to seek more medical care, 1.6 times more likely to report having chronic illnesses, and more likely to have greater income than the uninsured. Illness is a strong predictor of why Jamaicans seek medical care (R2 = 71.2% of 71.9%), and health insurance coverage accounted for less than onehalf percent of the variance in health care utilization. However, health care utilization is a strong predictor of self-reported illness, but it was weaker than illness explaining health care utilization (61.1% of 66.5%). Public health insurance was most common among those with chronic illnesses (76%) compared to 44% private health coverage and 38% had no coverage. Those in the upper

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income strata’s income was significant more than those in the middle and lower socioeconomic group, but chronic illnesses were statistically the same among the social classes. Health disparities in a nation are explained by socioeconomic determinants as well as health insurance status. Previous research showed that health care utilization and health disparities are enveloped in unequal access to insurance coverage and social differences [2, 4, 17-19]. The present paper revealed that health insurance coverage is mostly had by those in the upper class, with less than 20 in every 100 insured being in the lower socioeconomic class. Although this study found that those in the lower class does not have more chronic illness than those in the wealthy class, 86 out of every 100 uninsured respondents indicated that their health status was poor. Health insurance coverage provides valuable economic relief for chronically ill respondents as this allows them to access needed health care. Like Hafner-Eaton’s research [2], this paper found that health insurance status was the third most powerful predictor of health care utilization. Forty-nine to every 100 chronically ill persons use the public health care facilities. This mean that health insurance coverage appeases the health care burden of its holder, but the insured in Jamaica are mostly wealthy, older, chronically ill, married, and seek more medical care than the uninsured. The uninsured ill are therefore less likely to demand health care, and this economic burden of health care is either going to be the responsibility of the state, the individual or the family. The difficulty here is that the uninsured are more likely to be in the lower-tomiddle class, of working age or children, experienced more acute illness, 38 out of every 100 chronically ill are in the lower class, these provide a comprehensive understanding of the insured and uninsured that will allow for explanations in health disparities between the socioeconomic strata and sexes. With 43 out of every 100 people in the lower socioeconomic strata self-reported 402

being diagnosed with chronic illness, health insurance coverage, public health system and other policy intervention aid in their health, and health care utilization. Among the material deprivation of the poor is uninsurance. Those in the wealthy socioeconomic group in Jamaica were 3.5 times more likely to be holder of health insurance coverage than those in the lower socioeconomic strata. And Gertler and Sturm [3] identified that health insurance cause a switching from public health to the private health system, which indicates that a reduction in public health expenditure and health insurance will significantly influence the health of the poor. This research showed that only 19% of those with health insurance were in the lower class. Therefore issue of uninsurance creates futuristic challenges for the poor in regard to their health and health care utilization. As on the onset of illness, those in the lower income strata without health insurance must first think about their illness and weight this against the cost of losing current income in order to provide for their families as well as parents of ill children must also do the same. The public health care system will relieve the burden of the poor, and while those with health insurance are more likely to utilize health care, this is a futuristic product in enhancing a decision to utilize health care. But outside of those issues, their choices (or lack), the cost of public health care, national insurance scheme and general price index in the society further lowers their quality of life. Although the poor may be dissatisfied with the public health care system (waiting time, crowding, discriminatory practices by medical practitioners), better health for them without health coverage is through this very system. It can be extrapolated therefore from the present data that there are unmet health needs among some people in the lower socioeconomic strata. As those who do not have health insurance, want to avoid the public health care system owing to dissatisfaction or inafffordability, and will only seek health care when their symptoms are severe and sometimes 403

the complications from the delay make it difficult to be addressed on their visits. Among unmet health needs of the poor will be medication. Even if they attend the public health care system and are treated, the system does not have all the medications which is an indication that they are expected to buy some. The challenge of the poor is to forego purchasing medication for food, and this means their conditions would not have been rectified by the health care visitation. By their very nature, the socioeconomic realities of the poor such as lower access to education, proper nutrition, good physical milieu, poor sanitation and lower health coverage, cripple their future health status, this accounts for high premature mortality and hinders health care utilization. It is this lower health care utilization which accounts for their increase risk of mortality as the other deprivations such as proper sanitation and nutrition exposes them to disease causing pathogens which means that their inability to afford health insurance increased their reliance on the public health care system. The present findings showed that the uninsured are mostly poor and within the context of Lasser et al.’s work [20] that they receive worse access to care, are less satisfied with the care they receive and medical services than the insured in the US, this is an indication of further resistant of the poor from willingly demanding health care as this rehashes their dissatisfaction and humiliation. Despite the dissatisfaction and humiliation, their choices are substantially the public health care system, abstinence from care, risk of death, and the burden of private health care. Apart of the rationales why those in the lower socioeconomic strata have fewer health coverage than those in the wealthy income group are (1) inafffordability, (2) type of employment (mostly part time, seasonal, low paid and uninsured position) which makes it too difficult for them to be holders of health insurance and this retards the switch from public-to-private health care utilization. Recently a study conducted by Bourne and Eldemire-Shearer [21] found that 74% of those in the poorest income quintile utilized public 404

hospitals compared to 58% of those in the second poor quintile and 31% of those in the wealthiest 20%. Then, if public health becomes privatized or become increasingly more expensive for recipients, the socioeconomically disadvantaged population (poor, elderly, children and other vulnerable groups) will become increasingly exposed to more agents that are likely to result in their deaths, increased utilization of home remedy as well as the widening of the health outcome inequalities among the socioeconomic strata. Illness and particularly chronic condition can easily result in poverty, before mortality sets in. With the World Health Organization (WHO) opined that 80% of chronic illnesses were in
low and middle income countries and that 60% of global mortality is caused by chronic illness [7], leveling insurance coverage can reduce burden of care for those in the lower socioeconomic strata. The

importance of health insurance to health care utilization, health status, productivity, production, socioeconomic development, life expectancy, poverty reduction strategy and health intervention must include increase health insurance coverage of citizenry within a nation. The economic cost of uninsured people in a society can be measured by the lost of production, payment of sick time, mortality, lowered life expectancy and cost of care for children, orphanage and elderly who become the responsibility of the state from the death of the poor. Therefore the opportunity cost of reduced public health care budget is the economic cost of the aforementioned issues, and goes to the explanation of premature mortality in a society. Particularly the chronically ill, they benefit from health insurance coverage not because of the reduced cost of health care, but the increased health care utilization that result from health coverage. From the findings of Hafner-Eaton’s work [2], the chronically ill in the United States were 1.5 times more likely to seek medical care and while this is about the same for Jamaicans, health insurance is responsible to their health care utilization and not the condition or illness. 405

According to Andrulis [22], “Any truly successful, long-term solution to the health problems of the nation will require attention at many points, especially for low-income populations who have suffered from chronic underservice if not outright neglect” Embedded in Andrulis’s work is the linkage between poverty, poor health care service delivery, differences in health outcomes among the socioeconomic groups, higher mortality among particular social class, deep-seated barriers in health care delivery and the perpetuation of those and how they can increase health differences among the socioeconomic strata. The relationship between poverty and illness is well established in the literature [7, 8, 23] as poverty means deprivation from proper nutrition, safe drinking water, and those issues contribute to lower health, production, productivity, and more illness in the future. Free public health care or lower public health care cost does not mean equal opportunity to access, eliminate the barriers to equal opportunity, neither does it increase health and wellness for the poor and remove lower health disparities among the socioeconomic groups. However, lower-income, increase price indices, removal of government subsidy from public health care, increased uninsurance, lower health care utilization, increase poverty, premature mortality and lower life expectancy of the population and particular subpopulations. Increases in diseases (acute and chronic) are owing to lifestyle practices of people. Lifestyle practices are voluntary lifestyle choices and practices [24]. The poor are less educated, more likely to be unemployed, undernourished, deprived from financial resources, and their voluntary actions will be about survival and not diet, nutrition, exercise and other healthy lifestyle choice. Lifestyle choices such as diet, proper nutrition, and sanitation, safe drinking water are costly, which oftentimes occurs because of poverty, some people can afford to make these choices. It follows therefore that those in the lower socioeconomic strata’s voluntary action will be unhealthy choices which are cheaper. Poverty therefore handicaps its people, and 406

predetermines unhealthy lifestyle choices, which further accounts for greater mortality, lower life expectancy, health insurance coverage and private health care utilization. Conclusion

Poverty is among the social determinants of health, health care utilization, and health insurance coverage in a society. While the current study does not support the literature that chronic illnesses were greater among those in the lower socioeconomic strata, they were less likely to have health insurance coverage compared to the upper class. Poverty denotes socioeconomic deprivation of resources which appears in a society, and goes to the crux of health disparities among the socioeconomic groups and sexes. Health care utilization is associated with health insurance coverage as well as government’s assistance, and this embodies the challenges of those in the vulnerable groups. Within the current global realities, many governments are seeking to reduce their public financing of health care which would further shift the burden of health care to the individual, and this will even increase premature mortality among those in the lower socioeconomic strata. Governments in developing nations continue to invest in improving public health measures such as safe drinking water, sanitation, mass immunization) and the training of medical personnel, building clinics and hospitals and there is definite a need to include health insurance coverage to their public health measure as this will increase access to health care utilization. Any increase in health care utilization will be able to improve health outcome, reduce health disparities between the socioeconomic groups and the sexes that will see improvements in the quality of life of the poor.

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In summary, with the health status of the insured being 1.5 times more than the uninsured, their health care utilization being 1.9 times more than the uninsured and illness being a strong predictor of health care seeking, any reduction in the health care budget in developing nations denotes that vulnerable groups (such as elderly, children and poor) will seek less care, and this will further increase the mortality among those cohorts.

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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References 1. Miles S, Parker K. Men, women, and health insurance. The New England Journal of Medicine 1997; 336:218-221. 2. Hafner-Eaton C. Physical utilization disparities between the uninsured and insured: Comparisons of the chronically ill, acutely ill, and well nonelderly populations. JAMA 1993; 269:787-792. 3. Gertler P, Sturm R. Private health insurance and public expenditures in Jamaica. Journal of Econometrics 1997; 77:237-257. 4. Doty MM, Holmgren AL. Unequal access: insurance instability among low-income workers and minority. Issue Brief (Common Fund) 729:1-6. 5. Bourne PA. Self-reported health and medical care-seeking behaviour of uninsured Jamaicans. North Am J Med Sci 2010; 2: 71-80. 6. Bourne P. Health insurance coverage in Jamaica: Multivariate analyses using two crosssection survey data for 2002 and 2007. Int J of Collaborative Research on Internal Medicine and Public Health 1:195-213. 7. World Health Organization, WHO. Preventing Chronic Diseases a vital investment. Geneva: WHO; 2005. 8. Van Agt HME, Stronks K, Mackenbach JP. Chronic illness and poverty in the Netherlands. Eur J of Public Health 2000; 10:197-200. 9. Fox J ed. Health inequalities in European Countries. Aldershot: Gower Publishing Company Limited; 1989. 10. Illsley R, Svenson PG, ed. Health inequalities in Europe. Soc Sci Med 1990; 31(special issue):223-420. 11. Sen A. Poverty: An ordinal approach to measurement. Econometricia 1979; 44, 219231. 12. Casas JA, Dachs JN, Bambas A. Health disparity in Latin America and the Caribbean: The role of social and economic determinants. In: Pan American Health Organisation. Equity and health: Views from the Pan American Sanitary Bureau, Occasional Publication No. 8. Washington DC; 2001: pp. 22-49. 13. 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; 21:3146. 14. Planning Institute of Jamaica, (PIOJ), Statistical Institute of Jamaica, (STATIN). Jamaica Survey of Living Conditions, 1989-2007. Kingston: PIOJ, STATIN; 1989-2008. 15. 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). 16. 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. 409

17. Hayward RA, Shapiro MF, et al. Inequalities in health services among insured Americans. Do working-age adults have less access to medical care than the elderly. N Engl J Med 1988;318:1507-12. 18. Fiscella K, Williams DR. Health disparities based on socioeconomic inequities: implications for urban health care. Acad Med 2004;79:1139-47. 19. LaVeist TA, Carroll T. Race of physician and satisfaction with care among AfricanAmerican patients. J Natl Med Assoc 2002; 94:937-43. 20. Lasser KE, Himmelstein DU, Woolhandler S. Access to care, health status, and health disparities in the United States and Canada: Results of a Cross-National PopulationBased Survey. Am J Public Health 200696:1300-1307. 21. Bourne PA, Eldemire-Shearer D. Public hospital health care utilization in Jamaica. Australian J of Basic and Applied Scie 2009; 3:3067-3080. 22. Andrulis DP. Access to care is the centerpiece in the elimination of socioeconomic disparities in health. Ann Intern Med 1998; 129:412-416. 23. Foster AD. Poverty and illness in low-income rural areas. The American Economic Review 1994; 84:216-220. 24. Barnekow-Bergkvist M, Hedberg GE, Janlert U, Jansson E. Health status and health behaviour in men and women at the age of 34 years. European J of Public Health 1998; 8:179-182.

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Table 16.1. Crowding, expenditure, income, age, and other characteristics by health insurance status Health insurance status P Characteristics Non-insured Insured mean ± SD mean ± SD Crowding index 4.9 ± 2.6 4.1±2.1 t = 10.32, < 0.0001 Total annual food expenditure1 3476.09±2129.97 3948.12±2257.97 t = - 6.81, < 0.0001 Annual non-food expenditure1 3772.91±3332.50 6339.40±5597.60 t = - 21.33, < 0.0001 Income1 7703.62±5620.94 12374.89±9713.00 t = - 22.75, < 0.0001 Age (in year) 28.7±21.4 35.0 ±22.7 t = - 9.40, < 0.0001 Time in household (in years) 11.7±1.6 11.8±1.3 t = - 1.62, 0.104 Length of marriage 16.9±14.3 18.3±13.8 t = - 1.55, 0.122 Length of illness 14.7±51.1 14.1±36.2 t = - 0.217, 0.828 No. of visits to medical practitioner 1.4±1.0 1.5±1.2 t = - 0.659, 0.511
1

Expenditures and income are quoted in USD (Ja. $80.47 = US $1.00 at the time of the survey)

411

Table 16.2. Health, health care seeking behaviour, illness and particular demographic characteristics by health insurance status Health insurance status P Characteristic Coverage No coverage Private n (%) Public, NI Gold n (%) Other Public n (%) n (%) χ2 = 42.62, P < 0.0001 Health conditions Acute and other 53 (56.4) 24 (34.8) 13 (24.5) 415 (61.7) Chronic 41 (43.6) 45 (65.2) 40 (75.5) 258 (38.3) χ2 = 70.09, P < 0.0001 Health care seeking behaviour No 724 (89.3) 283 (81.3) 118 (75.2) 4735 (91.0) Yes 87 (10.7) 63 (18.2) 39 (24.8) 468 (9.0) χ2 = 67.14, P < 0.0001 Illness No 699 (86.2) 272 (78.6) 101 (64.3) 4453 (85.8) Yes 112 (13.8) 74 (21.4) 56 (35.7) 736 (14.2) χ2 = 78.10, P < 0.0001 Education level Primary and below 684 (84.4) 318 (92.2) 144 (91.7) 4536 (87.4) Secondary 80 (9.9) 23 (6.7) 9 (5.7) 577 (11.1) Tertiary 46 (5.7) 4 (1.2) 4 (2.5) 74 (1.4) χ2 = 596.08, P < 0.0001 Social class Lower 78 (9.6) 135 (39.0) 31 (19.7) 2345 (45.1) Middle 111 (13.7) 80 (23.1) 27 (17.2) 1085 (20.9) Upper 622 (76.7) 131 (37.9) 99 (63.1) 1773 (34.1) χ2 = 190.29, P < 0.0001 Area of residence Urban 373 (46.0) 106 (30.6) 63 (40.1) 1397 (26.8) Semi-urban 212 (26.1) 66 (19.1) 32 (20.4) 1091 (21.0) Rural 226 (27.9) 174 (50.3) 62 (39.5) 2715 (52.2) χ2 = 67.14, P < 0.0001 Self-rated health status Poor 699 (86.2) 272 (78.6) 101 (64.3) 4453 (85.8) Moderate-to-excellent 112 (13.8) 74 (21.4) 56 (35.7) 736 (14.2) χ2 = 30.06, P < 0.0001 Health care utilization Private 65 (79.3) 29 (47.5) 18 (46.2) 215 (46.8) Public 17 (20.7) 32 (52.5) 21 (53.8) 244 (53.2) 412

Table 16.3. Age cohort by diagnosed illness
Diagnosed illness Acute condition Cold Age cohort n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) Diarrhoea Asthma Diabetes mellitus Chronic condition Hypertension Arthritis Other Total

Children

97 (65.1)

13 (48.1)

51 (53.7)

3 (2.4)

0 (0.0)

0 (0.0)

54 (23.1)

218 (24.5)

Young adults

14 (94)

2 (7.4)

16 (16.8)

3 (2.4)

6 (2.9)

1 (1.8)

43 (18.4)

85 (9.6)

Other-aged adults

22 (14.8)

6 (22.2)

18 (18.9)

44 (35.8)

76 (36.9)

17 (30.4)

85 (36.3)

268 (30.1)

Young old

8 (5.4)

2 (7.4)

7 (7.4)

49 (39.8)

61 (29.6)

22 (39.3)

32 (13.7)

181 (20.3)

Old Elderly

8 (5.4)

3 (11.1)

2 (2.1)

19 (15.4)

49 (23.8)

14 (25.0)

13 (5.6)

108 (12.1)

Oldest Elderly Total

0 (0.0) 149

1 (3.7) 27

1 (1.1) 95

5 (4.1) 123

14 (6.8) 206

2 (3.6) 56

7 (3.0) 234

30 (3.4) 890

413

Table 16.4. Illness by age of respondents controlled for health insurance status Age of respondents Characteristic Uninsured Insured Mean ± SD Mean ± SD Illness Acute condition Cold 18.8 ± 23.5 21.0 ± 26.3 Diarrhoea 28.4 ± 30.3 31.8 ± 13.5 Asthma 21.0 ± 21.7 29.4 ± 22.9 Chronic condition Diabetes mellitus 58.7 ± 16.1 63.8 ± 15.4 Hypertension 62.1 ± 17.3 63.6 ± 15.7 Arthritis 64.0 ± 13.3 65.0 ± 18.7 Other condition 38.1 ± 25.0 39.2 ± 26.8 F statistic 73.1, P < 0.0001 23.3, P < 0.0001

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Table 16.5. Age cohort by diagnosed health condition, and health insurance status Diagnosed health condition Acute Chronic n (%) Age cohort Children Young adults Other aged-adults Young-old Old-old Oldest-old Total n (%) Diagnosed health condition Acute Chronic Uninsured n (%) n (%) Acute Chronic Insured n (%) n (%)

Characteristic

215 (42.6) 3 (0.8) 75 (14.9) 10 (2.6) 131 (25.9) 137 (2.6) 49 (9.7) 132 (34.3) 26 (5.1) 82 (21.3) 9 (1.8) 21 (5.5) 505 385 2 χ = 317.5, P < 0.0001

183 (44.1) 1 (0.4) 32 (35.6) 2 (1.6) 58 (14.0) 6 (2.3) 17 (18.9) 4 (3.2) 110 (26.5) 100 (38.6) 21 (23.3) 37 (29.4) 37 (8.9) 82 (31.7) 12 (13.3) 50 (39.7) 20 (4.8) 55 (21.2) 6 (6.7) 27 (21.4) 7 (1.7) 15 (5.8) 2(2.2) 6 (4.8) 415 259 90 126 2 2 χ = 234.5, P < 0.0001 χ = 73.6, P < 0.0001

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Table 16.6. Logistic regression: Explanatory variables of self-rated moderate-to-very good health
Explanatory variable Coefficient Std. error Odds ratio 95.0% C.I. R2 0.003 0.005 0.007 0.006

Average medical expenditure Health insurance coverage (1= insured) Urban Other †Rural Household head Age Crowding index Total food expenditure Health care seeking (1=yes) Illness Model fit χ2 = 574.37, P < 0.0001 -2LL = 1477.76 Nagelkerke R2 = 0.328 †Reference group ***P < 0.0001, **P < 0.01, *P < 0.05

0.000 0.410 0.496 0.462

0.000 0.181 0.180 0.197

1.00* 1.51* 1.64** 1.59* 1.00 1.46* 0.96*** 0.86*** 1.00*** 0.51** 0.24***

1.00 -1.00 1.06 - 2.15 1.15 - 2.34 1.08 - 2.34

0.376 -0.046 -0.156 0.000 -0.671 -1.418

0.154 0.004 0.035 0.000 0.211 0.212

1.08 - 1.97 0.95 - 0.96 0.80 - 0.92 1.00 - 1.00 0.34 - 0.77 0.16 - 0.37

0.004 0.081 0.010 0.003 0.005 0.204

416

Table 16.7. Logistic regression: Explanatory variables of self-reported illness
Explanatory variable Coefficient Std Error Odds ratio 95.0% C.I.

R2
0.001 0.003 0.002 0.037 0.002 0.009 0.611

Average medical expenditure Male Married Age

0.000 -0.467 0.527 0.031 0.000 -1.429

0.000 0.137 0.146 0.004 0.000 0.213 0.262

1.00* 0.63** 1.69*** 1.03*** 1.00** 0.24*** 342.11***

1.00 - 1.00 0.48 - 0.82 1.27 - 2.25 1.02 - 1.04 1.00 -1.00 0.16 -0.36 204.71 -571.72

Total food expenditure
Self-rated moderate-to-excellent health

Health care seeking (1=yes) 5.835 Model fit χ2 = 2197.09, P < 0.0001 -2LL = 1730.41 Hosmer and Lemeshow goodness of fit χ2 = 4.53, P = 0.81 Nagelkerke R2 = 0.665 †Reference group ***P < 0.0001, **P < 0.01, *P < 0.05

417

Table 16.8. Logistic regression: Explanatory variables of health care seeking behaviour
Explanatory variable Coefficient Std error Odds ratio 95.0% C.I. R2

Health insurance coverage (1= insured)
Self-reported illness Self-rated moderate-to-excellent health

0.620 5.913 -0.680

0.179 0.252 0.198

1.86** 369.92*** 0.51**

1.31 - 2.64 225.74 - 606.17 0.34 - 0.75

0.003 0.712 0.004

Model fit χ2 = 1997.86, P < 0.0001 -2LL = 1115.93 Hosmer and Lemeshow goodness of fit χ2 = 1.49, P = 0.48 Nagelkerke R2 = 0.719 †Reference group ***P < 0.0001, **P < 0.01, *P < 0.05

418

Table 16.9. Logistic regression: Explanatory variables of self-reported diagnosed chronic illness
Explanatory variable Male Married †Never married Coefficient -1.037 0.425 Std error 0.205 0.199 Odds ratio 0.36*** 1.53* 1.00 1.58* 1.05*** 1.13* 95.0% C.I. 0.24 - 0.53 1.04 - 2.26

R2 0.048 0.012

Health insurance coverage (1= insured)
Age Logged Length of illness

0.454 0.047 0.125

0.220 0.005 0.059

1.02 - 2.42 1.04 - 1.06 1.01 - 1.27

0.008 0.201 0.008

Model fit χ2 = 136.32, P < 0.0001 -2LL = 673.09 Hosmer and Lemeshow goodness of fit χ2 = 15.96, P = 0.04 Nagelkerke R2 = 0.277 †Reference group ***P < 0.0001, **P < 0.01, *P < 0.05

419

Table 16.10. Multiple regression: Explanatory variables of income
Unstandardized Coefficients Explanatory variable Constant Crowding index Upper class Middle Class †Lower class Household head B 11.630 0.206 1.265 0.692 Std. Error 0.061 0.008 0.052 0.047 Beta 95% CI 11.511 - 11.750 0.190 - 0.221 1.162 - 1.368 0.599 - 0.784 0.195 0.320 0.133 Standardized Coefficients

R2

0.625*** 0.649*** 0.347***

-0.181 0.137 0.165 0.109 0.145 0.130

0.038 0.042 0.040 0.039 0.046 0.049

-0.108*** 0.075** 0.094*** 0.063** 0.079** 0.063**

-0.256 - -0.106 0.054 - 0.220 0.088 - 0.243 0.033 - 0.185 0.055 - 0.235 0.033 - 0.226

0.012 0.007 0.006 0.003 0.002 0.003

Health insurance coverage (1= insured)
Self-rated good health status

Health care seeking (1=yes)
Urban Other town †Rural area Married †Never married

0.075

0.038

0.044*

0.000 - 0.150

0.001

F = 144.15, P < 0.0001 R2 = 0.682 †Reference group ***P < 0.0001, **P < 0.01, *P < 0.05

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Table 16.11. Logistic regression: Explanatory variables of health insurance status (1= insured)
Explanatory variable Age Income Chronic condition Health care seeking (1=yes) Married †Never married Upper class †Lower class Coefficient 0.014 0.000 0.563 0.463 0.647 Std. error 0.006 0.000 0.210 0.211 0.192 Odds ratio 1.01* 1.00*** 1.7** 1.59* 1.91** 95.0% C.I. 1.00 - 1.03 1.00 - 1.00 1.16 - 2.65 1.05 - 2.40 1.31 - 2.79 R2 0.040 0.082 0.013 0.010 0.024

0.841

0.227

3.46***

1.49 - 3.62

0.025

Model fit χ2 = 95.7, P < 0.0001 -2LL = 686.09 Hosmer and Lemeshow goodness of fit χ2 = 5.08, P =0.75 Nagelkerke R2 = 0.194 †Reference group ***P < 0.0001, **P < 0.01, *P < 0.05

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Chapter Seventeen Social determinants of self-reported health across the Life Course
Paul A. Bourne

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 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 422

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) 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)]. 423

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 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 424

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. 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

425

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 i.e. 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 , A t , Q t , HH t , C i , En i , MS i , HI i , HT i , SS i , LL i ,X i , CRi , D i , O i , Σ(NP i ,PP i ), M i ,N i , FS i , A i , W i , 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 (i.e. no reported health conditions four week leading up to the survey period), 0 if poor (i.e. 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 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

426

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 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 427

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 17.1).
Ht = f(H t-1, Rt , P mc , ED i , MSi, HI i , SS i,AR i, X i , Σ(NP i,PP i), 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 60+ years) and the initial model was once again tested. There were some modifications of the 428

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 (Table 17.2).
Ht = f(H t-1, ED i, MSi , HI i, ,ARi , X i, Σ(PP i), 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 17.3)
Ht = f(Ht-1, P mc , En i , HI i, X i , Σ(NP i),N i, εi)...........................................……………………………..... Model (6)

429

Based on table 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 17.4).
Ht = f(H t-1, W i, HI i, Σ(NP i), εi )...............................................…………………………….....Model (7)

From table 3, the model had statistically significant predictive power (model χ2 (19) =453.733, p < 0.001; 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 [ie Model (4)], elderly [ie Model (5)], middle age adults [ie Model (6)], and young adults [ie Model (7) are derivatives of Model (3). Good Health Status[ie 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)

430

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) 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 431

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. 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 (ie 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.

432

In Hambleton et al’s work, the scholars identified the factors (ie 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 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 433

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. 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

434

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.

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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Table 17.1: 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 -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 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

-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 17.2: 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

Table 17.3: Good Health Status of Middle Age Jamaicans by Some Explanatory Variables
Coefficient Std Error Wald statistic P Odds Ratio CI (95%)

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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

0.03 -0.29 -0.57 0.50 -0.09 0.00 0.31

0.15 0.15 0.36 0.45 0.04 0.00 0.12

0.04 3.67 2.44 1.24 6.44 0.53 7.41

0.834 0.055 0.119 0.265 0.011 0.465 0.006

1.03 0.75 0.57 1.66 0.91 1.00 1.37

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

-0.20 -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

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

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

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

0.82 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

3.29 1.25 6.89 0.009 χ2 (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 17.4: 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 -0.39 -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 -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 0.65 0.39 0.36 0.93 1.00 0.75 0.02 0.94 0.68 Upper 1.37 0.78 1.68 1.10 1.00 1.26 0.04 1.69 1.34

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 Eighteen Variations in health, illness and health care-seeking behaviour of those in the upper social hierarchies in a Caribbean society
Paul A. Bourne

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; 443

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 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 (i.e. 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

444

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 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 445

third of the Labour Force Survey (i.e., 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 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 446

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 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) 447

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 (i.e. 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 (i.e. 95% confidence interval).

Results
Table 18.1 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 (i.e. 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 448

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 (i.e. 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 (i.e. second wealthy or wealthiest 20%) – χ2 = 8.518, P = 0.744. Table 18.2 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.

449

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 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 18.3 shows information on particular variables that are correlated (or not) with selfreported 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 (i.e. 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 18.4 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 450

self-reported illness - Model fit χ2 = 1087.7, P < 0.0001. The significant variables (i.e. health care-seeking 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 18.5 displays variables that seek to explain the variability in self-reported health care-seeking 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 (i.e. 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) 451

between self-reported illness and social hierarchy (i.e. 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 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 (i.e. both acute and chronic conditions). Embedded in 452

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 (i.e. fair-to-poor health status) and found that lower socioeconomic class residents of Milwakee had the greatest fair-to-poor health 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 453

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-tovery 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 454

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 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 455

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 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 456

causes, and though they have lower rates of chronic illness than people in the lower socioeconomic group, the reality among the upper class is 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 (i.e. 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 (i.e. 84.3% of males and 48.7% of females); 9.8% smoked cigarettes (i.e. 12.4% of males and 6.7% of females); 10.4% smoked marijuana (i.e. 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 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 457

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 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

458

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 18.1. 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 18.2. 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 18.3. 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 18.4. 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.

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

1.0, 1.03 0.42, 1.04 1.37, 3.79 0.38, 1.98

-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 18.5. 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.

Coefficient 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 0.014 -0.109 -0.601 -0.291

P 0.079 0.676 0.042 0.513

1.00, 1.03 0.54, 1.49 0.31, 0.98 0.31, 1.79

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 Nineteen Self-reported health and medical care-seeking behaviour of uninsured Jamaicans
Paul A. Bourne

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 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 468

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%.

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 (i.e. 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 469

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. Twentyone 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 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 470

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 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 471

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 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

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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 (i.e. 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 (i.e. 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 per household member i, lnC; crowding of person i, CR i; and an error term (i.e. residual error). 473

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 ) MCSBi =f(PH t ,A i , MR i , ε i ) Measures 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.
3 4

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. 474 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 were 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 19.1 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 19.1). 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). 475

Seventeen percent of females reported a recurring illness which was significantly more than the 12% for males (Table 19.2). 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 19.3). 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. Multivariate Analysis Table 19.4 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; 476

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 19.5 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 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 care-seeking behaviour and social class; medical care-seeking behaviour and sex; and health care-seeking behaviour and area of residence. Embedded in this finding is the dominance 477

of a non-medical 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 careseeking 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 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

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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 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). 479

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 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. 480

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 (i.e. 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. 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] 481

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, semiurban, 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.

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

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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.

References
1. World Health Organization, (WHO). Preventing Chronic Diseases a vital investment. Geneva: WHO;2005. 2. Bourne PA, Beckford O. Illness and Unemployment in Jamaica. Paper presented at the Caribbean Studies Association, CSA, 34th Annual Conference Hilton, Kingston, Jamaica, June 1-4, 2009. 3. Sen A. Poverty: An ordinal approach to measurement. Econometrica 1979;44: 219-231. 4. Statistical Institute of Jamaica. Demographic statistics, 2007. Kingston: STATIN;2008. 5. 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, Mona, Jamaica;2007 6. International Labour Organization, (ILO). Health Insurance in Developing Countries: The Social Security Approach. Geneva: ILO;1990. 7. Call KT, Ziegenfuss J. Health insurance coverage and Access to Care Among Rural and Urban Minnesotans. Rural Minnesota J 2007;2, 11-35. 8. Pan American Health Organization, World Health Organization. Trade in Health Services: Global, regional, and country perspectives. Washington D.C: PAHA & WHO;2002. 9. Pan American Health Organization, The Inter-American Development Bank, The World Bank. Investment in Health: Social and Economic Returns. PAHO: Washington D.C.: PAHO;2001. 10. World Bank. The demand for health care in Latin America. Lessons from the Dominican Republic and El Salvador. Washington D.C: The World Bank;1993. 11. Bourne PA. Socio-demographic Correlates of Health care-seeking behaviour, selfreported illness and Self-evaluated Health status in Jamaica. Int J of Collaborative Research on Internal Medicine & Public Health 2009;1:101-130. 483

12. Bourne PA, Rhule J. Good Health Status of Rural Women in the Reproductive Ages. International Journal of Collaborative Research on Internal Medicine & Public Health 2009;1:132-155. 13. World Bank, Development Research Group, Poverty and human resources. Jamaica Survey of Living Conditions (LSLC) 1988-2000: Basic Information. Washington DC; 2002. (Accessed November 4, 2009, at http://www.siteresources.worldbank.org/INTLSMS/Resources/.../binfo2000.pdf) 14. PIOJ, STATIN. Jamaica Survey of Living Conditions, 2002. Kingston: PIOJ & STATIN;2003. 15. PIOJ, STATIN. Jamaica Survey of Living Conditions, 2007. Kingston, Jamaica: PIOJ & STATIN;2008. 16. 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];2007. 17. Cohen L, Holliday M. Statistics for Social Sciences. London: Harper & Row;1982. 18. Hair JF, Black B, Babin BJ, Anderson RE, Tatham RL. Multivariate data analysis, 6th ed. New Jersey: Prentice Hall;2005. 19. Mamingi N. Theoretical and empirical exercises in econometrics. Kingston: University of the West Indies Press;2005. 20. Zar JH. Biostatistical analysis, 4th ed. New Jersey: Prentice Hall;1999. 21. Hamilton JD. Time series analysis. New Jersey: Princeton University Press;1994. 22. Kleinbaum DG, Kupper LL, Muller KE. Applied regression analysis and other multivariable methods. Boston: PWS-Kent Publishing;1988. 23. Cohen J, Cohen P. Applied regression/correlation analysis for the behavioral sciences, 2nd ed. New Jersey: Lawrence Erlbaum Associates;1983. 24. Koutsoyiannis A. Theory of econometrics, 2nd ed. New York: MacMillan Publishing;1977. 25. Finnas F, Nyqvist F, Saarela J. Some methodological remarks on self-rated health. The Open Public Health J 2008;1: 32-39. 26. 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. 27. Idler EL, Kasl S. Self-ratings of health: Do they also predict change in functional ability? Journal of Gerontology 1995; 50B : S344-S353. 28. Planning Institute of Jamaica, (PIOJ). Economic and Social Survey Jamaica, 2007. Kingston: PIOJ;2008. 29. Statistical Institute of Jamaica, (STATIN). Demographic statistics, 2007. Kingston; 2008. 30. Pan American Health Organization, (PAHO). Health in the Americas 2007, Volume 11 – Countries. Washington D.C.: PAHO;2007. 31. Bain B. HIV/AIDS – The rude awakening/stemming the tide. In O. Morgan, O, (Ed.), Health Issues in the Caribbean. Kingston: Ian Randle;2005: pp. 62-76. 32. Morgan, O (ed). Health Issues in the Caribbean. Kingston: Ian Randle;2005. 33. Jamaica, Ministry of Health. Epidemiological profile of selected health conditions and services in Jamaica, 1990-2002. Kingston: Health Promotion and Protection Division, Ministry of Health;2005. 484

34. World Health Organization, (WHO). 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: WHO; 1948. 35. Hambleton IR, Clarke K, Broome HL, Fraser HS, Brathwaite F, Hennis AJ. Historical and current Correlates of self-reported health status among elderly persons in Barbados. Revista Panamericana de Salud Pứblica 2005;17: 342-352. 36. Grossman M. The demand for health - a theoretical and empirical investigation. New York: National Bureau of Economic Research;1972. 37. Smith JP, Kington R. Demographic and Economic Correlates of Health in Old Age. Demography 1997;34:159-70. 38. Bourne PA. Good health status of older and oldest elderly in Jamaica: Are there differences between rural and urban areas? The Open Geriatric Medicine J 2009;2:18-27. 39. Bourne PA, McGrowder DA, Crawford TV. Decomposing mortality rates and examining health status of the elderly in Jamaica. The Open Geriatric Medicine J 2009;2: 34-44. 40. 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. 41. Bourne PA, McGrowder DA, Holder-Nevins D. Public health behaviour-change 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.

485

Table 19.1: 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 Table 19.2: Sociodemographic characteristic by Sex Variable 486

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

Sex

P

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) 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)

Female < 0.001 438 (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

487

Table 19.3. 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

488

Table 19.4. Ordinary Logistic Regression: Correlates of Good Health Status of Uninsured Jamaicans
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 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 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* 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

-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

489

Table 19.5. 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

490

Chapter Twenty Health of children less than 5 years old in an Upper Middle Income Country: Parents’ views
Paul A. Bourne

Introduction
In many contemporary nations, objective indices such as life expectancy, mortality and diagnosed morbidity are still being widely used to measure the health of people, a society and/or a nation [1-6]. The World Health Organisation (WHO) in the Preamble to its Constitution in the 1940s wrote that health is more important than disease, as it expands to the social, psychological and physical wellbeing of an individual [7]; and lately that during the 21st century the emphasis must be on healthy life expectancy [8,9]. In keeping with its opined emphasis, the WHO formulated a mathematical approach that diminished life expectancy by the length and severity of time spent in illness as the new thrust in measuring and examining health. Although healthy life expectancy removes time spent in illness and severity of dysfunctions, it fundamentally rests on mortality. The WHO therefore, instead of moving forward, has given some scholars, who are inclined to use objective indices in measuring health, a guilty feeling about continuing this practice. The Caribbean, and in particular Jamaica, continues to use mortality and morbidity to measure the health of children or infants [1-6]. The use of mortality, morbidity and life expectancy is the practice of Caribbean scholars, and is widely used in Jamaica by the: Ministry of Health (MOHJ) [10]; Statistical Institute of Jamaica (STATIN) [11]; Planning Institute of Jamaica (PIOJ) [12]; PIOJ and STATIN [13] as well as the Pan American Health Organization 491

(PAHO) [14] in measuring health. In spite of the conceptual definition opined by the WHO in the Preamble to its Constitution in 1946, the health of children who are less than 5 years old in Jamaica is still measured primarily by using mortality and morbidity statistics. Recently a book entitled ‘Health Issues in the Caribbean’ [15] had a section on Child Health; however the articles were on 1) nutrition and child health development [16] and 2) school achievement and behaviour in Jamaican children [17], indicating the void in health literature regarding health conditions. An extensive review of health literature in the Caribbean region found no study that has used national survey data to examine the health status of children less than 5 years of age. The current study fills this gap in the literature by examining the health status of children less than 5 years of age using cross-sectional survey data which are based on the views of patients. The objectives of this study are 1) to examine the health and health care-seeking behaviour of the sample; and 2) to evaluate the mean age of the sample with a particular illness and to describe whether there is an epidemiological shift in these conditions.

Materials and methods
Sample The current study used two secondary nationally representative cross-sectional surveys (for 2002 and 2007) to carry out this work. The sub-samples are children less than 5 years old, and the only criterion for selection was being less than 5 years old. The sample in the current study is 3,062 respondents of ages less than 5 years. For 2002, a sub-sample of 2,448 less than-5 year olds was extracted from the national survey of 25,018 respondents in 2002, and information on 614 less than-5 year olds was extracted from the 2007 survey. The survey (Jamaica Survey of Living 492

Conditions) began in 1989 to collect data from Jamaicans in order to assess government policies. Since 1989, the JSLC has added a new module each year in order to examine that phenomenon, which is critical within the nation [18, 19]. In 2002, the focus was on 1) social safety nets, and 2) crime and victimization, while for 2007, there was no focus. Methods Stratified random sampling technique was used to draw the sample for the JSLC. 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 comprises 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 (i.e. LFS) was selected for the JSLC [18, 19]. The sample was weighted to reflect the population of the nation [18-20]. The JSLC 2007 was conducted in 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 the selfreported health status of Jamaicans. An administered questionnaire was used to collect the data from parents on children less than 5 years old, and the data were stored, retrieved 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 493

some modifications to the LSMS, as the JSLC is more focused on policy impacts. The questionnaire covered areas of socio-demographic variables – such as education; daily expenses (for the past 7 days); food and other consumption expenditures; inventory of durable goods; health variables; crime and victimization; social safety net and anthropometry. The non-response rates for the 2002 and 2007 surveys were 26.2% and 27.7% respectively. The non-response includes refusals and cases rejected in data cleaning. Measures Social class: This variable was measured based on the income quintiles: The upper classes were those in the wealthy quintiles (quintiles 4 and 5); the middle class was quintile 3 and the poor were the lower quintiles (quintiles 1 and 2). Age is a continuous variable in years. Health conditions (i.e. parent-reported illness or parent-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. 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. Parent-reported illness status. The question is ‘Have you had any illness other than due to injury (for example a cold, diarrhoea, asthma, hypertension, diabetes or any other illness) in the past four weeks? Here the options were Yes or No. 494

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 an independent sample t-test was used to examine the statistical correlation between a metric variable and a dichotomous categorical variable. The level of significance used in this research was 5% (i.e. 95% confidence interval).

Results
Demographic characteristic of sample In 2002, the sex ratio was 98.8 males (less than 5 years old) to 100 females (less than 5 years old), which shifted to 116.2 less than-5 year old males to 100 less than-5 year old females. The sample over the 6 year period (2002 to 2007) revealed internal migrations to urban zones (Table 20.1): In 2002, 59.6% of respondents resided with their parents and/or guardians in rural areas, which declined to 5.07%. The percentage of children less than 5 years of age whose parents were in the poorest 20% fell to 25.4% in 2007 over 29.6% in 2002. In 2007 over 2002, 1.7 times less children less than 5 years of age were taken to public hospitals, compared to 1.2 times less taken to private hospitals (Table 20.1). Approximately 6% more children less than 5 years were ill in 2007 over 2002. Based on Table 20.1, less than-5 year olds with particular chronic illnesses had: diabetes mellitus (0.6%); hypertension (0.3%) and arthritis (0.3%). However, none was recorded in 2007.

495

There were some occasions on which the response rates were less than 50%: In 2002, health care-seeking behaviour was 14.3%; parent-reported diagnosed health conditions, 14.2%; and visits to health care institutions, 8.9% (Table 1). For 2007, the response rate for health careseeking behaviour was 20.2%; parent-reported diagnosed health conditions, 20.2%, and less than 11% for cost of medical care. Health conditions Based on Table 20.1, the percentage of less than-5 year olds with particular acute conditions saw a decline in colds and asthmatic cases, as well as chronic conditions. Figure 20.1 revealed that in 2007 the mean age of children less than 5 years old with acute health conditions (i.e. diarrhoea, respiratory diseases and influenza) increased over 2002. On the other hand, the mean age of those with unspecified illnesses declined from 1.76 years (SD = 1.36 years) to 1.64 years (SD = 1.36 years). Concomitantly, the greatest mean age of the sample was 2.71 years (SD = 1.21 years) for asthmatics in 2007 and 2.59 years (1.24 years) in 2002. It should be noted here that the mean age of a child less than 5 years of age in 2002 with diabetes mellitus was 1.50 years (2.12 years).

496

Health status In 2002, the JSLC did not collect data on the general health status of Jamaicans, although this was done in 2007. Therefore, no figures were available for health status for 2002. In 2007, 43.4% of children less than 5 years old had very good health status; 46.7% good health status; 7.1% fair health status; 2.5% poor and 0.3% very poor health status. The response rate for the health status question was 96.9%. Ninety-seven percent of the sample was used to examine the association between health status and parent-reported illness - χ2 (df = 4) = 57.494, P < 0.001 – with the relationship being a weak one, correlation coefficient = 0.297. Table 20.2 revealed that 24.2% of children less than 5 years of age who reported an illness had very good health status, compared to 2 times more of those who did not report an illness. One percent of parents indicated that their children (of less than 5 years) who had no illness had poor health status, compared to 5.6 times more of those with illness who had poor health status. Health conditions, health status and medical care-seeking behaviour A cross-tabulation between health status and parent-reported diagnosed illness found that a significant statistical correlation existed between the two variables - χ2 (df = 16) = 26.621, P < 0.05, cc = 0.422, - with the association being a moderate one, correlation coefficient = 0.422 (Table 20.3). Based on Table 20.3, children less than 5 years old with asthma were less likely to report very good health status (5.9%), compared to those with colds (30.5%); diarrhoea (22.2%); and unspecified health conditions (22.7%). When health status by parent-reported illness (in %) was examined by gender, a significant statistical relationship was found, P < 0.001: males - χ2 (df = 4) = 25.932, P < 0.05, cc = 497

0.320, and females - χ2 (df = 4) = 39.675, P < 0.05, cc = 0.356. The health statuses of males less than 5 years old in the very good and good categories were greater than those of females (Figure 20.2). However, the females had greater health statuses in fair and poor health status than males, with more males reporting very poor health status than females.

Based on Figure 20.3, even after controlling health status and parent-reported illness (in %) by area of residence, a significant statistical association was found: urban - χ2 (df = 3) = 10.358, P < 0.05, cc = 0.238; semi-urban - χ2 (df = 3) = 9.887, P = 0.021, cc = 0.273, and rural χ2 (df = 3) = 45.978, P < 0.001, cc = 0.365. Concomitantly, children less than 5 years of age were the least likely to have very good health status (19.4%) compared to rural (25.8%) and semiurban children (25.9%). Furthermore, the respondents who resided in urban areas were 2.1 times more likely to have parent-reported very poor health status, compared to rural respondents. In examining health status and reported illness (in %) by social classes, significant statistical relationships were found, P < 0.05: poor-to-poorest classes - χ2 (df = 4) = 52.374, P = 0.021, cc = 0.393; middle class - χ2 (df = 3) = 8.821, P = 0.032, cc = 0.259, and wealthy class - χ2 (df = 3) = 10.691, P = 0.02, cc = 0.234. Based on Figure 20.4, middle class children who are less than 5 years old had the greatest very good health status (37%) compared to the wealthy class (26.8%) and the poor-to-poorest classes (16.1%). Fourteen percent of poor-to-poorest class children who are less than 5 years old had at most poor health status compared to 0% of the middle class and 4.9% of the wealthy class, while 1.8% of poor-to-poorest classes less than 5 years of age had very poor health status. When health status and parent-reported illness was examined by age, sex, social class, and area of residence, the correlation was a weak one – correlation coefficient = 0.295, P < 0.001, n=583. 498

A cross tabulation between health status and health care-seeking behaviour found a significant statistical association between the two variables - χ2 (df = 4) = 10.513, P < 0.033 with the correlation being a weak one – correlation coefficient = 0.281. A child less than 5 years old was 2.44 times more likely to be taken for medical care if he/she had at most poor health status. On the other hand, a child who had very good health status was 1.97 times more likely not to be taken to health care practitioners (Figure 20.5). In 2007, an examination of the health care-seeking behaviour and parent-reported illness of the sample revealed no statistical correlation - χ2 (df = 1) = 0.430, P = 0.618. Sixty-two percent of the sample, who was ill, was taken to health care practitioners, while 38.5% were not. On the other hand, more were taken for medical care than in 2007 in the 4-week period of the survey. No statistical correlation was noted for the aforementioned variables in 2002 - χ2 (df = 1) = 1.188, P = 0.276. Of those who reported ill, 63.7% were taken to health care practitioners.

Discussion
Infant mortality has been declining since the 1970s, and this has further decreased since 2004 [14]; this, as the literature shows, is not a good measure of health. The current study found that, using general health status, children less than 5 years of age in Jamaica had good health. The findings revealed that 90 out of every 100 less than-5 year olds had at least good health status, with 44 out of every 100 having very good health status. In spite of the good health status of less than-5 year olds in Jamaica in 2007, 20.8% of them had an illness in the 4-week period of the survey, which is a 5.9% increase over 2002. It is interesting to note the shift in this study away from specific chronic illnesses. In 2002, 30 out of every 1,000 less than-5 year olds in Jamaica were diagnosed with hypertension and arthritis (i.e. parent-reported), with 60 out of 1,000 having been parent-reported with diabetes mellitus. None such cases were found in 2007, suggesting 499

that in the case of the children who had those particular chronic illnesses, their parents had either migrated with them or they had died. Concomitantly, the country is seeing a reduction in children less than 5 years old with colds; however, marginal increases were seen in diarrhoea, asthma and unspecified health conditions over the last 6 years. Although there were increased reported cases of illness over the studied period, in 2007, 62 out of every 100 ill children were taken to medical practitioners, and this fell from 64 in every 100 in 2002. One of the arguments put forward by some people is that what retards or abates health care-seeking behaviour is medical cost. With the abolition of health care user fees for children since 2007, the culture must be playing a role in parents and/or guardians not taking children who are ill to medical care facilities for treatment. Medical cost cannot be divorced from the expenditure that must be incurred in taking the child to the health care facility. In 2007, 25 out of every 100 children less than 5 years of age had parents and/or guardians who were less than the poverty line. Although this has declined by 4.2% since 2002, it nevertheless means that there are children whose parents are incapacitated by other factors. Marmot [21] opined that the financial inability of the poor is what accounts for their lowered health status, compared to other social classes. The current study concurs with the findings of Marmot, as it was revealed that children less than 5 years of age from poor households had the least health status. This means that poverty is not merely eroding the health status of poor Jamaicans, but that equally it is decreasing the health status of poor children. Rural poverty in Jamaica is at least twice as great as urban poverty, and approximately 4 times more than semi-urban [13], which provides another explanation for the poor health status of children less than 5 years of age. The current study found that 3.2% of those children dwelling 500

in urban zones recorded at most poor health status, compared to 13.6% of rural children, suggesting that the health status of the latter group is 4.3 times worse than the former. This means that poverty in rural zones is exponential, eroding the quality of life of children who are less than 5 years old. Poverty in semi-urban areas was 4% which is 2.5 times less than that for the nation; and those less than 5 years of age recorded the greatest health status, supporting Marmot’s perspective that poverty erodes the health status of a people. Hence, the decline in health care-seeking behaviour for this sample is embedded in the financial constraints of parents and/or guardians as well as their geographical challenges. The terrain in rural zones in Jamaica is such that medical care facilities are not easily accessible to residents compared to urban dwellers. With this terrain constraint comes the additional financial burden of attending medical care facilities at a location which is not in close proximity to the home of rural residents, and this accounts for the vast health disparity between rural and urban children. As a result of the above, the removal of health care utilization fees for children less than 18 years of age does not correspond to an increased utilization of medical care services, or lowered numbers of unhealthy children less than 5 years of age. If rural parents are plagued with financial and location challenges, their children will not have been immunized or properly fed, and their nutritional deficiency would explain the health disparity that exists between them and urban children who have easier access to health care facilities. The removal of health care utilization fees is not synonymous with an increased utilization of medical care for children less than 5 years old, as 46.5% of the sample attended public hospitals for treatment in 2002, and after the abolition of user fees in April 2007 utilization fell by 1.7 times compared to 2002. In order to understand stand why there is a switch from health care utilization to mere survival, we can examine the inflation rate. In 2007, the 501

inflation rate was 16.8% which is a 133% increase over 2002 (i.e. 7.2%), which translates into a 24.7% increase in the prices of food and non-alcoholic beverages, and a 3.4% increase in health care costs [22]. Here the choice is between basic necessities and health care utilization, which further erodes health care utilization in spite of the removal of user fees for children. Health status uses the individual self-rating of a person’s overall health status [23], which ranges from excellent to poor. Health status therefore captures more of people’s health than diagnosed illness, life expectancy, or mortality. However, how good a measure is it? Empirical studies show that self-reported health is an indicator of general health. Schwarz & Strack [24] cited that a person’s judgments are prone to systematic and non-systematic biases, suggesting that it may not be a good measure of health. Diener, [25] however, argued that the subjective index seemed to contain substantial amounts of valid variance, indicating that subjective measures provide some validity in assessing health, a position with which Smith concurred [26]. Smith [26] argued that subjective indices do have good construct validity and that they are a respectably powerful predictor of mortality risks [27], disability and morbidity [27], though these properties vary somewhat with national or cultural contexts. Studies have examined self-reported health and mortality, and have found a significant correlation between a subjective and an objective measure [27-29]: life expectancy [30]; and disability [28]. Bourne [30] found that the correlation between life expectancy and self-reported health status was a strong one (correlation coefficient, R = 0.731); and that self-rated health accounted for 53% of the variance in life expectancy. Hence, the issue of the validity of subjective and objective indices is good, with Smith [26] opining that the construct validity between the two is a good one.

502

The current research found that parent-reported illness and the health status of children less than 5 years of age are significantly correlated. However, the statistical association was a weak one (correlation coefficient = 0.297), suggesting that only 8% of the variance in health status can be explained by parent-reported children’s illnesses. This is a critical finding which reinforces the position that self-reported illnesses (or health conditions) only constitute a small proportion of people’s health. Therefore, using illness to measure the health status of children who are less than 5 years of age is not a good measure of their health, as illness only accounts for 8% of health status. However, based on Bourne‘s work [30], health status is equally as good a measure of health as life expectancy. One of the positives for the using of health status instead of life expectancy is its coverage in assessing more of people’s general health status by using mortality or even morbidity data.

Conclusion
In summary, the general health status of children who are less than 5 years old is good; however, social and public health programmes are needed to improve the health status of the rural population, which will translate into increased health status for their children. The health disparity that existed between rural and urban children less than 5 years of age showed that this will not be removed simply because of the abolition of health care utilization fees. In keeping with this reality, public health specialists need to take health care to residents in order to further improve the health status of children who are less than 5 years old.

Conflict of interest
The author has no conflict of interest to report. 503

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.

References
1. Lindo, J. (2006) Jamaican perinatal mortality survey, 2003. Jamaica Ministry of Health. Kingston, pp. 1-40. 2. McCarthy, J.E., and Evans-Gilbert, T. (2009) Descriptive epidemiology of mortality and morbidity of health-indicator diseases in hospitalized children from western Jamaica. American Journal of Tropical Medicine and Hygiene, 80,596-600. 3. Domenach, H., and Guengant, J. (1984) Infant mortality and fertility in the Caribbean basin. Cah Orstom (Sci Hum), 20,265-72. 4. Rodriquez, F.V., Lopez, N.B., and Choonara, I. (2002) Child health in Cuba. Arch Dis Child, 93,991-3. 5. McCaw-Binns, A., Holder, Y., Spence, K., Gordon-Strachan, G., Nam, V., and Ashley, D. (2002) Multi-source method for determining mortality in Jamaica: 1996 and 1998. Department of Community Health and Psychiatry, University of the West Indies. International Biostatistics Information Services. Division of Health Promotion and Protection, Ministry of Health, Jamaica. Statistical Institute of Jamaica, Kingston 6. McCaw-Binns, A.M., Fox, K., Foster-Williams, K., Ashley, D.E., and Irons, B. (1996) Registration of births, stillbirths and infant deaths in Jamaica. International Journal of Epidemiology, 25,807-813. 7. 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. WHO, Geneva. 8. World Health Organization, (WHO). (2004) Healthy life expectancy 2002: 2004 World Health Report. WHO, Geneva. 9. WHO. (2000) WHO Issues New Healthy Life Expectancy Rankings: Japan Number One in New ‘Healthy Life’ System. WHO; 2000, Washington D.C. & Geneva. 504

10. Jamaica Ministry of Health, (MOHJ). (1992-2007) Annual report 1991-2006. MOHJ, Kingston. 11. Statistical Institute of Jamaica, (STATIN). (1981-2009) Demographic statistics, 19802008. STATIN, Kingston. 12. Planning Institute of Jamaica, (PIOJ). (1981-2009) Economic and Social Survey, 19802008. PIOJ, Kingston. 13. PIOJ, and STATIN. (1989-2009) Jamaica Survey of Living Conditions, 1988-2008. PIOJ and STATIN, Kingston. 14. Pan American Health Organization, (PAHO). (2007) Health in the Americas, 2007, volume II Countries. PAHO, Washington DC. 15. Morgan, W. (ed). (2005) Health issues in the Caribbean. Ian Randle, Kingston. 16. Walker, S. Nutrition and child health development. In Morgan, W. (ed). Health issues in the Caribbean. Ian Randle, Kingston, pp. 15-25. 17. Samms-Vaugh, M., Jackson, M., and Ashley, D. (2005) School achievement and behaviour in Jamaican children. In Morgan, W, (ed). Health issues in the Caribbean. Ian Randle, Kingston, pp. 26-37. 18. Statistical Institute Of Jamaica. (2008) 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]. 19. Statistical Institute Of Jamaica. (2003) 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]. 20. World Bank, Development Research Group, (2002). Poverty and human resources. Jamaica Survey of Living Conditions (LSLC) 1988-2000: Basic Information. 21. Marmot, M (2002) The influence of income on health: Views of an Epidemiologist. Does money really matter? Or is it a marker for something else? Health Affair, 21,31-46. 22. Bourne, P.A (2009) Impact of poverty, not seeking medical care, unemployment, inflation, self-reported illness, health insurance on mortality in Jamaica. North American Journal of Medical Sciences, 1, 99-109. 23. Kahneman, D., and Riis, J. (2005) Living, and thinking about it, two perspectives. In Huppert, F.A., Kaverne, B. and N. Baylis, The Science of Well-being, Oxford University Press. 505

24. Schwarz, N., and Strack, F. (1999) Reports of subjective well-being: judgmental processes and their methodological implications. In Kahneman, D., Diener, E., Schwarz, N, (eds). Well-being: The Foundations of Hedonic Psychology. Russell Sage Foundation: New York, pp. 61-84. 25. Diener, E. (1984) Subjective well-being. Psychological Bulletin, 95,542–75. 26. Smith, J. (1994) Measuring health and economic status of older adults in developing countries. Gerontologist, 34, 491-6. 27. Idler, E.L., and Benjamin, Y. (1997) Self-rated health and mortality: A Review of Twenty-seven Community Studies. Journal of Health and Social Behavior, 38, 21-37. 28. Idler, E.L., and Kasl, S. (1995) Self-ratings of health: Do they also predict change in functional ability? Journal of Gerontology 50B, S344-S353. 29. Schechter, S., Beatty, P., and Willis, G.B. (1998) Asking survey respondents about health status: Judgment and response issues. In Schwarz, N., Park, D., Knauper, B., and S. Sudman, S (ed.). Cognition, Aging, and Self-Reports. Ann Arbor. Taylor and Francis, Michigan. 30. Bourne, P.A. (2009) The validity of using self-reported illness to measure objective health. North American Journal of Medical Sciences, 1,232-238.

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Table 20.1. Socio-demographic characteristic of sample, 2002 and 2007 2002 2007 Variable n % n % Sex Male 1216 49.7 330 53.7 Female 1231 50.3 284 46.7 Income quintile Poorest 20% 725 29.6 156 25.4 Poor 554 22.6 140 22.8 Middle 474 19.4 126 20.5 Wealthy 402 16.4 117 19.1 Wealthiest 20% 293 12.0 75 12.2 Self-reported illness Yes 345 14.9 125 20.8 No 1969 85.0 475 79.2 Visits to health care facilities (hospitals) Private, yes 17 7.8 5 6.7 Public, yes 100 46.3 20 26.7 Area of residence Rural 1460 59.6 311 50.7 Semi-urban 682 27.9 125 20.4 Urban 306 12.5 178 29.0 Health (or, medical) care-seeking behaviour Yes 221 63.3 76 61.3 No 128 36.7 48 38.7 Health insurance coverage Yes, private 211 9.0 66 11.1 Yes, public * * 33 5.5 No 2123 91.0 496 83.4 Self-reported diagnosed health conditions Acute Cold 185 53.3 60 48.4 Diarrhoea 20 5.8 9 7.3 Asthma 46 13.3 17 13.7 Chronic Diabetes mellitus 2 0.6 0 0 Hypertension 1 0.3 0 0 Arthritis 1 0.3 0 0 Other (unspecified) 54 15.6 22 17.7 Not diagnosed 38 11.0 16 12.9 Number of visits to health care institutions 1.53 (SD = 0.927) 1.43 (SD = 0.989) Duration of illness Mean (SD) 8.51 days (6.952 days) 8.07 days (7.058 days) Cost of medical care Public facilities Median (Range)in USD 2.36 (157.26)1 0.00 (64.62)2 1 Private facilities Median (Range)in USD 13.76 (117.95) 10.56 (49.71)2 1 USD1.00 = Ja. $50.87 2 USD1.00 = Ja. $80.47 *In 2002, all health insurance coverage was private and this was change in 2005 to include some public option

Table 20.2. Health status by self-reported illness 507

Self-reported illness Health status Yes n (%) Very good Good Fair Poor Very poor Total
χ2 (df = 4) = 57.494, P < 0.001, cc = 0.297, n = 594

No n (%) 227 (48.3) 217 (46.2) 19 (4.0) 6 (1.3) 1 (0.2) 470

30 (24.2) 61 (49.2) 23 (18.5) 9 (7.3) 1 (0.1) 124

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Table 20.3. Health status by self-reported diagnosed illness Self-reported diagnosed illness Health status Very good Cold 18 (30.5) Diarrhoea 2 (22.2) Asthma 1 (5.9) Unspecified 5 (22.7) No 5 (31.3)

Good

31 (52.5)

5 (55.6)

4 (23.5)

11 (50.0)

8 (50.0)

Fair

7 (11.9)

2 (22.2)

8 (47.1)

3 (13.6)

3 (18.8)

Poor

2 (3.4)

0 (0.0)

4 (23.5)

3 (13.6)

0 (0.0)

Very good Total

1 (1.7) 59

0 (0.0) 9

0 (0.0) 17

0 (0.0) 22

0 (0.0) 16

χ2 (df = 16) = 26.621, P < 0.05, cc = 0.422,

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3 2.5 Mean age (in years) 2 1.5 1 0.5 0 Asthma Arthritis Hypertension Unspecified Cold Diarrhoea Diabetes

2002 2007

Parent-reported health condition Figure 20.1. Mean age of health conditions of children less than 5 years old, 2002 and 2007

510

Not diagnosed

Female Very poor Male

Poor Health status

Fair

Good

Very good 0 20 40 60

Parent-reported illness (%)

Figure 20.2. Health status by Parent-reported illness (in %) examined by gender

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Rural Very poor Poor Health status Fair Good Very good 0 10 20 30 40 50 60 70 Other town Urban

Parent-reported illness (%)

Figure 20.3. Health status by parent-reported illness (in %) examined by area of residence

512

Very poor

Wealthy classes Middle Poor classes

Poor Health status

Fair

Good

Very good 0 10 20 30 40 50 60 70

Parent-reported illness (%)

Figure 20.4. Health status by parent-reported illness (in %) examined by social classes

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Very poor

No Yes

Poor Health status

Fair

Good

Very good 0 10 20 30 40 50 60

Health care-seeking behaviour (%)

Figure 20.5. Health status by health care-seeking behaviour

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Chapter Twenty One An Epidemiological Transition of Health Conditions, and Health Status of the Old-Old-To-Oldest-Old in Jamaica: A comparative analysis
Paul A. Bourne

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 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. 515

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 (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 516

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 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 517

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 (i.e. LFS) was selected for the JSLC [14, 15]. The sample was weighted to reflect the population of the nation. 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 518 The survey is known as the Jamaica Survey of

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 (i.e. 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% (i.e. 95% confidence interval).

Result
Sociodemographic characteristics of sample

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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 in rural zones compared to a marginal reduction of 4.3% in semi-urban areas (Table 21.1). 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 (i.e. 576%) (Figure 21.1). A cross tabulation between self-reported illness and sex revealed that there was no significant statistical correlation between the two variables (Table 21.2). 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 21.4 and 21.5). 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 21.5). Although the aforementioned is true, the percent of old521

old 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 21.6). On examination, in 2002, the lowest mean age was recorded by people who indicated that they had 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 21.6). Based on Table 21.7, 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 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%). 522

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 crosstabulation between the two aforementioned variables was a significantly correlated one (χ2 (df = 2) = 39.888, P < 0.001) (Table 21.8). 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 21.9 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 21.10). 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

523

indicates that there is no statistical significant relationship between variables when there is a probability that an association does exists.

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 21.11). Based on Table 21.11, 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.

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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 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

525

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 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 526

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 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 527

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 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.

References
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1. Statistical Institute of Jamaica (STATIN). Demographic statistics, 2007. Kingston: STATIN; 2008. 2. Eldemire D. A situational analysis of the Jamaican elderly, 1992. Kingston: Planning Institute of Jamaica; 1995. 3. Eldemire D. The elderly and the family: The Jamaican experience. Bulletin of Eastern Caribbean Affairs. 1994; 19:31-46. 4. Franzini L, Fernandez-Esquer ME. Socioeconomic, cultural, and personal influences on health outcomes in low income Mexican-origin individuals in Texas. Soc Sci and Med. 2004; 59:16291646. 5. Okabayashi H, Liang J, Krause N, Akiyama H, Sugisawa H. Mental health among older adults in Japan: Do sources of social support and negative interaction make a difference? Soc Sci and Med. 2004; 59:2259-2270. 6. Statistical Institute of Jamaica (STATIN). Population Census 2001, Jamaica. Volume 1:Country Report. Kingston, Jamaica: STATIN; 2001. 7. DaVanzo J, Chan A. Living arrangements of older Malaysians: Who coresides with their adult children. Demography. 1994;31:9113. 8. Pan American Health Organization, (PAHO), World Health Organization, (WHO). Health of the elderly aging and health: A shift in the paradigm. USA: PAHO,WHO; 1997. 9. Bogue DJ. Essays in human ecology, 4. The ecological impact of population aging. Chicago: Social Development Center; 1999. 10. Planning Institute of Jamaica, (PIOJ), Statistical Institute of Jamaica, (STATIN). Jamaica Survey of Living Conditions, 2007. Kingston: PIOJ, STATIN;2008. 11. Bourne PA. Medical Sociology: Modelling Well-being for elderly People in Jamaica. West Indian Med J. 2008; 57:596-04. 12. Bourne PA. Good health status of older and oldest elderly in Jamaica: Are there differences between rural and urban areas? The Open Med J. 2009;2:18-27. 13. 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. 14. Statistical Institute Of Jamaica. Jamaica Survey of Living Conditions, 2007 [Computer file]. Kingston, Jamaica: Statistical Institute Of Jamaica [producer], 2007. Kingston, Jamaica: 529

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). STATIN; 2006. Demographic Statistics, 2005. Kingston:

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, 9:53 530

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 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 21.1. 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 21.2. 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 21.3. 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 21.4. 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 21.5. 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 21.6. 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

Table 21.7. Diagnosed Health Conditions by Aged cohort

537

20021

20072

Diagnosed Health conditions 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

Aged cohort Oldest-Old % 0.0 8.3 0.0 0.0 58.3 8.3 25.0 0.0 Old-Old % 7.2 2.7 1.8 11.1 44.1 12.6 11.7 2.7

Aged cohort Oldest-Old % 0.0 3.2 3.2 16.1 45.2 6.5 22.6 3.2

No

1 χ2 (df = 1) = 10.028, P =0.074 2 χ2 (df = 1) = 5.382 P =0.613

Table 21.8. Self-reported illness (in %) by health status. 538

Health Status Good Self-reported illness Yes No Total χ2 (df = 2) = 39.888, P < 0.001, cc=0.357 n (%) 21 (25.3) 62 (74.7) 83 Fair n (%) 60 (55.0) 49 (45.0) 109 Poor n (%) 60 (74.1) 21 (25.9) 81

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Table 21.9. Health care-seeking behaviour and health status, 2007 Health Status Good Health care-seeking behaviour No Yes Total χ2 (df = 2) = 10.539, P = 0.005, cc=0.265 n (%) 9 (42.9) 12 (57.1) 21 Fair n (%) 21(35.6) 38 (64.4) 59 Poor n (%) 8 (13.3) 52 (86.7) 60

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Table 21.10. Health care-seeking behaviour by health status controlled for aged cohort Health status Aged cohort Good Old-old1 Health CareSeeking Behaviour No 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 21.11. 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

0.347 -0.398

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 -

2.979 Constant 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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60 40 % 20 0 1 2 3 4 5 6 6 8 Health conditions 2002 2007 Figure 21.1. Diagnosed health conditions, 2002 and 2007 Figure 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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80 Illness (%) 60 40 20 0 Q1 Q2 Q3 Q4 Q5 Income Quintile 2002, Yes 2007, Yes

Figure 21.2. Self-reported illness (in %) by Income Quintile, 2002 and 2007

Figure 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 Twenty Two

Hypertensive and modeling their social determinants of self-rated health status in a middle-income developing nation
Paul A. Bourne and Christopher 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 population 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 [2, 3]. 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 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 545

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. 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 546

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 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.

547

The aim of this paper is to elucidate information on hypertension and the sociodemographic profile of those with the disease in a Latin American and Caribbean nation as well as to model self-rated health status of hypertensive. For this research, we used the SPSS computer statistical package, Version 16.0 (SPSS Inc; Chicago, IL, USA), and STATA. Cross tabulations were performed in order to examine demographics, health, and particular variables, and where 33.3% of the cells are less than 5 data vales, Fisher’s exact test was used instead of Chi-square. Multiple logistic regressions were used to analyze possible explanatory variables (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.

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 548

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.

549

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) [32-34]. 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 measured using total expenditure. Analytic model Using econometric analyses (multiple logistic regressions), Bourne and McGrowder [27] modeled social determinants of health of rural Jamaicans. The chosen method allows for the testing of many possible variables which account for health status, which was measured as a binary variable. The literature has shown that health status can be dichotomized into good-tovery good health status and poor-to-moderate health status [32-34]. Clearly, based on the findings in the literature, care should be taken in where moderate health status is placed as Bourne [34] opined that moderate health status is best fitted into good-to-very good health status. Thus, for this study the dichotomization of health status was moderate-to-very good and very poor-to-poor. Furthermore, the selected variables which used in this model building were based on the established evidence on social determinants of health. Some modifications were made to Bourne and McGrowder’s model as not all the variables which emerged in that model were applicable to the current work. In this model building, the variables were entered in block from 550

which the significant ones emerged as factors which account for moderate-to-very good health status of hypertensive in Jamaica.

Statistical analysis

We used the SPSS computer statistical package, Version 16.0 (SPSS Inc; Chicago, IL, USA), and STATA. Cross tabulations were performed in order to examine demographics, health, and particular variables, and where 33.3% of the cells are less than 5 data vales, Fisher exact test was used instead of Chi-square. Multiple logistic regressions were used to analyze possible explanatory variables (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 β coefficients, Wald statistics, and Odds ratio, with a confidence interval of 95% (CI 95%). 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 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

551

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 22.1 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). Table 22.2 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 22.3 presents information on sociodemographic characteristics and health care utilisation by population income quintile of sample.

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No significant statistical association existed between self-reported illness and self-rated health status (χ2 = 2.98, P = 0.562); 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 22.1 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 22.3): 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 associative 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 (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 553

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 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 554

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. 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 37 555

out of every 100 in the wealthy social strata, which somewhat supports Smith and Kington’s postulation. 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 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. 556

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, 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 557

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 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 558

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 reality, poverty, opportunity, social exclusion, unemployment, malnutrition, disease

management, early testing and lifestyle practices must be coalesced by health planners. A study 559

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 hypertension has changed compared to the traditional late life disease to middle-to-late years, and that it mostly affect females, rural residents, married respondents and marginally inflect the poor more than those in the wealthy social strata. And that the social determinants of self-rated health status are fundamentally different from those identified in the literature on the population, or other sub-populations.

Conflict of interest
560

The authors have 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 researchers.

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Figure 22.1. Health seeking behaviour (in %) by marital status and sex

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Table 22.1. Sociodemographic characteristics of study population, n = 206
Characteristic Sex Male Female Marital status Married Never married Divorced Separated Widowed Partner in household Yes No Did not respond Social assistance (PATH) Yes No Area of residence Urban Semi-urban Rural Population income quintile Poorest 20% Poor Middle Second wealthy Wealthiest 20% Age cohort Young adults Other aged adults Young-old Old-old Oldest-old Illness (self-reported) Yes No Health care seeking behaviour Yes No Health care utilization Public hospital Private hospital Public health centre Private health centre n 58 148 91 69 3 5 37 93 12 105 41 165 47 41 118 47 35 48 38 38 6 76 61 49 14 205 1 140 64 35 7 34 78 % 28.2 71.8 44.4 33.7