Child & Adolescent Health


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Child & Adolescent Health provides answers to many issues in relation to health and reproductive health matters of Jamaicans.

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Child & Adolescent Health

  1. 1. Child & Adolescent HealthTheory, Principle and Behaviour Paul Andrew Bourne
  2. 2. Child & Adolescent HealthTheory, Principle and Behaviour i
  3. 3. Child & Adolescent HealthTheory, Principle and Behaviour PAUL ANDREW BOURNE Socio-Medical Research Institute SOCIO-MEDICAL RESEARCH INSTITUTE KINGSTON, JAMAICA, WEST INDIES ii
  4. 4. ©Paul A. Bourne, 2011First Published in Jamaica, 2011 byPaul Andrew Bourne66 Long Wall DriveStony Hill,Kingston 9,St. AndrewNational Library of Jamaica Cataloguing DataChild & Adolescent Health: Theory, Principle and BehaviourIncludes indexISBNBourne, Paul AndrewAll rights reserved. Published, 2011Covers designed by Paul Andrew BourneAll the photographs were taken by Paul A. BourneSocio-Medical Research Institute, 66 Long Wall Drive, Stony Hill,Kingston 9, Kingston, Jamaica iii
  5. 5. To Evadney It is the big things that envelope history;so make them count, today and every time Paul A. Bourne, 2011 iv
  6. 6. PrefaceChild health is among the longstanding issues in health research and this is no different foradolescent health and reproductive health matters. Reproductive health issues have beenprimarily examined as a separate matter from general health in health literature in the Caribbean,particularly Jamaica. When health is studied the Jamaica and the wider Caribbean, it covers 1)illness (diagnosed – HIV/AIDS, et cetera), 2) self-reported health conditions, 3) self-rated healthstatus, 4) quality of life, 5) nutrition, 5) health care delivery, 6) health care system, 7) disability,8) mental health, 9) health consequences, 10) injuries, and 11) emergence and re-emergence ofinfectious diseases. A comprehensive review of the literature (in books, internet, intranet, library searchengines and research publications) in the Caribbean revealed no book that has twinned generalhealth and reproductive health matters of children and adolescent in the region. Health and healthissues are not limited to general health or reproductive health matters as positive construct ofhealth as offered by the World Health Organization (WHO) in the Preamble to its Constitution ismore than illness (biological conditions or germ theory) to include social and psychologicalwellbeing. Wellbeing as an endogenous variable comprises 1) behaviour, 2) choices anddecisions, and 3) health issues including quality of life. According to the Webster‟s lexicon, wellbeing is „a state of being happy, healthy, orprosperous‟. Good physical health is, therefore, a precondition for wellbeing, but happinessconstitutes good life for an individual, which are based on many elements. Moreover, do not v
  7. 7. forget, from Marcoux (2001) account, ageing is a global phenomenon that is here to stay.Furthermore, we should not turn a blind eye ageing as was pointed out by Turner (1998). In thisstudy, the researcher will construct a model of the determinants of wellbeing among theJamaican elderly, which includes cultural variables, environmental factors, psychosocialcharacteristics and economic issues in order to mushroom greater discourse and policy changesin keeping with the „new paradigm‟ shift of ageing. Happiness, according to Easterlin (2003) is associated with wellbeing, and so does ill-being (for example depression, anxiety, dissatisfaction). Easterlin (2003) argued that materialresources have the capacity to improve one‟s choices, comfort level, state of happiness andleisure, which militates against static wellbeing. Within the context that developing countriesand developed countries had at some point accepted the economic theory that economicwellbeing should be measured by per capita Gross Domestic Product (GDP) – (i.e. total moneyvalue of goods and services produced within an economy over a stated period per person).Amartya Sen, who is an economist, writes that plethora of literature exist that show that lifeexpectancy is positively related to Gross National Product (GNP) per capita. (Anand andRavallion 1993; Sen 1989: 8). Such a perspective implies that mortality is lower whenevereconomic boom exists within the society and that this is believed to have the potential to increasedevelopment, and by extension standard of living. Sen, however, was quick to offer a rebuttalthat data analyzed have shown that some countries (i.e. Sri Lanka, China and Costa Rica) havehad reduced mortality without a corresponding increase in economic growth (Sen 1989, 9), andthat this was attained through other non-income factors such as education, nutritionimmunization, expenditure on public health and poverty removal. The latter factors,undoubtedly, require income resources and so this is clear that income is unavoidable a critical vi
  8. 8. component in welfare and wellbeing. It is believed by some scholars that economic growthand/or development is a measure of welfare (see Becker, Philipson and Soares 2004). As health is a multi-faceted variable (Portrait et al. 2001) that looks beyond bio-medicalconditions. When wellbeing is mentioned, it goes beyond many of the established operationaldefinitions of health (i.e. physical functioning). Wellbeing is a state of psychological, social andeconomic state and this refers specifically to the worth of this condition in the discourse of socialsciences. Wellbeing is not simply a function of income although income is able to affordsomeone a „good life‟. The UNDP‟s, (UNDP 2006) human development index (HDI) is anindicator of wellbeing, and it is used for comparisons across countries. The HDI uses nationalincome (GDP per capita), heath status and education as causal predictors of wellbeing. Studies revealed that positive moods and emotions is associated with wellbeing (Leung etal. 2005) as the individual is able to think, feel and act in ways that foster resource building andinvolvement with particular goal materialization (Lyubomirsky, King, and Diener 2005). Thissituation is later internalized, causing the individual to be self-confident from which follows aseries of positive attitudes that guides further actions (Sheldon and Lyubomirsky 2006). Positivemood is not limited to active responses by individual, but a study showed that “counting one‟sblessings,” “committing acts of kindness”, recognizing and using signature strengths,“remembering oneself at one‟s best”, and “working on personal goals” are all positivelyinfluence wellbeing (Sheldon and Lyubomirsky 2006; Abbe et al. 2003). Happiness is not amood that does not change with time or situation; hence, happy people can experience negativemoods (Diener and Seligman, 2002). vii
  9. 9. The concept of health according to the WHO is multifaceted. “Health is state of completephysical, mental and social well, and not merely being the absence of disease or infirmity”(Whang 2005, 153). From the WHO‟s perspective, health status is an indicator of wellbeing(See also, Crisp 2005). Wellbeing for some, therefore, is a state of happiness – positive feelingstatus and life satisfaction (see for example, Easterlin 2003; Diener, Larson, Levine, andEmmons 1985; Diener 1984) satisfaction of preferences or desires, health or prosperity of anindividual (Diener and Suh 1997; Jones 2001; Crips 2005; Whang 2005), or what psychologistsrefer to as positive effects (Headey and Wooden 2004). Simply put, wellbeing is subjectivelywhat is „good‟ for each person (See for example, Crisp 2005). It is sometimes connected withgood health. Crisp offered an explanation for this, when he said that “When discussing thenotion of what makes life good for the individual living that life, it is preferable to use the term„wellbeing‟ instead of „happiness” (Crisp 2005), which explains the rationale for this bookillness, health status and quality of life. QoL is widely accepted by medical researchers and clinicians as an alternative paradigmto dysfunction in the measurement of health and treatment of health-care of customers (i.e.patients) (see for example, Seed & Lloyd, 1997; Sullivan et al., 1992). The rationale for thisparadigm is owing to its maximization perspective (also see Longest, 2002; WHO 1948). Manyscholars including economists (such as Sen, 1982; 1985; Easterlin 2001a, 2001b; Stutzer & Frey2003; Di Tella MacCulloch Oswald 2001) have proposed that QoL (or wellbeing) mustincorporate subjective as well as objective conditions. They contend that any construct whichwill be used to capture QoL (or wellbeing) must be such that it embodies economic wellbeing(i.e. Gross Domestic Product per capita growth) and emotional reactions to events as they are a viii
  10. 10. part of whole life of an individual. This argument is also forwarded by psychologists such asEdward Diener 1984; Richard Veenhoven 1991, that justify their use of happiness or self-reported overall QoL to assessment wellbeing (see Stutzer & Frey 2003; Veenhoven 1991;Easterlin 2001a. 2001b; Diener 1984, 2000). In order to assess overall QoL of an individual, it is argued that the „best‟ approach to betaken in this regard is to use a questionnaire that will collect information from people onparticular aspects of their lives and overall QoL (see for example, RA Cummins 2005, 2000;Todd Kashdan 2004; Helen Murphy & Elsa Murphy 2003; Michael Pacione 2003). Kashdanwrites that the assessment of subjective wellbeing (or QoL) can be addressed with aquestionnaire on happiness which the aforementioned literature has outlined as the proposition ofother scholars. Murphy & Murphy and Hutchinson et al, on the other hand, believe that QoLassessment can be done by way of self-reported satisfaction with life and subjective assessmentof the life by the individual. A part of this assessment was self-esteem; self-achievement (oractualizations) which are embodied in Abraham Maslow‟s 5 Needs hierarchy. Michael Pacioneopines that “The simplest model states that satisfaction with life in general is weighted sum ofsatisfactions with different domains or aspects of life(for example, job satisfaction) and that , inturn, these domain satisfactions are weighted sums of specific satisfiers and dissatisfiers…Amore complex formulation is the hierarchy of needs of model…” (2003:23). Cummins (2005),on the other hand, provides a contravening argument to the view of Pacione that needs must notbe used as an assessment of life‟s quality of an individual. He argues that the drawback to theuse of needs is embedded in the fact that low degree of needs does not necessarily associate withQoL (Cummins, 2005:700). Hence, Cummins‟ delimitation will not hold in the event that needsare at moderate or high valuations. ix
  11. 11. Clearly from the aforementioned positions, child and adolescent health must incorporateall aspect of the wellbeing (or quality of life) of the individual. In order to forward anunderstanding of what constitutes wellbeing or ill being, a system must be instituted that willallow us to coalesce a measure that will unearth peoples‟ sense of overall quality of life fromeither economic-welfarism (see Becker et al. 2004), psychological theories (Diener, Suh, andOishi, 1997; Headey and Wooden 2004; Kashdan 2004; Diener 2000), practices and behaviours.People are made better off, if their current desires are fulfilled, and so any study of health (orwellbeing – quality of life) must assess peoples‟ reproductive health matters and experiences thatinfluence health outcomes. Health is an exogenous as well as an endogenous variable, and when it is used as anendogenous variable it is influenced by many factors. To capture the state of the quality of life ofhumans, we are continuously and increasingly seeking to ascertain more advance methods thatwill allow us to encapsulate a quantification of wellbeing that is multidimensional andmultifaceted. According to Langlois and Anderson (2002), approximately 30 years ago, aseminal studies conducted by Smith (1973, 2) “proposed that wellbeing be used to refer toconditions that apply to a population generally, while quality of life should be limited toindividuals‟ subjective assessments of their lives …” They argue that a distinction between thetwo variables have been lost with time. From Langlois and Anderson‟s monograph, during the1960s and 1970s, wellbeing was approached from a quantitative assessment by the use of GDPor GNP (also See, Becker, Philipson and Soares 2004), and unemployment rates; this they referto as a “rigid approach to the [enquiry of the subject matter] subject”. According to Langlois andAnderson (2002), the positivism approach to the methodology of wellbeing was objectification,an assessment that was highly favoured by Andrews and Withley (1976) and Campbell et al x
  12. 12. 1976. This is the rationale behind this book utilization of a positivism methodology (usingeconometric analyses – modeling and surveys). In measuring quality of life, some writers have thought it fitting to use Gross DomesticProduct per capita (i.e. GDP per capita) to which they referred to as standard of living (Lipsey1999; Summers and Heston 1995; Hanson 1986). According to Summers and Heston (1995),“The index most commonly used until now to compare countries material wellbeing is theirGDP POP.” The United Nations Development Programme has expanded on the materialwellbeing definition forwarded primarily by economists, and has included life expectancy andeducational attainment (Human Development Reports, 2005, p. 341) and other social indicators(Diener 1984; Diener and Suh 1997). This operational definition of wellbeing has becomeincreasingly popular in the last twenty-five years, but given the expanded definition of health ascited by the WHO, wellbeing must be measured in a more comprehensive manner than usingmaterial wellbeing as seen by economists. In recognition of the realities above, this book usedsubjective wellbeing, health, health conditions and health status as well as reproductive healthmatters. The question that must be answered by scholars before lambasting subjective wellbeingis “Can subjectivity be a scientifically studied?” An economist writing on „objective wellbeing‟ summarized the matter simply by statingthat “…one can adopt a mixed approach, in which the satisfaction of subjective preferences istaken as valuable too” (Gaspart 1998, 111) (see also Cummin1997a, 2001). Diener (2000) in anarticle titled „Subjective Wellbeing: The Science of Happiness and a Proposal for a NationalIndex‟ theorizes that the objectification of wellbeing is embodied within satisfaction of life. Hispoints to a construct of wellbeing called happiness. Edward Diener who I consider the father of xi
  13. 13. happiness as a measure of subjective wellbeing has provided the platform for the scientific studyof subjective wellbeing (happiness). And this has been expensively studied by many economistslike Oswald and Easterlin. Other economists have researched different subjective measure ofhealth like Michael Grossman, Smith and Kington. Grossman used econometric techniques tostudy subjective health of the world‟s population, and this was expanded upon by Smith andKington. According to Smith and Kington (1997), using Ht= f (Ht-1, Pm Go, Bt, MCt ED, Āt, ) toconceptualize a theoretical framework for “stock of health” noted that health in period t, Ht, isthe result of health preceding this period (Ht-1), medical care (MCt), good personal health (Go),the price of medical care (Pm), and bad ones (Bt), and a vector of family education (ED), and allsources of household income (Āt). Embedded in this function is the wellbeing that individualenjoys (or not enjoys) (see Smith and Kington 1997, 159-160). Therefore there is an answer tothe scientific inquiry of any phenomenon, particularly wellbeing and quality of life. Outside ofscientific study of subjective health, Thomas Kuhn has provided enough evidence that the socialscience can research social phenomena with the same degree of scientificness like the naturalsciences like physics, chemistry, mathematics and medicine. With empirical evidence showing that science is not science because it is pure (or natural)provide some focus for the examination of social issues like health and reproductive healthmatters. There is no reason for the separation of general health from reproductive health issues,and this book closes the gap between the seemingly two phenomena in a single volume. Theseparate and distinct marker between general health and reproductive health matters is an elusiveone, should desist and replaced by singled focus. xii
  14. 14. This book is the first of its kind in assess health issues –including reproductive healthmatters and health status - in a single volume. Each chapter utilizes a theoretical framework,mathematical, and justifies the comprehensive methodology that is used in therein. Embedded inthe theoretical framework is an econometric technique that is highly mathematical and will notbe simplified in this book. For those readers who are interested in understanding thefundamentals of the theoretical framework, they can do further reading in any advancedmultivariate textbook (regressions – linear, logistic, and discriminant analyses). In keeping withmy belief that written materials must be of low readability, I endeavour to ensure that sufficientexplanations are provided for the methodology as well as each chapter. It follows, therefore, thatall the complex mathematical techniques are hidden, and the methodological principles aresimplified for the purpose of general readership and ease of reading the material. This book is intended to be a text for undergraduate and graduate students indemography, sociology, social work, anthropology, public health, public administration,economics, management studies, public policy, gerontology and general medicine as well ashealth administrators, researchers and policy personnel. The materials are the behaviour,practices, attitudes and perspectives of children and adolescents. Having provides somediscussion on the non-issue of the non-scientificness of subjective views, particularly wellbeing(including happiness, quality of life, illness and health status), the book is an insight into mattersthat have been problematic for years, and some recommendations were given that can be furtherassessed by medical practitioners, public administrators and policy specialists. Paul Andrew Bourne Socio-Medical Research Institute March 2011 xiii
  15. 15. Table of ContentsDedication ivPreface vAcknowledgement xviPart 1: HEALTH STATUSChapter 1: Childhood Health in Jamaica: changing patterns in health conditions of children 0-14 years 1Chapter 2: Child Health Disparities in an English-Speaking Caribbean nation: Using parents‟ views from a national survey 30Chapter 3: Self-rated health status of young adolescent females in a middle-income developing country 58Chapter 4: Self-assessed health of young adults in an English-speaking Caribbean nation 77Chapter 5: Quality of Life of Youths in Jamaica 108Chapter 6: Health of children less than 5 years old in an Upper Middle Income Country: Parents‟ views 133Chapter 7: Biosocial determinants of health and health seeking behaviour of male youths in Jamaica 158Chapter 8: Demographic shifts in health conditions of adolescents aged 10-19 years, Jamaica: Using cross-sectional data for 2002 and 2007 184Chapter 9: Self-reported Health of Youth: Using Health Conditions to measure Health 209Chapter 10: The changing faces of diabetes, hypertension and arthritis in a Caribbean population 232Chapter 11: Variations in social determinants of health using an adolescence population: By different measurements, dichotomization and non-dichotomization of health 257Chapter 12: Health status of patients with self-reported chronic diseases in Jamaica 284 xiv
  16. 16. Part 2: REPRODUCTIVE HEALTH MATTERSChapter 13: Sociodemographic correlates of age at sexual debut among women of thereproductive years in a middle-income developing nation 311Chapter 14: Young males whose first coitus began at most 15 years old 338Chapter 15: Young males who delay first coitus for the statutory age and beyond in Jamaica 362Chapter 16: Factor Differentials in contraceptive use and demographic profile among females who had their first coital activity at most 16 years versus those at 16+ years old in a developing nation 386Chapter 17: Reproductive health matters: Women whose first sexual intercourse occurred at 20+ years old 418Chapter 18: Sexually assaulted females on their sexual debut: Reproductive health matters 442Chapter 19: Reproductive health matters among Infrequent versus Frequent young adult-male-church attendees 467Chapter 20: Multiple sexual partnerships among young adults in a tropically developing nation: A public health challenge 497Chapter 21: Females with multiple sexual partners and their reproductive health matters: A comprehensive analysis of women aged 15-49 years in a developing nation 530 xv
  17. 17. AcknowledgementThe writing of a book is a time consuming and a tedious process, which is assisted by manypeople. A book is not a singulate effort and this must be recognized by the author(s), editor(s)and/or publisher(s). Like many other authors, I am indebted to many people who contributed indifferent ways to the completion of this book. These individuals are 1) Mrs. Evadney Bourne, 2)Kimani Bourne, 3) Kerron Bourne, 4) Paul Andrew Bourne, Jnr, who stayed up with me oncountless nights, and longer on Saturdays and Sundays. Ms. Neva South-Bourne, whose tirelessefforts and endless patience in proofreading some of the chapters as well as Mrs. CindiScholefield. I am also indebted to the Derek Gordon Databank, University of the West Indies,Mona (Jamaica) that made the dataset available from which many of the chapters emerged. Themajority of the chapters are published works in different journals, and I am grateful for theirpermission to use the materials in this book (North American Journal of Medical Sciences,Health, Current Research Journal in Social Sciences, International Journal of CollaborativeResearch on Internal Medicine and Public Health, HealthMed Journal, and Journal of Clinicaland Diagnostic Research; Journal of Applied Sciences Research). Finally, I would like to thankall my co-authored who wrote different articles with me. Any errors of omission or commissionin this book should not be ascribed to anyone or organizations as these are of the author. xvi
  18. 18. Part 1: Health Status 1
  19. 19. Chapter 1Childhood Health in Jamaica: changing patterns in healthconditions of children 0-14 years Paul Andrew BourneThe new thrust by WHO is healthy life expectancy. Therefore, health must be more thanmorbidity. It is within this framework that a study on childhood health in Jamaica is of vitalimportance. This paper 1) expands the health literature in Jamaica and by extension theCaribbean, 2) will aid public health practitioners with research findings upon which they are ableto further improve the quality of life of children, 3) investigates the age at with children inJamaica become influenced by particular chronic diseases and 4) assesses the subjectivewellbeing of children. The current study extracted a sample of 8,373 and 2,104 children 0-14years from two surveys collected jointly by the Planning Institute of Jamaica and the StatisticsInstitute of Jamaica for 2002 and 2007 respectively. A self-administered questionnaire was usedto collect the data. Ninety-one percent of children in Jamaica, for 2007, reported good health.The number of children who had diarrhoea fell by 84.2% in 2007 over 2002, and a similarreduction was observed for those with asthma (42.1% in 2002 and 19.7% in 2007). Anothercritical finding was that 1.2% of children, in 2007, had diabetes mellitus compared to none in2002. Public health now has an epidemiological profile of health conditions of children and thedemographic shifts which are occurring and this can be used for effective management andplanning of the new health reality of the Jamaican child.INTRODUCTIONOne of the measures of child health and the health status of the general populace is infantmortality or mortality, which is well studied in Jamaica and the wider Caribbean [1-11]. Thesimple rationale for the use of mortality in evaluating health status is owing to its ease in which itcan be used to precisely measure its outcome unlike other indicators such as quality of life,subjective wellbeing, happiness or life satisfaction [12-22]. Another reason for the use of infantmortality in the measurement of health is because of the strong inverse significant correlationbetween it and/or general mortality and life expectancy [23,24]. There is no denial therefore that 2
  20. 20. infant mortality and/or mortality in general play a critical role in determining health outcomes.Although life expectancy emerged from mortality, the former only speak to length of life and notthe quality of those lived years. An individual can live for 40 years or even 100 years, of whichall those years were lived in severe morbidity. It is owing to aforementioned rationale why theWorld Health Organization (WHO) developed a mathematical technique which discount the lifeexpectancy by the years spent in disability or morbidity [25]. The WHO therefore emphasizedhealthy life expectancy and not life expectancy. Health therefore must be more than morbidity asit expands to quality of life. Within the broadest definition of health conceptualized by the WHO in the 1940s [26], issocial, psychological and physical wellbeing and not the mere absence of diseases suggestingthat health is more than living to the quality of those lived years. Health has been expanded tomean much more than the absence of diseases to include measures of healthy life expectancy,happiness, utility, personal preference, and self-reported quality of life [12-22]. Simply put,wellbeing is subjectively what is ‗good‘ for each person [26]. It is sometimes connected withgood health. Crisp [26] offered an explanation for this, when he said that ―When discussing thenotion of what makes life good for the individual living that life, it is preferable to use the term‗wellbeing‘ instead of ‗happiness‖, which explains the rationale for this project utilizing the termwellbeing and not good health. The issue of wellbeing is embodied in three theories – (1) Hedonism, (2) Desire, and (3)Objective List. Using ‗evaluative hedonism’, wellbeing constitutes the greatest balance ofpleasure over pain [26, 27]. With this theorizing, wellbeing is just personal pleasantness, whichrepresents that more pleasantries an individual receives, he/she will be better off. The very 3
  21. 21. construct of this methodology is the primary reason for a criticism of its approach (i.e.‗experience machine‘), which gave rise to other theories. Crisp [26] using the work of ThomasCarlyle described the hedonistic structure of utilitarianism as the ‗philosophy of swine‘, becausethis concept assumes that all pleasure is on par. He summarized this adequately by saying that―… whether they [are] the lowest animal pleasures of sex or the highest of aestheticappreciation‖ [26]. The desire approach, on the other hand, is on a continuum of experienced desires. Thisis popularized by welfare economics. As economists see wellbeing as constituting satisfaction ofpreference or desires [26, 27], which makes for the ranking of preferences and its assessment byway of money. People are made better off, if their current desires are fulfilled. Despite thistheory‘s strengths, it has a fundamental shortcoming, the issue of addiction. This forwarded bythe possible addictive nature of consuming ‗hard drugs‘ because of the summative pleasure itgives to the recipient. Objective list theory: This approach in measuring wellbeing list items not merelybecause of pleasurable experiences nor on ‗desire-satisfaction‘ but that every good thing shouldbe included such as knowledge and-or friendship. It is a concept influenced by Aristotle, and―developed by Thomas Hurka as perfectionism‖ [26]. According to this approach, theconstituent of wellbeing is an environment of perfecting human nature. What goes on an‗objective list‘ is based on reflective judgement or intuition of a person. A criticism of thistechnique is elitism. Since an assumption of this approach is that, certain things are good forpeople. Crisp [26] provided an excellent rationale for this limitation, when he said that ―…evenif those people will not enjoy them, and do not even want them‖. 4
  22. 22. In Arthaud-day et al work [28], applying structural modeling, subjective well was foundto constitute ―(1) cognitive evaluations of ones life (i.e., life satisfaction or happiness); (2)positive affect; and (3) negative affect.‖ Subjective wellbeing therefore is the individual‘s ownviewpoint. If an individual feels his/her life is going well, then we need to accept this as theperson‘s reality. One of drawbacks to this measurement is, it is not summative, and it lacksgeneralizability. In keeping therefore with the broad definition of health forwarded by the WHO, anystudy of health must go beyond mortality. A comprehensive search of health literature in theCaribbean in particular found no research that 1) using national cross-sectional survey(s)examined health status of children, 2) investigated the changing pattern of morbidity whichaffect children ages 0-14 years, 3) investigated whether health status (ie. subjective wellbeing)and self-reported morbidities (ie health conditions) are correlated, and if they are good measurefor each other, 4) investigated whether from among the health conditions, chronic diseases andthe time they begin to affect children as well as the 5) demographic characteristics of healthconditions affecting children. The current study will examine the aforementioned issues as healthliterature in the region on child health must expand beyond infant mortality. The objectives ofthe study are to 1) expand the health literature in Jamaica and by extension the Caribbean, 2)understand the status of child health outside of mortality, 3) aid public health practitioners withresearch upon which they are able to further improve the quality of life of children by addingquality to their lived years, 4) investigate the age at with children in Jamaica become influencedby chronic disease, it typology and 5) evaluate the subjective wellbeing of children as is done forthe general populace and elderly [30-37]. 5
  23. 23. The current study used two cross-sectional surveys which were conducted jointly by thePlanning Institute of Jamaica and the Statistical Institute of Jamaica (for 2002 and 2007) thatcollect data on Jamaicans. A subsample of 8,373 and 2,104 children 0-14 years was extractedfrom a sample of 25,018 and 6,783 respondents for 2002 and 2007 respectively. The survey wasa national probability sample of Jamaica, and it was weighted to reflect the populace and sub-populations. The response rate for each survey was in excess of 72%. Descriptive statistics, suchas 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 associationbetween non-metric variables, and Analysis of Variance (ANOVA) was used to test therelationships between metric and non-dichotomous categorical variables whereas independentsample t-test was used to examine a statistical correlation between a metric variable and adichotomous categorical variable. The level of significance used in this research was 5% (ie 95%confidence interval).METHODS AND MATERIALSThe current study extracted a sample of 8,373 and 2,104 children 0-14 years from two surveyscollected jointly by the Planning Institute of Jamaica and the Statistics Institute of Jamaica for2002 and 2007 respectively.[38,39] The method of selecting the sample from each survey wassolely based on an individual being less than or equal to 14 years. The survey (Jamaica Survey ofLiving Condition) began in 1989 to collect data from Jamaicans in order to assess policies of thegovernment. Since 1989, yearly the JSLC adds a new module in order to examine thatphenomenon which is critical within the nation. In 2002, the foci were on 1) social safety net and 6
  24. 24. 2) crime and victimization; and for 2007, there was no focus. The sample for the earlier surveywas 25,018 respondents and for the latter, it was 6,783 respondents. The survey was drawn using stratified random sampling. This design was a two-stagestratified random sampling design where there was a Primary Sampling Unit (PSU) and aselection of dwellings from the primary units. The PSU is an Enumeration District (ED), whichconstitutes a minimum of 100 residence in rural areas and 150 in urban areas. An ED is anindependent geographic unit that shares a common boundary. This means that the country wasgrouped into strata of equal size based on dwellings (EDs). Based on the PSUs, a listing of all thedwellings was made, and this became the sampling frame from which a Master Sample ofdwelling was compiled, which in turn provided the sampling frame for the labour force. Onethird of the Labour Force Survey (ie LFS) was selected for the JSLC. [40, 41] The sample wasweighted to reflect the population of the nation. The JSLC 2007 [40] was conducted May and August of that year; while the JSLC 2002was administered between July and October of that year. The researchers chose this survey basedon the fact that it is the latest survey on the national population and that that it has data on self-reported health status of Jamaicans. A self-administered questionnaire was used to collect thedata, 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 MeasurementStudy (LSMS) household survey. There are some modifications to the LSMS, as JSLC is morefocused 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 7
  25. 25. anthropometry. The non-response rate for the survey for 2007 was 26.2% and 27.7%. The non-response includes refusals and rejected cases in data cleaning.MeasuresSocial class: This variable was measured based on the income quintiles: The upper classes werethose in the wealthy quintiles (quintiles 4 and 5); middle class was quintile 3 and poor those inlower 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).Age is a continuous variable in years.Child. A person who has celebrated less than or equal to 14 years.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.Statistical AnalysisDescriptive statistics, such as mean, standard deviation (SD), frequency and percentage wereused to analyze the socio-demographic characteristics of the sample. Chi-square was used toexamine the association between non-metric variables, and Analysis of Variance (ANOVA) was 8
  26. 26. used to test the relationships between metric and non-dichotomous categorical variables whereasindependent sample t-test was used to examine a statistical correlation between a metric variableand a dichotomous categorical variable. The level of significance used in this research was 5%(ie 95% confidence interval).RESULTFor this paper there were two samples (8,373 from 2002 data survey and 2,104 from the 2007survey). In 2002, the sample was 50.7% males and 49.3% females compared to 51.3% males and48.7% females for 2007. The mean age for the sample in 2002 was 7.2 years (SD = 4.2 years)and 7.3 years (SD = 4.3 years) for 2007. The proportion of the sample in particular social class(using population income quintile) was relative the same across the two years. The number ofdays recorded as suffering from illness fell by 2 days in 2007 over 2002 (median number of daysexperiencing ill-health). In 2002, 9.4% of the sample reported an illness/injury in the 4-weekperiod of the survey and this increased by 34.0% (to 12.6%). The percent of the sample thatvisited health care practitioners marginally increase from 56.7%, in 2002, to 58.6% in 2007.Concurrently, 9.3% of sample was covered by health insurance (ie total private in 2002) and thisincreased by 62.4% and a part of this was accounted for by a 5.1% having public healthinsurance coverage. In 2002, 62.6% of the sample dwelled in rural areas, 25.1% in semi-urbanareas and 12.3% in urban areas compared to a shift which was noticed in 2007 as 53.2% residedin rural areas and 20.2% in semi-urban areas with 26.6% lived in urban zones (Table 1.1). The general health status of children in Jamaica, for 2007, was good (91.3%) comparedto 6.7% fair and 2.0% poor. 9
  27. 27. Interestingly, in the current study, a shift in health condition was noticed in 2007 over2002. The number of children who had diarrhoea fell by 84.2% in 2007 over 2002, and a similarreduction was observed for those with asthma (42.1% in 2002 and 19.7% in 2007). Anothercritical finding was that 1.2% of children, in 2007, had diabetes mellitus compared to none in2002. On the contrary, 37.5% of children, in 2007, had cold which increased from none in 2002(Table 1.1). A cross-tabulation between health conditions and sex of respondents, revealed that nosignificant statistical correlation existed between the two variables and that this was for bothyears: For 2002 - χ2 (df = 2) = 0.232, p> 0.05; and for 2007 - χ2 (df = 5) = 8.915, p> 0.5 (Table1.2). In spite of the aforementioned, the new diabetic cases were accounted for by females (for2007). In 2002, no significant statistical relationship existed between diagnosed healthconditions and area of residents (χ2 (df = 4) = 1.301, p > 0.05). On the other hand, a statisticalcorrelation was observed for 2007 between the aforementioned variables. Furthermore, morechildren in semi-urban areas had cold than those who dwelled in other areas. On the contrary,diabetic cases were found in urban areas and none in other geographical zones. The findingsrevealed also that more rural children had asthma and more urban children had unspecifiedhealth conditions (Table 1.3). Table 1.4 revealed that no significant association was found between diagnosed healthcondition and social class (ie population income quintile). However, the diabetic cases werespread among the lower class (poorest 20%, 1.9%; and poor, 1.8%) and the upper class (wealthy,2.0%). 10
  28. 28. The examination of diagnosed health conditions by mean age of respondents revealedthat a significant relationship existed between the two aforementioned variables in 2007, Fstatistic = 4.875, p < 0.001; but none in 2002 - F statistic = 3.334, p > 0.05. In 2007, the meanage of a child with diabetes mellitus was 12.33 years (SD = 2.1 yrs), 95% CI = 7.16 – 17.5(Table 1.5). However the mean age a child with diarrhoea lower than a child and other healthconditions. The first time in the history of the Jamaica Survey of Living Conditions (JSLC) thathealth status and self-reported health condition was collected together was in 2007. Hence, thecurrent study will cross-tabulate both in order to determine whether a significant correlationexist between them and what is the strength of a relationship if one does exist. Based on Table1.6 a weak significant statistical association exist between health status and self-reported healthcondition - χ2 (df = 2) = 174.512, p < 0.0001, cc= 0.282. On further examination of the findings,it was observed that no child was classified has having very good health status. Ninety-fourpercent of sample who had no health condition reported good health compared to 70% of thosewho had at least one health condition. Of those who had at least one health condition, 9.4% ofthem reported poor health status compared to 1% who had no health condition (Table 1.6). Using independent sample t-test, in 2002, the current study found that there was asignificant difference between the mean age of those who sought and not seek medical care –t3.425 , p < 0.001. The mean age of those who do not seek medical care higher, 6.2 years (SD =4.1), compared to those who seek care, 5.2 years (SD = 4.2 years). However, there was nodifference in 2007: seek care – mean age 5.2 years (SD = 4.1 years) and not seek care – meanage 5.8 years (SD = 4.2 years). 11
  29. 29. On examination as to whether a significant statistical correlation existed between healthcare-seeking behaviour and sex of respondents, none was found in each year – p > 0.05 (Table1.7).DISCUSSIONIt is established in epidemiology that diseases in childhood do influence poor health in adulthood[42], suggesting the value of child health to health status over the life course. Anotherimportance to the study of health status is its contribution to all typology of development ashuman capital is critical to socio-economic and political systems. In Jamaica, the StatisticalInstitute of Jamaica [42] estimated that for 2007, there was 28.3% of the nation‘s population wasless than 14 years. Simply put, there are 45 children for every 100 working age (ages 15-64years) Jamaican; and to omitted the health status of this cohort is to substantially neglect acritical sector of the population. The current study found that 2 in every 100 children had poorhealth status; and that weak significant statistical correlation existed between health status andself-reported health conditions. This therefore concurs and contradicts another study that foundstatistical association between health conditions and health status [36]. Hambleton et al. [36],examining data for elderly Barbadians, found that self-reported health conditions accounted formost of the variability in health status (ie. current diseases accounted for 33.5% out of R2 =38.3%). This takes the study in the direct of current diseases (ie health conditions) of children inJamaica. This paper revealed 34% increase in cases of self-reported diseases in Jamaicanchildren. Only 13 in 100 children in Jamaica, in 2007, had a least one health condition. Theseconditions include cold, diarrhoea, asthma, diabetes mellitus and other unspecified diseases. In 12
  30. 30. 2007, 20 in every 100 children had asthma, 5 out of every 100 diarrhoea cases, 38 in every 100had cold and 21 in every 100 unspecified conditions. Of the different typology of chronicdysfunctions, 12 in every 1,000 reported diabetes mellitus and no cases were found ofhypertension and arthritis. Given the breadth of the unspecified category, this could includecancers, HIV/AIDS and other communicable or non-communicable diseases. In spite of thisuncertainty, what emerged from the current research is the change in pattern of health conditionsof children between 2002 and 2007. A study conducted by Walker [43] found that growthretardation in children influence blood pressure, obesity, and other chronic health conditions, andthat some 5-6% of children in Trinidad and Tobago, and Jamaica are classified in this group.Walker also found that these children are more likely to experience more episodes of diarrhaea,fever and other morbidities. This research revealed that number of cases of asthma, diarrhoea and unspecifiedconditions fell accompanied with a corresponding rise in cold and diabetes mellitus. Interestinglyto note is that the 1.2% of child population that were diagnosed diabetic patients represents 2.3%of the female population. The diabetic cases were not only females, but urban residents. Of thosewith diabetes, 1.9% was in the poorest 20%, 1.8% poor and 2.0% of the wealthy social class.Continuing, the mean age of female diabetic children was 12.3 years; and this indicates the yearage in which diabetes mellitus begin to affect females in Jamaica. The aforementioned findingexplains the disproportionate number of females to males in the general population that havediabetes -14% females to 7.7% males [40]. Although no cases of hypertension was reported inthis paper, it is established that diabetes mellitus is correlated with hypertension. 13
  31. 31. Diabetes Mellitus is not the only challenge faced by patients, but McCarthy [44] arguesthat between 30 to 60% of diabetics also suffer from depression, which is a psychiatric illness.Diabetes mellitus does influence the health status of children and follows them across the lifecourse. It affects lifestyle choice, functional capacity, and like McCarthy said the psychologicalstate of people. This health condition also affects other disease. Morrison [45] opined thatdiabetes mellitus and hypertension have now become two problems for Jamaicans and in thewider Caribbean. This situation was equally collaborated by Callender [46] who found that therewas a positive association between diabetic and hypertensive patients - 50% of individuals withdiabetes had a history of hypertension [46]. Children with diabetes mellitus therefore are highlylikely to develop hypertension in the future, and so children in Jamaica in the future will havetwin chronic conditions. This envelope further shifts in health conditions of children in Jamaica;Morrison alluded to a transitory shift from infectious communicable diseases to chronic non-communicable diseases as a rationale for the longevity of the Anglophone Caribbean populaceand this does not mitigates against lowered healthy life expectancy of the sexes in particularfemales who live 6 years more than males [34,42]. Diabetes mellitus and any other typology of chronic diseases do more than affect healthylife expectancy; they are directly correlated with mortality. Statistics from the Statistical Instituteof Jamaica [42] is the leading cause of deaths in female Jamaicans. The reality of changingpattern of health conditions from communicable to non-communicable and the fact that this isaccounted with urban poor and wealthy, indicate that public health policies are needed to addressthis currently and in the future. Another important fact that embedded in the current study is theearly age in which females are having chronic disease, and this indicates the length of time withwhich they will life with this non-curable disease or likeliness of mortality. 14
  32. 32. A study on morbidity and mortality patterns in the Caribbean established that thetransition in morbidity is not atypical to Jamaica [47], and that the leading cause of mortality inregion is similar to developed nations. WHO [48] opined that 80% of chronic illnesses were inlow and middle income countries, indicating the preponderance of chronic illness in regions suchas the Caribbean as well as the fact that chronic illnesses are also a part of the landscape ofindustrialized nations. With the changing pattern of morbidity of children in Jamaica, this willsupport modifications in lifestyle behaviour which must begin from children to the populace. Although there is no statistical difference between the 3 area of residents and healthconditions, the fact that the chronic dysfunctions were found in urban areas denote that publichealth policies must begin in earnest in those places. There is another situation that must beexplored here and that is response of health services, and the management of care for those whoare affected by chronic illnesses. It should be noted that 57 out of every 100 children were takenfor medical care which speaks to the high proportion of children despite being ill who were nottaken to traditional medical facilities. A part of the rationale for this non-medical care seekingbehaviour of children is adults‘ definition of health and the cultural perspective of health. Generally, health in Jamaica is defined as the absence of illness which although isnegative and narrow in scope speaks to people‘s perspective on the matter. Interestingly in thisdiscourse is not only the narrowed definition of health, but that severity in health conditions issubstantially what drives medical care-seeking and not on the onset of illness or preventativecare. This goes to the crux of why only 57 out of every 100 children who are ill would be takento health care practitioners as their families are less likely to taken then for conditions such as thecold, but also provide an explanation for the low medical care seeking behaviour for the generalpopulace. 15
  33. 33. Statistics revealed that for the last 2 decades (1988-2007), there were 4 times (years) inwhich males sought more medical care than females – 1991 (48.5% males to 47.4% females);1995(59.0% males to 58.9% females): 1997 (60.0% males to 59.3% females) and 2006 (71.7%males to 68.8% females) [30, 41, 40], which speaks to some embedded culturalization for thishealth care-seeking disparity in nation. While this is not atypical to Jamaica [49-51], that factthat the current study revealed that there was no significant statistical difference between maleand female children being taken for medical care, the disparity that exist in the general populacebegin in young adulthood. This is the period in which identify formulation begins in adolescentsand when males begin to imitate the practices of adult men. The adolescent male therefore willseek less medical care because his adult counter believes that this is weak, feminine and reduceshis machoism. One anthropologist in seeking to explain the practices of Caribbean men used sociallearning theory to examine the lifestyle practices of boys [52]. Chevannes [52] argued that theyoung imitate the roles of society members through role modeling of what constitute acceptableand good roles which is supported by reinforcement. The young male is a subset of the society,and if men are less likely to seek health care because of a cultural perspective that they form ofill-health which goes to the crux of their manhood and possibly seeks to threaten it, young malesas soon as they are somewhat responsible for their choices will do more of the same as theirmentors. This gender role of sexes and health disparity which results after childhood is notlimited to Jamaica or the Caribbean but a study carried out by Ali and de Muynck [53] found thatstreet children in Pakistan had a similar gender stereotype about health, health care and medicalcare seeking-behaviour. Using a descriptive cross-sectional study carried out during Septemberand October 2000 of 40 school-aged street children (8-14 years), they found boys were reluctant 16
  34. 34. to seek medical care except when there is severity of ill-health, it threatens their economiclivelihood or there is a perceived reduction in functional capacity. The reason being that mildailment is not severe enough to barr them from physical functioning and within the context of thegeneral population that men ought to be tough, this means that they are okay; and so somemorbidity are not for-hospital, which was so the case in Nairobi slums [54]. This again justifieswhy some children in Jamaica are not taken to health practitioners as there is a perception thatsome illness requires home remedy. Statistics revealed that 56.0% of children (ages 0-4) who were not taken for medicaltreatment despite having an illness was because home remedies were used, figure was 32.8% forthose 5-9 years and 25.6% for those 10-19 years [40]. Inaffordability accounted for 33%, 32.5%and 35.9% of those ages 0-4 years, 5-9 years and 10-19 years respectively who were not broughtto health care practitioner even though they were ill.CONCLUSIONThe general health status of children in Jamaica is good; but this mitigate against the relativelylow age with which females are reported to have had diabetes mellitus and the changing patternof health conditions which have occurred since the 2002. Public health now has anepidemiological profile of health conditions of children and the demographic shifts which areoccurring and this can be used for effective management and planning of the new health realityof the Jamaican child. With the removal of health care user fees for children ages 0-18 yearsfrom the health care landscape of Jamaica (since May 28, 2007), the transition to chronic cases inthis cohort means that health care expenditure in the future will rise as we seek to care for thosepatients over there life course. It is critical that future research examine the composition of 17
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  40. 40. Table 1.1. Sociodemographic characteristic of sampleVariable 2002 2007 N= 8373 N=2104Sex Male 50.7 51.3 Female 49.3 48.7Health care-seeking behaviour Yes 56.7 58.6 No 43.3 41.4Health insurance coverage Yes 9.3 15.1 No 90.7 84.9Area of residence Rural 62.6 53.2 Semi-urban 25.1 20.2 Urban 12.3 26.6Self-reported illness Yes 9.4 12.6 No 90.6 87.4Diagnosed Health conditions Cold - 37.5 Diarrhoea 31.6 5.0 Asthma 42.1 19.7 Diabetes mellitus (ie diabetes) - 1.2 Hypertension - - Arthritis - - Other 26.3 20.8 Not - 17.0Population Income quintile Poorest 20% 26.0 26.0 Poor 22.9 22.6 Middle 20.3 19.5 Wealthy 18.0 18.9 Wealthiest 20% 12.8 13.0Age Mean (SD) 7.2 yrs (4.2 yrs) 7.3 yrs (4.3 yrs)Length of illness Median 7 days 5.0 daysNumber of visits to health practitioner(s) median 1.0 1.0Crowding mean (SD) 2.5 persons (1.5 5.5 persons (2.3 persons) persons) 23
  41. 41. Table 1.2. Diagnosed health conditions by Sex, 2002 and 2007Variable 20021 20072Diagnosed Health conditions Male Female Male FemaleCold - 35.7 39.2Diarrhoea 27.3 37.5 3.1 6.9Asthma 45.5 37.5 21.7 17.7Diabetes - 0.0 2.3Hypertension - - -Arthritis - - -Other 27.3 25.0 19.4 22.3No - - 20.2 11.5 1 2 χ (df = 2) = 0.232, p> 0.05 2 2 χ (df = 5) = 8.915, p> 0.5 24
  42. 42. Table 1.3. Diagnosed health conditions by area of residenceVariable 20021 20072 Rural Semi-urban Urban Rural Semi-urban UrbanDiagnosed HealthconditionsCold - - - 27.0 56.5 36.0Diarrhoea 33.3 40.0 0.0 - 2.2 8.0Asthma 41.7 40.0 50.0 25.4 15.2 18.7Diabetes - - - - - 2.3Hypertension - - - - - -Arthritis - - - - - -Other 25.0 20.0 50.0 20.6 13.0 23.3No - - - 27.0 13.0 12.0 1 2 χ (df = 4) = 1.301, p > 0.05 2 2 χ (df = 10) = 25.079, p = 0.005, cc = 0.297 25
  43. 43. Table 1.4. Diagnosed health conditions by Population income quintileVariable 20021 20072Diagnosed Poorest Poor Middle Wealthy Wealthiest Poorest Poor Middle Wealthy WealthiestHealth 20% 20% 20% 20%conditionsCold - - 16.7 14.3 50.0 35.8 37.5 44.3 36.7 30.0Diarrhoea 75.0 - 66.7 57.1 0.0 3.8 12.5 4.9 2.0 0.0Asthma 0.0 - - - - 22.6 17.9 18.0 14.3 27.5Diabetes - - - - - 1.9 1.8 0.0 2.0 0.0Hypertension - - - - - - - - - -Arthritis - - - - - - - - - -Other 25.0 - 1.0 28.6 50.0 28.3 19.6 16.4 20.4 20.0No - - - - 7.5 10.7 16.4 24.5 22.5 1 2 χ (df = 6) = 8.105, p > 0.05 2 2 χ (df = 20) = 25.079, p > 0.05 26
  44. 44. Table 1.5. Mean Age of respondent who has a particular health conditionVariable 20021 20072Diagnosed Health conditions Mean age (SD) 95% CI Mean age (SD) 95% CICold - - 4.4 yrs (4.0 yrs) 3.55 – 5.15Diarrhoea 1.5 yrs (1.5yrs) - 0.09 -3.09 3.5 yrs (2.8 yrs) 1.93 – 5.15Asthma 5.0 yrs (3.0 yrs) 2.51-7.49 6.5 yrs (3.5 yrs) 5.51 – 7.47Diabetes - - 12.33 yrs (2.1 yrs) 7.16 – 17.5Hypertension - - - -Arthritis - - - -Other 5.4 yrs (3.8 yrs) 0.62 – 10.18 6.0 yrs (4.5 yrs) 4.82 – 7.26No - - 5.8 yrs (4.3) 4.46 – 7.20 1 F statistic = 3.334, p > 0.05 2 F statistic = 4.875, p < 0.001 27
  45. 45. Table 1.6. Health status by self-reported illnessVariable 20021 20072 Self-reported illness Self-reported illness None At least one None At least oneHealth status (in %) (in %) (in %) (in %)Very good - - - -Good - - 94.3 70.2Fair - - 4.7 20.4Poor - - 1.0 9.4 1 In 2002, health status data were not collected. This took place the first time in 2007 2 2 χ (df = 2) = 174.512, p < 0.0001, cc= 0.282 28
  46. 46. Table 1.7. Health (or medical) care-seeking behaviour by sexVariable 20021 20072 Sex SexHealth care-seeking behaviour Male Female Male Female Sought care 42.2 44.5 40.8 42.0 Did not seek care 57.8 55.5 59.2 58.01 2 χ (df = 1) = 0.419, p > 0.052 2 χ (df = 1) = 0.040, p > 0.05 29
  47. 47. Chapter 2Child Health Disparities in an English-Speaking Caribbeannation: Using parents’ views from a national survey Paul Andrew Bourne , Cynthia Grace Francis & Elaine EdwardsPrevious studies in the English-Speaking Caribbean, and in particular Jamaica, have used apiecemeal approach to the study of child health, and none emerged that has modelled good healthstatus while evaluating other areas of health. The current study seeks to evaluate the generalhealth of children from the perspective of their parents‘ views in an English-Speaking Caribbeannation as well as the typology of dysfunctions, health disparities, social determinants of self-evaluated health of children, and provide policy formulators as well as health researchers withpertinent information that can be used to formulate health intervention programmes and guidethe focus of future research. A sample of 2,642 children (≤ 18 years) was used for this analysis.The data were taken from the 2002 Jamaica Survey of Living Conditions (JSLC). Stratifiedprobability sample was used to collect the data. The JSLC used an administered questionnaire todetail recall information on particular activities from parents. The questionnaire was modelledfrom the World Bank‘s Living Standards Measurement Study (LSMS) household survey.Multivariate models were used to establish statistical association between good health status andsocial determinants, health seeking behaviour, and length of illness. Eleven percent of the samplereported an illness in the last 4-weeks. Of those who indicated an illness, 16.5% claimed thattheir illness were non-diagnosed by medical practitioners. Fifty-eight percent of those whoindicated diagnosed illness had acute conditions (34.7% influenza, 4.5% diarrhoea and 19.2%respiratory diseases), 2% chronic diseases (i.e. diabetes mellitus) and 24.1% unspecifiedconditions. Six explanatory determinants were found that explain good health status: age (OR =0.95, 95% CI = 0.90-1.00); health care-seeking behaviour (OR = 0.29, 95% CI = 0.15-0.56);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). Although health indicators suchas life expectancy, infant mortality, illnesses, and nutrition as well as socio-economicdeterminants such as poverty and education have improved exponentially in Jamaica as well asin the wider Latin America and the Caribbean, child health disparities still exist in Jamaica. Thefindings are far reaching, provide more information than objective indices, and can be used to aidpolicy formulation and guide future research. 30
  48. 48. IntroductionIn 1946, the World Health Organisation1 (WHO) joined the discussion on health which resultedin a conceptual definition that expanded on the popular absence of diseases. The WHO theorizedthat health must incorporate social, economic and psychological variables and not merely theabsence of diseases. This was documented in the preamble to its Constitution1 in 1948. Engel2-6who was a physician later became involved in the discourse and added a conceptual model. Heopined that the treatment of mentally ill-patient must include the physical, social andpsychological conditions. He called this conceptual framework, a biopsychosocial model.Despite the efforts of WHO and Engel to broaden the biomedical model (ie diseases causingpathogens), scholars such as Bok7 argued that the WHO‘s conceptual definition of health is toobroad and by extension elusive to operationally measure. He therefore cited that the difficultywith measuring the WHO‘s conceptual definition of health is such that it should not be used byresearchers. Bok‘s perspective did not include a suggestion to replace this but speaks to thedominance of traditional approach to the measurement of health. The traditional approaches suchas mortality, diagnosed illness and life expectancy have objectively measurable outcomes whichare among the rationales offered for justifications of their usages. Using mortality or morbidity to measure health is a narrow approach. This on the otherhand is on the opposite extreme of the health pendulum as health is more than not havingdysfunctions or death.8 Death is the outcome of some morbidities, accidents, injuries, suicide andother conditions. Those aforementioned issues omit the role that social determinants play onpeople health. These social determinants include poverty, income, marital status, crime andviolence, culture, and much more.9-27 Poverty is empirically established as strongly correlated 31
  49. 49. 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 whichresults from poverty may influence ones physical illness, but there are social issues surroundingpoverty that may not result in injuries or even diseases. We can argue within the reality ofcontemporary 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 highlyflawed as the WHO28 opined that 80% of chronic illnesses were in low and middle incomecountries. This undoubtedly suggests that illness interfaces with poverty and other socio-economic challenges. Poverty does not only impact on illness, it causes pre-mature deaths, lowerquality of life, lower life and unhealthy life expectancy, low development and other social illssuch as crime, high pregnancy rates, and social degradation of the community. Using twodecades worth of data on Jamaica, Bourne29 found that there was a positive correlation betweenpoverty and unemployment; poverty and illness; and crime and unemployment as well as anegative correlation between poverty and not seeking medical care. 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 aswell as Cuba that have examined health status of children have substantially only examinedmortality, birth, morbidity and to a lesser extent nutrition.30-37 Those studies are once againhighlighting the strength of the biomedical model in contemporary Caribbean nations, and to alesser extent not recognize the value of the social determinants in health and health care. TheWHO and any other scholars have joined the discourse in the value of social determinants sincethe 2000 and this has seen many publications on the matter.16-19,21 Although the WHO opinedthat health research and by extension health must include the social determinants,21 32
  50. 50. subconsciously the dominance of the biomedical approach is so engrained in psyche that in 2009WHO published a document entitled ‗World Health Statistics‘ and the social determinants wereomitted from the section on health indicators. The document examined mortality, morbidity,typologies of dysfunctions, burden of diseases, immunization, sanitation, healthy lifeexpectancies, health expenditure, health care-utilization and omitted critical social determinantssuch as poverty, marital status, education, and so on. Like WHO, Caribbean scholars are so focused on the objective health measures (such aslife expectancy, mortality and diagnosed morbidity) that their work lack policy inventionstrategy that include critical social determinants. Humans are multi-dimensional animals,suggesting that omitting social determinants are excluding critical tenets that can enhance policyformulation in improving health and guide political actions.18 In 2007, poverty rates in ruralJamaica was twice that of urban poverty39 and within the context of empirical findings the healthstatus of children in the former areas cannot be the same as those in the latter areas. Povertytherefore affects the choices, physical environment, nutrients intakes, health care utilization, andthe quality of life of parents as well as their children. Having identified the weaknesses of manyof the previous studies and the role of social determinant in health and health intervention, thecurrent study will fill this gap by examining child health from the perspective of socialdeterminants (including area of residence). In addition to the identified weakness of many studiesthat have examined health in children, the current study using Casas et al.‘s40 work recognize thathealth disparity in Latin America and the Caribbean is accounting for some of the inequalities inhealth outcomes. Casas et al cited that the region demonstrated the greatest disparities in incomeand other social determinants, indicating a justification for the disparity in infant mortalitybetween poor and developed countries.26 The aims of the present work are to evaluate the general 33
  51. 51. health of children from the perspective of their parents‘ views in an English-Speaking Caribbeannation as well as the typology of dysfunctions, health disparities, social determinants of self-evaluated health of children, and provide policy formulators as well as health researchers withpertinent information that can be used to formulate health intervention programmes and guidethe focus of future research.Materials and MethodsThe Jamaica Survey of Living Conditions (JSLC) was commissioned by the Planning Institute ofJamaica (PIOJ) and the Statistical Institute of Jamaica (STATIN) in 1988.39 These twoorganizations are responsible for planning, data collection and policy guideline for Jamaica, andhave been conducting the JSLC annually since 1989.39 The JSLC is a administered questionnairewhere respondents are asked to recall detailed information on particular activities. Thequestionnaire 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 morefocused on policy impacts. The questionnaire covers demographic variables, health,immunization of children 0–59 months, education, daily expenses, non-food consumptionexpenditure, housing conditions, inventory of durable goods and social assistance. Interviewersare trained to collect the data from household members. The survey is conducted between Apriland July annually. The current study extracted a sub-sample of 2,642 respondents 18 years andbelow from a larger nationally cross-sectional survey of 6,782 Jamaicans. This paper used thedataset of the JSLC for 2007.42 34
  52. 52. MeasuresTable 2.1 shows the operational definitions of some of the explanatory variables used in thispaper. An explanation of some of the variables in the model is provided here.Statistical analysisStatistical 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, standarddeviation (SD), frequency and percentage were used to analyze the socio-demographiccharacteristics 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 equality of meansamong non-dichotomous categorical variables. Logistic regression examined the relationshipbetween the dichotomous binary dependent variable and some predisposed independent(explanatory) variables (dependent variable was 1 if reported good health status and 0 if poorhealth). A pvalue < 0.05 was selected to established statistical significance. The final model wasbased on those variables that were statistically significant (p < 0.05). Categorical variables werecoded using the ‗dummy coding‘ scheme. The predictive power of the model was tested using the ‗omnibus test of model‘ andHosmer and Lemeshow‘s43 technique was used to examine the model‘s goodness of fit. Thecorrelation matrix was examined in order to ascertain whether autocorrelation (or multi-collinearity) existed between variables. Cohen and Holliday44 stated that correlation can be 35
  53. 53. low/weak (0–0.39); moderate (0.4–0.69), or strong (0.7–1). This was used in the present study toexclude (or allow) a variable. Where collinearity existed (r > 0.7), variables were enteredindependently into the model to determine those that should be retained during the final modelconstruction. The final decision on whether to retain was based on the variables‘ contribution tothe predictive power of the model and its goodness of fit. Finally, forward stepwise technique inlogistic regression was used to identify variables as well as determine the magnitude (orcontribution) of each statistically significant variable, and the odds ratio (OR) for interpretingeach of the significant variable.ResultsDemographic CharacteristicThe current study had a sample of 2, 642 respondents (ages 0 to 18 years): 50.9% males and49.1% 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%). Fifty-two percent of the sample resided in rural areas compared to 28% in urban and 20% in peri-urban areas. Eleven percent of the sample reported an illness in the last 4-weeks. Of those whoindicated an illness, 16.5% claimed that their illness were non-diagnosed by medicalpractitioners. 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 yousought medical care in the last 4-weeks? Of those who responded to the medical care-seekingquestion, 58.4% claimed yes. When the respondents were asked ―Why did you not seek medicalcare?‖ 17.8% said that they could not afford it, 50.8% was not ill enough and 19.5% used home 36
  54. 54. 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 verypoor. There was a significant statistical difference between the mean age of respondents andself-reported diagnosed health conditions – F statistic = 8.4, P < 0.0001. The mean age of childbeing diagnosed with particular illness was 6.5 years (SD = 5.1; 95% CI = 5.5-7.1). The meanage 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 = 5.9diabetes mellitus) and 8.4 years (SD = 5.9; other – unspecified conditions). Table 2.2 highlights particular social, economic and biological variables by area ofresidence. 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 alonger period than urban children compared to 2 times more than peri-urban children. Theidentified cases of chronic condition (i.e. diabetes mellitus) were a rural matter (1.8%). Table 2.3 shows self-reported diagnosed health conditions by particular demographiccharacteristics. Rural children were highly likely to indicate most of the health conditionscompared to other children from other geographical zones. However, urban children were mostlikely to be diagnosed with respiratory diseases (35.7%) compared to peri-urban children withinfluenza (27.7%) and rural children with diarrhoea (92.3%). All the reported cases of diabetesmellitus were from rural zones (100.0%). Table 2.4 presents information between health care-seeking behaviour and particulardemographic variables. A child who received medical care in the last 4 weeks was 1.8 times 37
  55. 55. more likely to have health insurance coverage and 3.9 times more likely to report poor healthstatus. No significant statistical association was found between health care-seeking behaviourand social hierarchy (P = 0.866), health care-seeking behaviour and age (P = 0.503) and healthcare-seeking behaviour and sex of respondents (P = 0.356).Multivariate analysisTable 2.5 highlights the explanatory social determinants of good health status of children inJamaica. 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 = 0.15-0.56); middleclass (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 themodel – model chi-square = 46.4, P < 0.0001.DiscussionThe current study highlighted that 89 out of every 100 children in Jamaica did not have an illnessin 4-week period of a survey. Instead of using diseases to measure health, 91 out of every 100reported at least good health status (including 45 out of every 100 very good self-evaluatedhealth statuses). Using health conditions and mortality of children 0 – 18 years, the PanAmerican Organization (PAHO) concluded that most of Jamaica‘s children were in goodhealth.45 This finding is concurred by the current study, but this does not provide a holisticunderstanding of the health disparities in child health in the nation. The current findings revealedthat 36 out of every 100 rural children were living in household in the poorest 20% compared to14 out of every 100 in peri-urban households and 11 out of every 100 in urban households. Does 38