• Share
  • Email
  • Embed
  • Like
  • Save
  • Private Content
Happiness in Older Adulthood
 

Happiness in Older Adulthood

on

  • 9,107 views

This book seeks to examine happiness in older ages (older adulthood)

This book seeks to examine happiness in older ages (older adulthood)

Statistics

Views

Total Views
9,107
Views on SlideShare
9,106
Embed Views
1

Actions

Likes
1
Downloads
68
Comments
0

1 Embed 1

http://www.slideshare.net 1

Accessibility

Categories

Upload Details

Uploaded via as Adobe PDF

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment

    Happiness in Older Adulthood Happiness in Older Adulthood Document Transcript

    • Happiness in OlderAdulthoodWellbeing, Health & life satisfactionPaul Andrew Bourne
    • Happiness in OlderAdulthoodWellbeing, Health & life satisfactionPaul Andrew BourneSocio-Medical Research InstituteKingston, Jamaica i
    • ©Paul A. Bourne, 2011First Published in Jamaica, 2011 byPaul Andrew Bourne66 Long Wall DriveStony Hill,Kingston 9,St. AndrewNational Library of Jamaica Cataloguing DataHappiness in Older Adulthood: Illness, Health & lifesatisfactionIncludes 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 ii
    • PrefaceDr. George Engel has expanded the biomedical model in the 1960s, in which he emphasizes theimportance of socioeconomic and psychological conditions in treating mentally ill patients, andthat this extended beyond this group to all patients. Other scholars have used happiness, lifesatisfaction, self-rated health and quality of life to evaluate health instead of the traditionalabsence of illness. Happiness, life satisfaction and health status are as close as possible to theideal definition of health as offered by the WHO. However, these are infrequently used in healthdiscourse, particularly among those in older adulthood in Jamaica. Understanding and planning for aged Jamaicans cannot rely on only illness, self-ratedhealth and mortality. Since 1989, the Statistical Institute of Jamaica and the Planning Institute ofJamaica have been collecting data on Jamaicans to guide policy formulation. Self-reportedillness is usually collected and this is used to assess the health status of the population. The firsttime that self-rated health status was collected from Jamaicans was in 2007. Therefore, planningfor the health of the population was primarily based on the traditional perspective (biomedicalmodel or the germ theory). Despite Dr. George Engel‟s proposition of the biopsychosocial model since the 1950s,the Planning Institute of Jamaica and the Statistical Institute of Jamaica have not seen it fitting tocollect data on different subjective indices of health such as happiness, life satisfaction, qualityof life and self-rated health status all at once (up to 2007). This means that researchers who usethe data from the aforementioned institutes as well the institutions cannot verify the validity ofdifferent subjective indices as well as whether there are differences among the measures. The iii
    • elderly are people who are highly vulnerability to diseases, loneliness, fear, frustration,depression and frailty, and so planning for their health cannot limit itself to health conditions andself-reported health. This is moreso on the premise that we do not know the coverage ofexogenous health, life satisfaction, wellbeing and illness. This book intends to commence a discourse on health that is expansive from the absenceof illness to include 1) self-rated health, 2) wellbeing, 3) life satisfaction, and 4) happiness.Happiness in Older Adulthood: Wellbeing, Health & life satisfaction comprises of 15 chapters,and the author intends for this to be a thrust in expanding the construct of health in datacollection as well as understanding peoples‟ perspective on health. iv
    • AcknowledgementThe completion of this book is owed to a number of people who offered their time, cognitiveskills and data availability. In keeping with the aforementioned issues, I am grateful, pleased andindebted to the following people and/or institutions – including relatives such as my aged mother(Ms. Janet “Medda” Green), brother (Mr. Kervin Roger Smith), niece (Janet Smith), nephew(Kevin Smith). And, 1) Ms. Neva South-Bourne for her advice in penning my ideas, 2) Mrs.Evadney Bourne, my wife, for support, understanding and patience when things were difficultand surmountable at times, 3) all my co-writers, 4) God, for his wisdom, 5) the Data Bank in SirArthur Lewis Institute of Social and Economic Studies, the University of the West Indies, Mona,Jamaica for making the dataset available for use in this study, and 6) all my associates (includingbest friends) whose love, support and encouragement provided the impetus that I drew from tocomplete this project. I would also like to single out the different journals that gave me thepermission to reproduce some of the chapters – including North American North of MedicalSciences, and Current Research in Social Sciences. v
    • Table of ContentsPreface iiiAcknowledgement vIntroduction viiiChapter 1 1Happiness among Older Men in Jamaica: Is it a health issue?Chapter 2 33Happiness, life satisfaction and health status in a Caribbean nation: Using a cross-sectionalsurveyChapter 3 66A cross-sectional survey of the health status, life satisfaction and happiness of older men inJamaica - associations between questionnaire scoresChapter 4 89Good Health Status of Older and Oldest Elderly in Jamaica: Are there differences between ruraland urban areas?Chapter 5 118Decomposing Mortality Rates and Examining Health Status of the Elderly in JamaicaChapter 6 149An Epidemiological Transition of Health Conditions, and Health Status of the Old-Old-To-Oldest-Old in Jamaica: A comparative analysisChapter 7 179Health status of patients with self-reported chronic diseases in JamaicaChapter 8 205The changing faces of diabetes, hypertension and arthritis in a Caribbean population vi
    • Chapter 9 230Comparative Analysis of Health Status of men 60+ years and men 73+ years in Jamaica: Arethere differences across municipalities?Chapter 10 260Health in Older AdulthoodChapter 11 285Self-rated Wellbeing of Elderly JamaicansChapter 12 319Wellbeing in Older AdulthoodChapter 13 352Social Determinants of Subjective Wellbeing of Elderly in JamaicaChapter 14 393A conceptual framework of wellbeing in some Western nationsChapter 15 414The wellbeing discourse vii
    • Introduction Paul A. BourneHuman AgeingThe Caribbean has been identified as the most rapidly ageing region of the world. During the1960 -1995 period, there was a 76.8% increase in the elderly population (United Nations, 2005;Bourne, 2010). The mean growth rate in the elderly population was 5.3%, which was recordedfor the period 1995-2000. The Caribbean elderly as a percentage of total population has beenprojected to reach about 15% by 2020, an almost four-fold increase over the 1950 figure of 4.3%(United Nations, 2005; PAHO, 1997). Is this any different in Jamaica? Jamaica‟s elderly population (ages 60+ years) has increased significantly since the mid1960s (Eldemire, 1997; Bourne, 2010) indicating increased life expectancy. Life expectancy atbirth for males between 1879 and 1882 was 37.02 years and for females it was 39.80 years(Bourne, 2010; Statistical Institute of Jamaica, 2010). Between 2002 and 2004 males areexpected to live for 71.26 years and females 77.07 years (Appendix I), which is a clear indicationof demographic ageing of the Jamaican population. Statistics revealed that over 10% ofJamaicans were older than 60 years in 2009 (Bourne, 2010; Statistical Institute of Jamaica,2010). An examination of 5-year age cohorts of the elderly population in Jamaica revealed that85+ years is the fastest growing from the general elderly population (Figure 6.1). Thus, thesociety is experiencing an oldest-old population explosion never before seen in its history, andthis point to the gains made in public health measures, and improvements in the standard ofliving of the general populace since the 20th century. viii
    • Figure 6.1: Percentage change in elderly population by five year age groups, 1991-2001. Global Issues on Ageing Even though, the ageing process is lifelong and though this may be constructed withineach society differently, many decades have elapsed since Galton‟s study on the health status ofpeople. Despite changes in human development and the shifts in world population towarddemographic ageing – people living beyond 65 years (see ILO 2000; Wise 1997), the issues ofthe aged and their health status have not taken front stage on the radar of demographers unlikemany other demographic issues. This is equally true for many Caribbean nations. Demographershave spent years studying mortality, and this has been used as an indicator of life expectancysuch as the Coale and Demeny Model life tables and by extension health status. Life expectancy,on the other hand, has always been viewed as the avenue through which demographers evaluate ix
    • the health status of people; as lived years is an indicator of living beyond certain healthconditions. Thus, health and wellbeing are tied to mortality patterns, which is rightfully so butthis approach gives little emphasis on conditions that are likely to decrease morbidity andthereby reduce mortality. With this being the case, demographers have consumed more timeassessing mortality and life expectancy and morbidity because of their close approximation ofwellbeing (or health status), and this is similarly the case for Caribbean demographers. Caribbean Demographic TrendsDemographic development in the Caribbean has taken a similar path like the rest of the world(STATIN 2006; United Nations 2005c). Over the years, the movement as being such thatmortality and fertility has been declining, and the population 60 years and older has beenincreasing proportionately more than percentage who are children. Jamaica as well as the rest ofthe Caribbean and Latin America is said to be at the second stage of the demographic transitionmodel. (STATIN 2007). Several Caribbean countries such as Jamaica, Cuba, Barbados, Trinidadand Tobago could be said to be approaching the third stage of the transition. The demographictransition refers to the changes in population growth that is attributable to transition from high tolower levels of fertility and mortality. So for countries to be at the third stage of the transition,they would be experiencing population ageing due to persistently low fertility, even lowermortality. Like the rest of the world, these changes also brought improvement in livingconditions, advancement in medicine and improvement in health care and discovery and use offamily planning measures. Statistics revealed that the total fertility from 1970 to 1975 for the world was 4.49 andfrom 2000 to 2005, it fell to 2.65; whereas in Latin America and the Caribbean between 1970and 1975, it was 5.05 and this was further reduced to 2.55 from 2000 to 2005 (United Nations x
    • 2005c, xxi). As early as 2005, some countries in the Caribbean had reached replacement levelfertility. Total fertility per woman in the Bahamas reached is 2.2, Barbados 1.5, Jamaica 1.93(Demographic Statistics, 2006) and Trinidad and Tobago, 1.6 (United Nations 2006, 87-89).Barbados, Jamaican and the twin islands of Trinidad and Tobago are currently experiencingbelow replacement level fertility (Total Fertility Rate – TFR of 2.1 – United Nations 2000, 4).Since 2005, this has become a demographic reality for many developed nations. The exampleshere are some countries in Eastern Europe (TFR, 1.3) Southern Europe (TFR, 1.4) and NorthernEurope (TFR, 1.7) and the United States, 2.0 (United Nations 2007; 2005c, xxi). In addition,mortality in the Caribbean has been falling coupled with increased life expectancies that arecomparable with those in developed nations, beyond 71 years. (United Nations 2005c, xxii),which according to Rowland (2003, 18) are components within the demographic transitionmodel. Return migration also plays a significant role in the ageing of the Caribbean‟s population.Jamaica, like Trinidad and Tobago, and Barbados are experiencing the return of some of thosepeople who migrated in the 1950s-1960s, who are now elderly. In addition to return migration ofaged Jamaicans, the continuously high emigration of young people (Caribbean Food andNutrition Institute 1999) has further exasperated population ageing in the country. From the datareported in Table 1.14, at least 65 percent of the net migration is accounted for by ages less than30 years. Even though the negative net migration of Jamaicans has been reduced by more one-half since the last twenty years (1988-2006), the pattern of those who emigrate has remained thesame. This explains the return migration of elderly Jamaicans within the context of net outflowat the younger ages which is depletion of the human resources of the country. Although the netmigration outflow of migrants from Jamaica, for each year, has never surpassed 1 percent of the xi
    • total population for the year in question, the cumulated effect of this over a long period is equallyaiding in the explanation of the nation‟s ageing population. Therefore, many Caribbean countries began experiencing population ageing since asearly as in the 1950s and/or the 1960s. In 1950, 8.5 percent of Barbados‟ population was 60years and older; Suriname, 8.4, which was higher than 6.9 percent for the Caribbean and 8.2percent for world. Jamaica‟s population ageing, on the other hand, did not begin until the 1960s.Using the growth rate of the population for different age groups as an indicator of ageingpopulation, Jamaica‟s population 65 years and over doubled from 1960-1970 and 1943-1960,which only occurred in this age group. However, in the Caribbean, the matter has recently begunto be of concern (Caribbean Food and Nutrition Institute 1999, 192, 217). The reason for thisthrust is because the rate of increase of this age cohort compared to the other age cohort. By2050, the population of people 60 years and older in some Caribbean nations will more thandouble, while the young population (ages 0 to 14 years) would have been reduced by one-half. Some developing states such as Barbados, and Trinidad and Tobago, and Jamaica arecurrently experiencing a shift toward a population age. In 2007, all three Caribbean nations hadin excess of 10 percentages of their population ages 60 years and older. Barbados, on the otherhand, has the largest percentage of person ≥ 60 years (13.2%). The issue of the ageing of apopulation cannot be simply overlooked and has far reaching implication for labour supply,pension system, health care facilities, products demanded, mortality, morbidity, and publicexpenditure among other events. Ageing is not simply about mortality, fertility and/ormorbidity. The phenomenon is about people, their environment and how they must coexist inorder to survive. Ageing, therefore, is here to stay. In order to grasp the complexities of this xii
    • phenomenon, Lawson‟s monograph adequately provides a summative position on the matter.She noted that: Actually, it is predicted (U.N) that developing countries are likely to have an oldergeneration crisis about the year 2030, that is about the same time as most developed countries(Lawson 1996, 1). This demographic transition is not only promulgated by Lawson, but was argued byCowgill (1983) who believed that during the next half-century (2050), there is strong possibilitythat this transition will be an issue for some developing nations. This implies that populationageing which has been the experience of many developed nations (Gavrilov and Heuveline 2003;Marcoux 2001; Lawson 1996) will be a reality for some lesser developed countries and moredeveloping regions in the future. Seniors cannot be neglected as they will constitute an increasingly larger percentage oftotal population and sub-populations in different regions than in previous centuries (UN 2005;WHO 2005; Chou 2005; STATIN 2004; Apt 1999; Caribbean Food and Nutrition Institute1999a; Randal and German 1999; US Census Bureau 1998; Eldemire 1995, 1994; EuropeanFoundation for the Improvement of Living and Working Conditions 1993; Mesfin et al. 1987;Grell, 1987; National Health and Welfare 1982). According to Randal and German (1999), thenumber of aged persons living in developing countries will more than double by 2025, „reaching850 million‟. The Caribbean is not different as according to Grell (1987), the English-speakingCaribbean from the 1970 census revealed that between 8.8 and 9.8 percent of the populace were60 years and older. A matter Lawson noted began in Jamaica since the 1900s (Lawson 1996, 1-37). To be more specific population ageing in Jamaica, began in the 1960s. xiii
    • Demographic Trends: JamaicaIn 2007, the annual growth rate for the Jamaican population since 1996 has always been less than1.0%, and the figure for 2006 is estimated to be 0.5% (Demographic Statistics 2006) which islower than the global average of 1.2 percent (CIA 2007). With regard to globe‟s population,10.4% of individuals are 60 years or older (United Nations 2005c). Jamaica‟s elderly populationin 2005 rose marginally by 0.3% to 10.7% in 2006 (PIOJ 2007). The United Nations data showthat 8% of people in the developing nations are 60 years or over (United Nations 2005c), whichis approximately 2% less than the number of aged people in Jamaica. According to theDemographic Statistics (2006), 10.9% of Jamaicans females are 60 years and older compared to10.3% of males. Eldemire notes that the increased aged populace in Jamaica began in the 1960‟s(Eldemire 1995). Despite the indecisiveness to reach consensus on a definition of ageing from the UnitedNations‟ perspective on the elderly, „old age‟ begins at 60 years while other scholarsconceptualize ageing to commence at age 65 years or older (See for example Lauderdale 2001;Elo 2001; Manton and Land 2000; Preston et al. 1996; Smith and Kington 1997a; Smith andWaitzman 1994; Rudkin 1993). The WHO says that we can either use the chronological age of60 or 65 years or over to indicate the beginning of ageing (WHO 2002, 125). So why is there nostandardized definition for the elderly or where ageing begins? Thane (2000) noted that „old age‟for all people was defined as 60 years in medieval times. She justified this by forwarding anargument for the established age. In medieval England, men and women ceased at 60 years to beliable for compulsory service under labour laws or to participate in military duties. AncientRome, on the other hand, „old age‟ began from early 40 to 70 years, with 60 years being „somesort of annus climactorius’. Some Demographers see seniors - the elderly or the aged (old xiv
    • people) - as beginning at chronological age of 65 years and older, and not an individual who is60 years of age. Up to 1992, the Statistical Institute of Jamaica defined old-age as those people65 years and older (Demographic Statistics 1992). At that time Professor of demographer at theUniversity of the West Indies at Mona was primarily responsible for the many of the output ofthat Institution, and the training of staff. This may explain why the Statistical Institute ofJamaica used 65 years in its conceptualization of old-age. Furthermore, Western societies use 65years and older to represent the elderly (seniors) as this is the period when people become fullyeligible for Social Security benefits. One Caribbean scholar emphasized that there is no absoluteness in the operationaldefinition of the “elderly” (Eldemire 1995, 1). She commented that from the World Assembly ofAgeing (which was held in Vienna in 1982), the “elderly” is using the chronological age of 60years and older „as the beginning of the ageing process‟. Jamaica having signed the ViennaDeclaration of Ageing, which defines ageing to begin at 60 years, Eldermire questionedacademics and other scholars for their rationale in using 65 years. This paper seeks to evaluatethe wellbeing of the age and not those who are eligible for Social Security benefits. Hence, forthis study „old age‟ or the elderly (seniors) will begin from the chronological age of 60 years andolder. From the JSLC reports published by the PIOJ and STATIN, which is primarily focusedon the traditional construct of health using the biomedical model, the researcher is forwarding aposition that if we were to more effectively capture the wellbeing status of Jamaicans, we mustoperationally expand the definition of health in such a manner that it encompassesbiopsychosocial factors such as – (i) biological; (ii) psychological; (iii) social; (iv) economic, and(v) environmental conditions, as this vulnerable group may even be worse off than reported, xv
    • given the definition chosen to measure health status. There is no published works on the generalwellbeing of the Jamaican elderly in which the researchers have sought to capture a quality oflife index which encompasses biological, sociological, psychological and environmentalconditions. It is within this general framework, that this study of the elderly is timely as it seeksto expand an assessment of the subjective wellbeing of aged Jamaicans from the perspective ofmore comprehensive model. The rationale that explains the use of 65+ to represent elderly is solely due to thestatistical data that are available prior to 1991. Before 1991, the Statistical of Jamaica‟soperational definition for the elderly was 65 years and older. Hence, their publication between1844 and 1991 did not produce years for 60+. However, post 1992; the organization beganproviding data for both ages. As such, the researcher used 65+ because he wanted to examinefigure from 1844 to 2006. However, in the Caribbean, the matter has recently begun to be of concern (CaribbeanFood and Nutrition Institute 1999, 192, 217). The reason for this thrust is because the rate ofincrease of this age cohort compared to the other age cohort. By 2050, the population of people60 years and older in some Caribbean nations will more than double, while the young population(ages 0 to 14 years) would have been reduced by one-half. Some developing states such as Barbados, and Trinidad and Tobago, and Jamaica arecurrently experiencing a shift toward a population age. In 2007, all three Caribbean nations hadin excess of 10 percentage of their population ages 60 years and older. Barbados, on the otherhand, has the largest percentage of person ≥ 60 years (13.2%). xvi
    • Life expectancy Does the increase in life expectancy means a better quality of life or subjective wellbeingof elderly Jamaicans? A study by Powell, Bourne and Waller (2007) found that the psychosocialwellbeing of Jamaicans was moderately high (mean score = 6.8 out of 10), and offers anexplanation for the quality of life of its people. Furthermore, they found that the subjectivewellbeing of those in the lower subjective social class had a minimal score (mean score = 5.8 outof 10) compared with those in the upper class (mean score = 6.5 out of 10) and those in themiddle class (mean score = 6.8 out of 10) (Powell, Bourne and Waller 2007). They continuedthat Jamaicans (69%) indicated that their current economic situation was at most average, with19% reporting that it was bad. Nothing was mentioned about the elderly‟s population quality oflife, but can we assume that a two-fold increase in life expectancy over 1880-1882 means betterquality of life? Using the antithesis of illness to measure health (not reporting an illness), many studieshave examined health of the Jamaican elderly population (Bourne, 2008a; 2008b; Bourne, 2009a;Bourne, 2010) and another decomposed the mortality rate of the aged population (Bourne,McGrowder and Crawford, 2009). The use of illness to evaluate health is both narrow andnegative in scope (Bourne, 2009b; Longest, 2002; Brannon & Feist, 2007), which is thejustification of the World Health Organization‟s (WHO) broadened conceptualization of healthto more than the absence of illness to social, physical and psychological wellbeing (WHO,1948). Within the broadened conceptualization of health forwarded by the WHO in the preambleto its Constitution in 1946, the use of illness or antithesis of illness is emphasizes the absence ofsome disease causing pathogens, and not really health (Bourne, 2009b). Thus there is the need toexpand the measurement of health from illness or the antithesis of illness to evaluate a broader xvii
    • definition of health and/or wellbeing, particularly among the elderly population because of thecomposition of this cohort and the importance of understanding their wellbeing for the purposeof planning. This study investigates health, happiness and satisfaction with life for older men in amiddle-income developing country, Jamaica. Happiness, life satisfaction, and health status areamong some of the subjective indexes used to evaluate health (or wellbeing) of an individual,community or population. Happiness is well established in the scientific literature as a goodpredictor of subjective wellbeing and/or overall life with satisfaction as it covers a number ofpositive psychological conditions such as marriage, a job, success in life, adaptation to lifeevents, and negative affective conditions such as the lost of life or property, failed examinations,and dissolution of union deteriorate both health and further deepen the negative impact on lifeand by extension happiness (Diener, 1984; 2000; Easterlin, 2001a; 2001b; 2003; 2004; Stutzer &Frey, 2003; Frey & Stutzer, 2000; 2002; Ng, 1996; 1997). Subjective indexes cover a wider gamut of an individual‟s life compared to diagnosedhealth conditions, morbidity, reproductive health and life expectancy. Yet, the planning andstatistical agencies in Jamaica have been collecting national living conditions data includinghealth conditions since 1989 (Planning Institute of Jamaica (PIOJ) and Statistical Institute ofJamaica (STATIN), 1989-2008), and health condition has been used to measure the health of thepopulation, gender of the participants and health within areas of residence. For the first time in2007 both agencies added health status to health conditions in the yearly national cross-sectionalsurvey that is used to evaluate the population‟s living conditions. Happiness therefore, like lifesatisfaction and health status, provides a better idea of people‟s quality of life than does illhealth. The use of objective indexes such as diagnosed illness, gross domestic product, life xviii
    • expectancy and mortality are among measures that are said to be limited in scope and justify theuse of subjective indexes by some scholars (Diener, 1984; 2000; Easterlin, 2001a; 2001b; Stutzerand Frey, 2003; Frey and Stutzer, 2000; Ng, 1996; 1997; Oswald, 1997). Despite theaforementioned rationale on happiness, no national study has been conducted in Jamaica onhappiness, life satisfaction and health status, particularly on older men. Initially, when happiness was put forward by Diener (1984) as a measure of wellbeing, itwas rigorously opposed by some scholars as subjective who said it could not be used to measurehealth or wellbeing. Many traditional economists believed that happiness was subjective and thatthis could not be precisely measured, and this accounted for their reservations about accepting it.They believed that Gross Domestic Product per capita (GDP per capita) or income per capita wasan objective measure and that could in fact be precisely quantified. Unlike traditionaleconomists, Diener (1984; 2000), a psychologist, theorized that happiness could in fact be usedto measure subjective wellbeing and this was later adopted by economists (Oswald, 1997; Ng,1996; 1997; Blanchflower and Oswald, 2004; Veenhoven, 1991; 1993; Easterlin, 2001a; 2001b;Stutzer and Frey, 2003; Frey and Stutzer, 2000; DiTella, et al., 2003). Easterlin (2001a, 2001b, 2003, 2004) found a statistical association between happinessand income. He argued that, “The relationship between happiness and income is puzzling”,(Easterlin, 2001a: 465) and that people with higher incomes were happier than those with lowerincomes, but that economic growth does not mean happiness. Easterlin used happiness tomeasure subjective wellbeing, which was found to be highly correlated with income. He wentfurther when he said that, “Those with higher income will then be better able to fulfill theiraspirations and, other things equal, will, on average, feel better off…This is the point-of-timepositive association between happiness and income”(Easterlin 2001a:472). Like Easterlin, all xix
    • the aforementioned economists used happiness to evaluate subjective wellbeing as they acceptedthat happiness is an indicator of people‟s judgement of their overall quality of life (Veehnoven,1991; 1993). Randomly selecting Europeans and Americans from the 1970s to 1990s, Di Tella etal. (2003) did not find this complex relation between income and happiness. They however notedthat some variables such as unemployment, unemployment benefits and others are exogenousvariables as they are influenced by political decisions and do influence income. Diener (2000) argued that wellbeing can be explained outside of welfare theory or apurely objective utility approach, and this was supported by other scholars (Liang, 1984; Dieneret al., 1999; Diener and Suh, 1997; Cummins, 1997). Arthaud-day et al.‟s (2005) work appliedstructural modeling and found that subjective wellbeing comprised of (1) cognitive evaluationsof ones life (i.e., life satisfaction or happiness); (2) positive affect; and (3) negative affectiveconditions. Unlike Arthaud-day et al., Diener (2000) proposed that subjective wellbeing can beoperationalized by some basic indicators such as emotional components („Taking all thingstogether, how happy would you say you are?‟) and cognitive components or life satisfaction(„All things considered, how satisfied are you with your life as a whole nowadays?‟). Summers & Heston noted that, “…GDPPOP is an inadequate measure of countriesimmediate material well-being, even apart from the general practical and conceptual problems ofmeasuring countries national outputs” (Summer & Heston, 1995:2) From that perspective, themeasurement of quality of life is highly economic and excludes psychosocial factors as theemphasis is on objective indexes of wellbeing (Gaspart, 1998) and not in keeping with thebreadth of wellbeing offered by the World Health Organization in the preamble to itsConstitution (WHO, 1948). Thus, quality of life (wellbeing) extends beyond financial resources(money), although they improve wellbeing or the „human lot.‟(Easterlin, 1974; 1995; Marmot, xx
    • 2002). Using data for developing countries, Camfield noted that subjective wellbeing constitutesthe existence of positive emotions and the absence of negative ones within a space of generalsatisfaction with life. Cummins (1997) argued that subjective and objective indexes of materialwell-being along with the absence of illnesses, efficiency, social closeness, security, place incommunity, and emotional wellbeing means that life‟s satisfaction comprehensively envelopessubjective wellbeing. Diener (2000) in an article titled „Subjective Well-Being: The Science ofHappiness and a Proposal for a National Index‟ theorized that the objectification of wellbeing isembodied within satisfaction of life. This explains the rationale for the use of life satisfactionand/or happiness to operationalize wellbeing instead of GDP per capita (or income per capita). Extensive review of the literature turned up just one study in Jamaica that examined lifesatisfaction (Hutchinson, et al., 2004). In this study, the scholars found that women had a loweroverall life satisfaction (72%) than men (76%). Employment status, education, gender, unionstatus, church attendance, self-esteem, and current health status were determinants of lifesatisfaction. In Di Tella et al.‟s work, they found income, employment status, interpersonal trust,health status, marital status, education, sex and inflation, the rate of change of consumer prices inthe country, unemployment benefits, and the number of children in households was predictors ofhappiness. In descending order, they found that marital status, income and employment statushad the greatest influence on happiness. Although there is very little or research study in the English speaking Caribbean onhappiness of the general populace or on the elderly population, Stutzer & Frey (2003) hasidentified a few predictors of happiness: income; aspiration; and unemployment. Konow &Earley‟s study (1999) revealed that employment status, positive and negative affective xxi
    • conditions, social support and marital status were correlated with happiness. Some of these (i.e.,employment status, marital status, living arrangement, age, education, gender) were alsorecorded as being statistical associated with happiness in Blanchflower & Oswald‟s study.ReferencesArthaud-day ML, Rode JC, Mooney CH, Near JP. The Subjective Well-being Construct: A Testof its Convergent, Discriminant, and Factorial Validity. Social Indicators Research, 2005;74(3):445-476.Blanchflower DG, Oswald AJ. Well-Being Over Time In Britain And The USA. Journal ofPublic Economics, 2004, 88(7-8,Jul):1359-1386.Bourne PA. Health Determinants: Using Secondary Data to Model Predictors of Well-being ofJamaicans. West Indian Medical J. 2008a; 57(5):476-481. [Pub Med]Bourne PA. Medical Sociology: Modelling Well-being for elderly People in Jamaica. WestIndian Medical Journal 2008b; 57(6):596-604. [Pub Med]Bourne PA. Good Health Status of Older and Oldest Elderly in Jamaica: Are there differencesbetween rural and urban areas? Open Geriatric Medicine Journal. 2009a; 2:18-27.Bourne PA. (2009b). Social determinants of health in Jamaica: Are there differences between thesexes and are of residence? HealthMED Journal 3(4):359-373. [2009 Impact factor = 0.125].Bourne PA. 2010. Population Ageing and the State of the Elderly, with emphasis on Jamaica.Caribbean Quarterly 56(2).Bourne PA, McGrowder DA, & Crawford TV. (2009). Decomposing Mortality Rates andExamining Health Status of the Elderly in Jamaica. The Open Geriatric Medicine Journal 2:34-44.Brannon L, Feist J. Health psychology. An introduction to behavior and health, 6th ed. LosAngeles: Wadsworth; 2007.Camfield L. Using subjective measures of wellbeing in developing countries. Glasgow,Scotland: University of Strathclyde; 2003.Centre of Health Service Development, Faculty of Health and Behavioural Sciences Universityof Wollongong; Towards a National Measure of Functional Dependency for Home Care Servicesin Australia: Stage 1 report of the HACC dependency data items project 2000 updated 2001. xxii
    • Clark AE, Frijters P, Shields MA. Income and happiness: evidence, explanations and economicimplication. Working paper No. 5. National Center for Econometric Research; 2006.Cohen L, Holliday M. Statistics for Social Sciences. London, England: Harper and Row, 1982.Cummins R. Self-rated quality of life scales for people with an intellectual disability: a review.Journal of Applied Research in Intellectual Disabilities 1997; 10:199–216.Di Tella R, MacCulloch RJ, Oswald AJ. The macroeconomics of happiness. Review ofEconomics and Statistics 2003;85:809-827.Diener E, Larson RJ, Levine S, Emmons RA. Intensity and frequency: Dimensions underlyingpositive and negative affect. Journal of Personality and Social Psychology, 1985; 48:1253-1265.Diener E, Oishi S, Lucas RE. Personality, culture and subjective wellbeing: Emotional andcognitive evaluations of life. Annual Review of Psychology 2003; 54:403-425.Diener E, Suh E. Measuring quality of life: Economic, social subjective indicators. SocialIndicators Research1997; 40:189-216.Diener E, Suh M, Lucas E, Smith H. Subjective well-being: Three decades of progress.Psychological Bulletin 1999; 125:276-302.Diener E. Subjective well-being. Psychological Bulletin 1984; 95: 542–75.Diener E. Subjective well-being: the science of happiness and a proposal for a national index.Am Psychologist 2000; 55: 34–43.Easterlin RA. Building a better theory of well-being. Prepared for presentation at the ConferenceParadoxes of Happiness in Economics, University of Milano-Bicocca, March 21-23, 2003.Easterlin RA. Does Economic Growth Improve the Human Lot? Some Empirical Evidence inNations and Households in Economic Growth: Essays in Honour of Moses Abramowitz, EdDavid PA, Reder MW, Academic Press, New York and London; 1974.Easterlin RA. How Beneficent Is the Market? A Look at the Modern History of Mortality, theReluctant Economist. Cambridge: Cambridge University Press 2004; 101-38.Easterlin RA. Income and happiness: Towards a unified theory. The Economic Journal 2001;111:465-484. (2001a)Easterlin RA. Life Cycle Welfare: Evidence and Conjecture. Journal of Socio-Economics 2001;30:31-61.Easterlin RA. Will Raising the Incomes of All Increase the Happiness of All? Journal ofEconomic Behavior and Organization1995; 27:35-47. xxiii
    • Easterlin, R. (1996). Growth Triumphant: The Twenty-first Century in Historical Perspective,Ann Arbor, MI: University of Michigan Press.Eldemire D. The Elderly and the Family: The Jamaican Experience. Bulletin of EasternCaribbean Affairs, 1994; 19:31-46.Eldemire, D. 1997. The Jamaican elderly: A socioeconomic perspective and policyimplications. Social and Economic Studies, 46: 175-193.Frey BS, Stutzer A. Happiness and Economics. Princeton University Press; 2002.Frey BS, Stutzer A. Happiness, Economy and Institutions. Economic Journal 2000; 110:918-938.Gardner JW, Lyon JL. Cancer in Utah Mormon men by lay priesthood level. American Journalof Epidemiology 1982; 116:243-257.Gaspart F. Objective measures of well-being and the cooperation production problem. SocialChoice and Welfare 1998; 15 (1):95-112.Graham TW, Kaplan BH, Cornoni-Huntley JC, James SA, Becker C, Hames CG, Heyden S.Frequency of church attendance and blood pressure elevation. Journal of Behavioral Medicine1978; 1:37-43.Hutchinson G, Simeon DT, Bain BC, Wyatt GE, Tucker MB, LeFranc E. Social and Healthdeterminants of well-being and life satisfaction in Jamaica. International Journal of SocialPsychiatry 2004; 50(1):43-53.Jackson M, Walker S, Forrester T, Cruickshank J, Wilks R. Social and dietary determinants ofbody mass index in Jamaican of African. European Journal of Clinical Nutrition 2003; 57:621-627.Kahneman, D. & Riis, J. (2005). Living, and thinking about it, two perspectives, inHuppert, F.A., Kaverne, B. and N. Baylis, The Science of Well-being, Oxford UniversityPress.Kart CS. The Realities of Aging: An introduction to gerontology, 3rd. Boston, United States:Allyn and Bacon; 1990.Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffe MW. Studies of illness in the ages. Theindex of ADL: standardized measure of biological and psychosocial function. JAMA, 1993; 185(12):914-919. xxiv
    • Katz, D.L., Brunner, R.L., St. Jeor, S.T. et al. Dietary fat consumption in a cohort of Americanadults, 1985-1991: covariates, secular trends, and compliance with guidelines, American Journalof Health Promotion, 1998; 12 382- 390.Katz, S., Down, T.D., Cash, H.R., & Grotz, R.C. Progress in the development of the index ofADL. The Gerontologist, 1970;10(1), 20-30.Kidd S and Whitehouse E, „Pensions and old age poverty‟, in Closing the coverage gap, 2009,pp.41-56.Kimball M, Willis R. Utility and happiness; 2005. Available at:www.stanford.edu/group/SITE/papers2005/Kimball.05.doc. Accessed on: August 31, 2006.Konow J, Earley J. The Hedonistic Paradox: Is Homo-Economicus Happier? Mimeo, LoyolaMarymount University, Dept. of Psychology; 1999.Kurlowicz L, Wallace C. The Mini Mental State Examination (MMSE) Number 3, Series.Hartford Institute of Geriatric Medicine; 1999Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental activitiesof daily living. Gerontologist. 1969; 9(3):179-86.Leung BW, Moneta G, McBride-Chang C. Think positively and feel positively: Optimism andlife satisfaction in late life. International Journal of Aging and human development 2005;61:335-365.Liang J. Dimensions of the Life Satisfaction Index A: A structural formulation. Journal ofGerontology, 1984; 39:613-622.Longest BB, Jr. Health Policymaking in the United States, 3rd. Chicago, Illinois: Foundation ofthe American College Healthcare; 2002.Lyubomirsky S, King L, Diener E. The benefits of frequent positive affect: Does happiness leadto success? Psychological Bulletin 2005; 6, 803-855.Lyubomirsky S. Why are some people happier than others? The role of cognitive andmotivational process in wellbeing. American Psychologist 2001; 56:239-249.Marmot M. The influence of Income on Health: Views of an Epidemiologist. Does money reallymatter? Or is it a marker for something else? Health Affairs. 2002; 21: 31-46.Moody HR. Is religion good for your health? Gerontologist 2006:147-149.Ng YK. A Case for Happiness, Cardinalism and Interpersonal Comparability. Economic Journal1997; 107:1848-1858. xxv
    • Ng YK. Happiness Surveys: Some Comparability Issues and an Exploratory Survey Based onJust Perceivable Increments. Social Indicators Research 1996; 38:1-27.Oswald AJ. Happiness and Economic Performance. Economic Journal 1997; 107:1815-1831.Palmore, E. 1981. Social patterns in normal aging: Findings from the Duke longitudinal study.Durham: Duke University Press.PAHO (Pan-American Health Organization). (1997). Health Conditions in the Caribbean.Scientific Publication No. 561; Washington DC: PAHO;Pavot W, Diener E. Review of the Satisfaction with Life Scales. Psychological Assessment 1993;5:164-172.Planning Institute of Jamaica (PIOJ). Economic and Social Survey Jamaica 1980-2008.Kingston: PIOJ; 1981-2009.Planning Institute of Jamaica, (PIOJ), Statistical Institute of Jamaica (STATIN). Jamaica Surveyof Living Conditions, 1989-2007. Kingston: PIOJ, STATIN; 1990-2008.Powell, L.A., Bourne, P., Waller, L. Probing Jamaica‟s Political Culture, vol. 1: MainTrends in the July-August 2006 Leadership and Governance Survey. Kingston: Centre ofLeadership and Governance, Department of Government, University of the West Indies,Mona; 2007.Schimmel J. Development as happiness: The subjective perception of happiness and UNDP‟sanalysis of poverty, wealth and development. Journal of Happiness Studies 2009; 10:93-111.Sheldon K, Lyubomirsky S. How to increase and sustain positive emotion: The effects ofexpressing gratitude and visualizing best possible selves. Journal of Positive Psychology 2006;1:73-82.Statistical Institute of Jamaica (STATIN). 1977-2010. Demographic statistics, 1976-2009.Kingston: STATIN.Statistical Institute of Jamaica. Population Census 2001 (Volume 8): Marital and Union Status.Kingston, Jamaica: Statistical Institute of Jamaica; 2004.Stutzer A, Frey BS. 2003. Reported subjective well-being: A challenge for economic theory andeconomic policy. Working paper No. 07. Center for Research in Economics, Management andthe Arts; 2003Subramanian SV, Kin D, Kawachi I. Covariation in the socioeconomic determinants ofhappiness: A multivariate multilevel analysis of individuals and communities in the USA.Journal of Epidemiology and Community health 2005; 59:664-669. xxvi
    • Summers R, Heston A. (1995). Standard of Living: SLPOP An Alternative Measure of NationsCurrent Material Well-Being. CICUP 96-2, A. Available at:http://pwt.econ.upenn.edu/papers/standard_of_living.pdf. Accessed on: November, 2010.United Nations (UN). 2005. World population prospect: The 2004 revision. Department ofEconomic and Social Affairs, Population Division. New York: UN.United Nations Development Programme. Human Development Report, 1997. New York,United States: UNDP; 1997.Veenhoven R. Happiness in Nations: Subjective Appreciation of Life in 56 Nations, 1946-1992.Erasmus University Press, Rotterdam; 1993.Veenhoven R. Healthy happiness: Effects of happiness on physical health and the consequencesof preventive health care. Journal of Happiness Studies 2008; 9:449-469.Veenhoven R. Is Happiness Relative. Social Indicators Research 1991; 24:1-34.Warnes, A. M, ed. 1982. Geographical perspectives on the elderly. New York: John Wiley and Sons.Watson D, Clark LA. Self Versus Peer Ratings of Specific Emotional Traits: Evidence ofConvergent and Discriminant Validity. Journal of Personality and Social Psychology 1991;60:927-940.World Health Organization (WHO). Preamble to the Constitution of the World HealthOrganization 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 HealthOrganization, no. 2, p. 100) and entered into force on April 7, 1948. “Constitution of the WorldHealth Organization, 1948.” In Basic Documents, 15th ed. Geneva, Switzerland: WHO, 1948.WHO. World report on violence and health. Geneva, Switzerland: WHO; 2002.Wilks R. Hypertension in the Jamaican Population. A presentation to the Trinidad & TobagoNational Consultation on Chronic Non-Communicable Diseases, September 2007.Wills E. Spirituality and subjective wellbeing: Evidence for a new domain in the personalwellbeing index. Journal of Happiness Studies 2009; 10: 49-69.Winkelmann L, Winkelmann R. Why are the unemployed so unhappy? Evidence from paneldata. Economics 1998; 65:1-15.Wooden M, Headey B. The effects of wealth and income on subjective well-being and ill-being.Australia: Melbourne Institute of Applied Economic and Social Research; 2004. xxvii
    • Happiness in OlderAdulthoodWellbeing, Health & life satisfaction xxviii
    • Chapter 1Happiness among Older Men in Jamaica: Is it a health issue? Paul Andrew Bourne, Chloe Morris & Denise Eldemire-ShearerThis paper seeks to expand the literature by investigating the effect of health status on happiness,happiness on health status, life satisfaction on happiness as well as some demographic variablesin order test the existing knowledge on elderly men (ages 60 years and older) in Jamaica. Astratified random sample of 2,000 elderly men in Jamaica was used to carry out this paper. Thedata were collected with a 137-item self-administered questionnaire, and entered, retrieved andstored in SPSS for Windows 16.0 (SPSS Inc; Chicago IL, USA). Happiness was found not to becorrelated with health status of elderly men in Jamaica nor was health status associated withhappiness; and that there was no difference based on area of residence. Happiness and healthstatus cannot be used to proxy each other for the elderly cohort as they are independent events.IntroductionHappiness is well established in scientific publications as a good predictor of subjectivewellbeing and/or overall life satisfaction (Graham, 2008; Selim, 2008; Borghesi, & Vercelli,2007; Mahon et al., 2005; Layard, 2006; Seligman & Csikszentmihalyi, 2000; Diener, Lucas, &Oishi, 2002; Diener, 1984, 2000; Easterlin, 2001; Veenhoven, 1993). A group of scholars foundthat the statistical association between happiness and subjective wellbeing was a strong one -correlation coefficient r = 0.85 in the 18 OECD countries – (Kahneman, & Riis, 2005), whichemphasizes the importance that people place on happiness in assessing their subjectivewellbeing. Happiness which is an area in positive psychology (Seligman & Csikszentmihalyi, 1
    • 2000; Huppert, 2006; Brannon & Feist, 2007) goes beyond the mere positive state of anindividual to physical health and social life, and economic state to life in general (Borghesi, &Vercelli, 2007; Lima & Nova, 2004; Stutzer & Frey, 2003; Easterlin 2003; Frey & Stutzer,2002a, 2002b; Brickman, Coates, & Janoff-Bulman, 1978). Happiness is as a result of a number of positive psychological factors such as marriage, ajob, success in life, adaptation to life events, and negative affective conditions such as the lost oflife or property, failed examinations, and dissolution of union deteriorate both health and furtherdeepen the negative impact on life and by extension happiness (Borghesi & Vercelli, 2007;Easterlin, 2003; Kahneman, & Riis, 2005). In seeking to unearth ‗why some people are happier‘,Lyubomirsky (2001) approached it from the perspective of positive psychology. She noted that,to comprehend disparity in self-reported happiness between individuals, ―one must understandthe cognitive and motivational process that serve to maintain, and even enhance happiness andtransient mood‖ (Lyubomirsky, 2001, 239) Lyubomirsky identified ‗comfortable income‘,‗robust health‘, supportive marriage‘, and ‗lack of tragedy‘ or ‗trauma‘ in the lives of people asfactors that distinguish happy from unhappy people (see also, Borghesi & Vercelli, 2007;Kahneman, & Riis, 2005; Frey & Stutzer, 2002a, 2002b; Easterlin, 2003). Those findings onlyconcurred with an earlier work by Diener, Suh, Lucas, & Smith (1999). Diener, Horwitz &Emmon (1985) were able to add value to the discourse when they showed that income affectssubjective wellbeing. Frey & Stutzer (2002a) provided more information on the aforementioneddiscourse, when he opined that absolute income does not seem to have a strong influence onhappiness or health (or subjective wellbeing). Researchers found that the wealthy (those earningin excess of US 10-million, annually) had a marginally greater self-reported wellbeing (personal 2
    • happiness) than that of those who were lower wealthy (earned less than 10 million US annually)(Diener, Horwitz & Emmon, 1985). People‘s cognitive responses to ordinary and extraordinary situational events in life areassociated with subjective wellbeing (Chida & Steptoe, 2008; Steptoe et al., 2008; Pressman &Cohen, 2005; Lyubomirsky, 2001; Sheldon & Lyubomirsky 2006). It is found that happierpeople are more optimistic and as such conceptualize life‘s experiences in a positive manner.Studies revealed that positive moods and emotions are associated with wellbeing (Fowler &Christakis, 2008; Leung, Moneta, & McBride-Chang, 2005) as the individual is able to think,feel and act in ways that foster resource building and involvement with particular goalmaterialization (Lyubomirsky, King, & Diener, 2005). This situation is later internalized,causing the individual to be self-confident from which follows a series of positive attitudes thatguide further actions (Sheldon & Lyubomirsky, 2006). Positive mood is not limited to activeresponses by individual, but a study showed that ‗counting one‘s blessings‘, ‗committing acts ofkindness‘, recognizing and using signature strengths, ‗remembering oneself at one‘s best‘, and‗working on personal goals‘ all positively influence wellbeing (Sheldon & Lyubomirsky, 2006;Abbe, Tkach, & Lyubomirsky, 2003). Recently conducted meta-analysis longitudinal studiesrevealed that happiness and other positive moods are not only positively correlated with healthstatus; but that they are negatively associated with mortality Chida Y, Steptoe A. (2008),suggesting the value of happiness to life. Happiness is not a mood that does not change with timeor situation; hence, happy people can experience negative moods (Diener & Seligman, 2002);and happiness is a good proxy for assessing subjective wellbeing. 3
    • Human emotions are the coalesced of not only positive conditions but also negativefactors (Watson et al. 1999). Hence, depression, anxiety, neuroticism and pessimism are seen asa measure of the negative psychological conditions that affect subjective wellbeing (Evans et al.2005; Harris & Lightsey, 2005; Kashdan 2004). From Evans and colleague, Harris & Lightseyand Kashdon‘s monographs, negative psychological conditions affect subjective wellbeing in anegative manner (i.e. guilt, fear, anger, disgust); and positive factors influence self-reportedwellbeing in a direct way– this was concurred in a study conducted by Fromson (2006); and byother scholars (McCullough et al. 2001; Watson and Clark et al 1988a, 1988b). Acton & Zodda(2005) aptly summarized the negative affect of subjective wellbeing in the sentence that says―expressed emotion is detrimental to the patients recovery; it has a high correlation with relapseto many psychiatric disorders.‖ Previously mentioned studies using happiness to examine wellbeing were on populationand not on elderly cohorts (ages 60 years and older). McConville et al. (2005) in ‗Positive andnegative mood in the elderly: the Zenith study‘ established that different moods of people affectboth their physical as well as their mental well-being. They argued, ―Poor quality moods wereassociated with deficits in diverse areas of cognitive function, health, and social relationship‖(McConville et al., 2005). The Zenith study was to examine the quality of positive and negativeattitudes on health status. The population was 387 individuals from three European countries(France, Italy and Ireland). Another study on the elderly population found that biologicalchanges of humans do affect their psychological state, and that psychological and psychosocialchanges influence biological functioning (or physical health) (Kart, 1990) Well-being for some scholars, therefore, is a state of happiness (ie positive feeling status 4
    • and life satisfaction) (Diener, 1984; Easterlin, 2003; Diener, Larson, Levine & Emmon, 1999).Simply put, well-being is subjectively what is ‗good‘ for each person (Crisp 2005). It issometimes connected with good health. Crisp offered an explanation for this, when he said that―When discussing the notion of what makes life good for the individual living that life, it ispreferable to use the term ‗well-being‘ instead of ‗happiness‘ (Crisp, 2005). O‘Donnell and Tait(2003) believed that health is a primary indicator of well-being; and so provide an understandingof the correlation between health, subjective wellbeing, happiness, and life‘s satisfaction(O‘Donnell & Tait, 2003; Ringen, 1995). From the scientific literature, self-rated health status ishighly reliable to proxy for health which ‗successfully crosses cultural lines‘ (Ringen 1995).O‘Donnell and Tait concluded from their study that self-reported health status can be used toindicate wellbeing as all respondents who had chronic diseases reported very poor health. From the literature, happiness and health status, happiness and wellbeing, and happinessand life satisfaction are associated. Using the scientific findings on the aforementioned issue, anextensive review of the literature found no study that has every examined happiness and healthstatus of elderly men in Jamaica, which is the rationale for this paper. Given that happinesscovers life satisfaction and health, an examination of happiness and health status of elderly menin Jamaica will provide invaluable information as to the state of this group. An extensive review of the literature revealed that there has never been a study done inthe Caribbean, in particularly Jamaica on happiness of this vital cohort, so this is a criticalrationale for the study as it will provide insight in this cohort along with an understanding of howthey perceive things and life which can guide public policy. Another rationale is happiness, apredictor of health status which would allow for the collection of data on whether or not they are 5
    • good predictors of each other. This paper examined whether (1) happiness is a function of healthstatus; (2) happiness is a function of health status and some demographic variables; (3) healthstatus is a function of happiness; (4) health status is a function of happiness and somedemographic variables in order to provide information on this cohort. Using probit analysis, thispaper sought to model the aforementioned issues from data on elderly men (ages 55 years andolder) in Jamaica.MethodsParticipants and questionnaireThe study used primary cross-sectional survey data on men 55 years and older from the parish ofSt. Catherine in 2007; it is also generalizable to the island. The survey was submitted andapproved by the University of the West Indies Medical Faculty‘s Ethics Committee. Stratifiedmultistage probability sampling technique was used to draw the sample (2,000 respondents).A132-item questionnaire was used to collect the data. The instrument was sub-divided intogeneral demographic profile of the sample; past and current health status; health-seekingbehaviour; retirement status; social and functional status. The overall response rate for the surveywas 99% (n=1,983). Data was stored, retrieved and analyzed, using SPSS for Windows (16.0). The Statistical Institute of Jamaica (STATIN) maintains a list of enumeration districts(ED) or census tracts. The parish of St. Catherine is divided into a number of constituenciesmade up of a number of enumeration districts (ED). The one hundred and sixty-two (162)enumeration districts in the parish of St. Catherine provided the sampling frame. Theenumeration districts were listed and numbered sequentially and selection of clusters werearrived at by the use of a sampling interval. Forty (40) enumeration districts (clusters) were 6
    • subsequently selected with the probability of selection being proportional to population size(Table 1.1). The enumeration districts in the parish of St. Catherine provided the sampling frame andthe sample size was determined with the help of the Statistical Institute of Jamaica (STATIN).The enumeration districts were listed and single-stage cluster sampling was used to select thesample. The enumeration districts were numbered sequentially and selection of clusters wasarrived at by calculating a sampling interval. From a randomly selected starting point, forty (40)enumeration districts (clusters) were subsequently selected with the probability of selectionbeing proportional to population size. The sample of 2000 was selected based on a proportion ofthe Census Data (Table 1.1). The parish of St. Catherine had approximately 233,052 males, (preliminary census data2001) of which 33,674 males were 55+ years. STATIN maintains maps with enumerationdistricts or census tracts which included the selected EDs and access routes and had references tothe selected site of a starting point household within each ED. The starting point was determinedby randomly selecting a household with a man 55 years and over from the list of persons in theED. With this information the interviewers travelled in a north-easterly or closest to north-easterly direction beginning with the first selected household, and conducted interviews in eachhousehold that had a male 55 years and older. Only one male per household was selected; and inhouseholds with more than one individual fitting the characteristic of the sample, a coin wastossed to determine the person who will be interviewed. (North-East was randomly selected bySTATIN as the direction of travel from the starting point). Where the selected household was found to be subsequently devoid of an older man (dueto out-migration or death), an adjacent household was canvassed. Where households had a man 7
    • 55+ years as a resident and he was not at home a call-back form was left indicating a proposedtime that the interviewer would return which would not be longer than two days after the initialvisit. The sample population does not only speak to the parish of St. Catherine, it isgeneralizable to the island of Jamaica. The sampling frame was men fifty-five years and older inthe parish of St Catherine. The parish of St. Catherine was chosen as previous data suggested thatit has the mix of demographic characteristics (urban, rural and age-composition) which typifyJamaica surveys (Statistical Institute of Jamaica 2004; Wilks 2007; Jackson et al. 2003) For this paper descriptive status was employed to provide background information on thesample; and chi-square was used to examine non-metric variables. Level of significance waspvalue<0.05 and the only exclusion criteria was if more than 20% of the cases of the variablewere missing.MeasureHappiness is measured based on people‘s self-report on their happiness (Frey & Stutzer, 2002a,2002b; Easterlin 2001; Borghesi, & Vercelli, 2007). This operationalization is based on a basicindicator proposed by Diener (2000), including a more emotional component referring tohappiness (‗Taking all things together, how happy would you say you are?‘). It is a Likert scalequestion, which ranges from high to low happiness. It was coded into a binary variable, whetheror not the individual had moderate-to-high or low happiness: 1=moderate to high happiness, 0 =otherwise.Life satisfaction. Diener (2000) had proposed that happiness includes emotional components anda more cognitive component referring to life satisfaction (‗All things considered, how satisfiedare you with your life as a whole nowadays?‘), for this paper the researcher separated happiness 8
    • (emotional) from cognitive (life satisfaction). Life satisfaction is a binary variable, where 1=good-to-excellent self-reported overall satisfaction in life, 0=otherwise.Health Status is measured using people‘s self-rate of their overall health status (Kahneman, &Riis, 2005), which ranges from excellent to poor health status. The variable used in this paperfor health status is a binary one, whether or not the person had good-to-excellent or poor healthstatus. It was then coded as a dummy variable, 1=good-to-excellent health status, 0=otherwise.Age group is categorized into three sub-groups. These are (1) ages 55 to 64 years; (2) ages 65 to74 years; and (3) age 75 years and older (ie 75+ years).Listing of covariatesResidence is a binary variable, 1=lives in urban area, 0=lives in rural area.Employment status is a binary variable, where 1=employed, 0=otherwise.Health retirement plan is a binary variable, where 1=having a health retirement coverage,0=otherwise.Occupation is a binary variable, where 1=current or past occupation which was in the categoryof professional, 0=otherwise.Marital status is a non-binary variable, where 1=married, 0=otherwise; 1= separated, divorced orwidowed, 0=otherwise and single is the reference group.Childhood health status is a binary variable, 1=self-reported poor health status, 0=otherwise.Household head is a binary variable, 1=self-reported head of household, 0=otherwise.Social networking is operationalized based on yes or no to being a member of a social club;civic organization; or community organization. This was dichotomized to be 1 if yes and 0 ifotherwise. This variable excludes being a member of a church. 9
    • ADL. This is a functional status of 12 events. These include eating; bathing; dressing; usingtoilet; shopping; preparing meals; feeding oneself; continence; taking or using transportation;managing medication; money management; and laundry.ModelTheoretical backgroundAccording to micro econometric happiness function, subjective wellbeing (ie happiness) is afunction of different variables (including some demographic ones) (Stutzer & Frey 2003) [Model(1)]. Wit = + Xit + it…………………………………………………..……….. [1] Where Wit represents subjective well-being, Xit denotes x1, x2, x3, and so on, in whichx1 to xn are variables – ‗sociodemographic‘, ‗environmental‘, and ‗social‘, ‗institutional‘ and‗economic conditions‘ In this paper, the literature (ie micro econometric happiness function) will be expanded toinclude health status in childhood, current health status, life satisfaction, and area of residence bytesting this theory using elderly men in Jamaica [Model (1)]. In addition to the aforementionedmicro econometric happiness function, the study will also seek to examine health status.Variables such as happiness, life satisfaction and some demographic variables will beinvestigated simultaneously [Model (2)].Estimation ModelThe interests of this paper are to examine whether happiness can be predicted by health status aswell as the role of life satisfaction, and self-reported childhood health status on happiness ofelderly men in Jamaica. Continuing, it is also to investigate whether health status can be 10
    • predicted by happiness; what are the demographic factors that can predict either happiness orhealth status of elderly men in Jamaica as well as determine, if there is a difference between ruraland urban areas. The multivariate model used in this paper is an expansion of the literature(Stutzer and Frey‘s work on happiness) which is displayed in equations (2) and (3).Hit = β0 + β1HSit + β2HSi(t-1) + β3LSit+ βijDij+ εi ...……….………………..………...[2]HSit = β0 + β1Hij + β2HSi(t-1) + β3LSit + βijDit+εi ………………………….…….…….[3]where Hit denotes happiness of person i in time period t (current period); HSit means healthstatus of person i in current time period t; HSi(t-1) denotes the childhood health status of period iprevious period (t-1); LSit is life satisfaction of person i in current time period (t); Dit = d1, d2,d3, d4…..dn, which include sociodemographic and socioeconomic variables of individual i incurrent time period (t). β0 indicates happiness at the beginning of the period; β1 to βij denotesthe parameter for each variable from variable 1 to j. The models [Eqn. (2) and (3)] allow for each factor that is associated with happiness[Eqn. (2)] or health status [Eqn. (3)] to be examined separately. Those approaches have beenwidely and successfully applied in a plethora of studies on the correlates of happiness (Easterlin2001; Veenhoven 1993, Stutzer & Frey 2003; Frey & Stutzer 2002; Frey & Stutzer 2002;Blanchflower & Oswald 2004; Argyle 1999) and/or health status (Bourne 2008a, 2008b;Grossman 1972; Smith & Kington 1997; Hambleton et al. 2005; Bourne & McGrowder 2009)This is the rationale for the usage of micro-econometric happiness function (Lima & Nova 11
    • 2006), Bourne and McGrowder‘s (2009) health status function as they allow for the analysis ofcurrent study. Because the dependent variable for this paper, happiness or health status, is a binary one,probit analysis was used to estimate the impact of life satisfaction, current health status,childhood health status, including other socio-demographic variables (such as employmentstatus, education, marital status, age of elderly, social support, and church attendance) onhappiness or current health status of elderly men in Jamaica. Furthermore, this paper will mainlyreport the results of those variables that are statistically significant (p<0.05). Furthermore, the variables used in this paper are based on (1) literature review whichshows that these are likely to correlate with the particular dependent variable, and 2) thecorrelation matrix was examined in order to ascertain if autocorrelation (or multicollinearity)existed between independent variables. Based on Cohen and Holliday (1982), correlation can below (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. Any of the independent variables which had moderate to highcorrelation was excluded from the model. The correlation between life satisfaction and happinesswas 0.633; happiness and social networking (correlation coefficient = 0.12, p = 0.003); happinessand marital status (correlation coefficient = 0.107, p = 0.026); marital status and income category(correlation coefficient =0.193, p< 0.001); social networking and marital status (r=0.205,p<0.001); social networking and age group (correlation coefficient = 0.188, p<0.001); socialnetworking and occupation (correlation coefficient =0.320, p< 0.001); social networkingeducational category (correlation coefficient =0.420, p<0.001); ADL and age cohort (correlationcoefficient =-0.813, p=0.032); income and occupation (correlation coefficient =0.7775, p < 12
    • 0.001); and, income and education (correlation coefficient =0.356, p<0.001); employment andeducation category (correlation coefficient =0.283, p<0.001). However, there was no correlationbetween happiness and present occupation (p=0.761); happiness and income (p=0.233);happiness and employment status (p=0.516); as well as life satisfaction and employment status(p=0.261). Hence, life satisfaction and happiness; occupation and income category will not besimultaneously used as explanatory variables.Results: Socio-demographic Characteristics of SampleThe sample was 2,000 men ages 55 years and older (42.6% were 55 to 64 years; 35.6% were 65to 74 years; 21.9% were 75 years and older). Fifty one percent of the sample lived in rural areas;59.1% had social network; 55.4% reported good health status and 25.6% indicated poor healthstatus; 53.9% were retired, 25.6% were actively employed and 20.6% unemployed; 58.8% didnot own their homes, and 34.3% were single and 44.7% were married elderly men. Majority ofthe sample had primary or elementary level education (83.1%); 85.9% reported that they do notregularly exercise; 82.5% reported good health in childhood; and 88.12% were heads of theirhouseholds (Table 1.2). One half of the sample indicated that they spent Ja. $100 (US $1.45)monthly for medical expenditure; 34% of the respondents bought their prescribed medication;17.1% reported that they have been hospitalized since their sixth birthday and 65.8% reportedthat they took no medication. Of those who mentioned that they were ill during childhood(17.5%, n=350), 34.9% said that the illness was measles or chicken pox, 26.3% mentionedasthma, 10.0% pneumonic fever, 8.9% polio, 6.6% accidents, 4.6% jaundice, 1.7% hernia, and5.1% indicated gastroenteritis. Twenty four percent of elderly men indicated that they wererarely happy, 40.5% said sometimes, 31.0% mentioned often and only 4.5% reported always.Furthermore, 17.7% of the sample reported that they were seriously ill as children. 13
    • Of the sample (n=2,000), 24.0% indicated that they were rarely happy; 40.5% indicatedsometimes; 31.0% mentioned most times and 4.5% reported always. Hence, approximately 65%of the sample was happy at least sometimes. With respect to life satisfaction, 32.9% of thesample indicated that they were rarely satisfied with their life; 33.7% revealed sometimes; 29.9%mentioned most times and 3.5% reported always. Of the sample, 62.7% revealed that they were able to carry out particular daily activitiescompared to 37.4% who reported that they were unable to perform daily activities.Results: Multivariate AnalysisThe results from the probit regression analyses of happiness are presented in Table 1.3. Theresults for the current health status are presented in Table 1.4. Therefore, this paper willmainly report the results of those variables that are statistically significant (p<0.05). Current happiness of elderly men in Jamaica was found to be statistically influence bylife satisfaction (95% CI: 0.417, 1.215; p <0.001) and aged men 75 years and beyond (95% CI: -1.193, -0.054; p=0.032) with reference to those 55 to 64 years of age. For life satisfaction,Current and childhood health status as well as education, age of elderly men, social support,church attendance, occupation (both current and past), and marital status were found not toinfluence current happiness (p > 0.05). Continuing, current happiness of elderly men was thesame whether they live in urban or rural areas (p=0.813) (Table 1.2). Based on Table 1.3, themodel is a good fit for the data (log likelihood=153.039; chi-square = 106.479, P=0.985). Current health of the sample was found be significantly statistically influenced by age ofthe elderly (ages 65 to 74 years – 95%CI: -1.513, -0.622; ages 75+ - 95% CI: -2.130, -1.022; 14
    • p<0.001), social support (95% CI: 0.016, 1.315, p=0.045) and area of residence (95% CI: -0.959,-0.085, p=0.019) (Table 1.4). Continuing, urban elderly men had a lower current health statusthan their rural counterparts. Variables such as life satisfaction, employment status, education,head of household, occupational type (both past and current), health status in childhood, churchattendance and happiness were not found to statistically influence current health status of elderlymen in Jamaica. Based on Table 1.4, the model is a good fit for the data (log likelihood=149.068;chi-square = 102.798, P=0.971).DiscussionThe study revealed 24 elderly men in every 100 were rarely happy, 41 in every 100 werehappy sometimes, 31 in every 100 indicated most times and 5 in every 100 reported always;and that 55 out of every 100 were in good health, 26 in every 100 said fair and 19 out ofevery 100 said excellent health status. The survey evidence presented here suggested thatthere was no statistical correlation between happiness and health status of elderly men inJamaica, and it goes further to show that happiness cannot be a predictor of health status aswell as health status cannot be a predictor of happiness. Happiness was found not to correlatewith health status of elderly men in Jamaica nor was health status associated with happiness;and that there was no difference based on area of residence. This denotes that happiness doesnot provide an understanding of health status and vice versa as well as the fact that overalllife satisfaction of elderly men in Jamaica is not explained by health status. However, lifesatisfaction was a predictor of happiness for older men. In this research health status does not influence happiness which is contrary to theother studies (Siahpush et al., 2008; Borghesi, & Vercelli, 2007; Kahneman, & Riis, 2005; 15
    • Easterlin, 2003; Brickman, Coates & Janoff-Bulman 1978; Stutzer & Frey 2003; Frey &Stutzer 2002a, 2002b; Blanchflower & Oswald, 2003; Argyle 1999; Michalos, Zumbo, &Hubley, 2002). One scholar went further than the negative statistical association betweenhappiness and health status when he argued that over life‘s course, happier people werehealthier people which suggest that correlation is even in later life for both sexes. This papercannot concur with such a finding as there is no statistical relationship between happinessand health status at older ages for men in Jamaica, suggesting that happiness is not a goodpredictor of health status. Happiness therefore can be used to proxy health status of oldermen in Jamaican. Research literature has long established that life satisfaction and happiness areestimates for each other and encapsulate the overall experiences of the individual (Selim,2008; Siahpush et al., 2008). Happiness is a crucible pursuit of human existence (James1902). It is multidimensional and thus justifies its usage in measuring wellbeing instead of atraditional approach of income per capita (Gross Domestic Product per capita, GDP) (Diener,Lucas, & Oishi, 2002; Diener, 1984, 2000; Easterlin, 2003; Diener, Larson, Levine, &Emmon, 1999) Happiness which was first introduced by a psychologist (Diener, 1984) as asubjective measure in assessing wellbeing has been accepted by some economists as a goodproxy for wellbeing (Graham, 2008; Borghesi, & Vercelli, 2007; Mahon et al., 2005; Layard,2006; Easterlin, 2001; Veenhoven, 1993; Argyle, 1999; Stutzer & Frey 2003; Easterlin,2003; Brickman, Coates & Janoff-Bulman, 1978; Frey & Stutzer, 2002a, 2002b;Blanchflower & Oswald, 2004). Based on this established fact, information is now availableon the multidimensional state of elderly men in Jamaica. Although happiness is fluid, thispaper has revealed that a small proportion of elderly men in Jamaica reported that they were 16
    • always happy (approximately 5 out of every 100) compared to 24 out of every 100 whoclaimed they were rarely happy. Embedded in this finding is the negative psychological stateof many elderly people as this is reflected in their happiness (or unhappiness); and theirhappiness is not influenced by their health status. Lyubomirsky (2001) forwarded a number of issues that justified happy from unhappypeople. She identified ‗comfortable income‘, ‗robust health‘, supportive marriage‘, and ‗lackof tragedy‘ or ‗trauma‘ in the lives of people as factors that distinguish happy from unhappypeople. In this paper, 44% were married; 88% heads of household; 26% employed; 54%retired, 83% had primary or elementary education, for those who are employed 93% earnedless than US $283.23 per month (Ja$70.61=1US$) and although those variables were foundnot to statistically influence happiness, the aforementioned studies declared that they do.According to Borghesi, & Vercelli (2007), education, employment status, social capital andenvironmental variables influence happiness, this is not the case for older men in Jamaica.Neither is marital status, occupational type, social support or church attendance. However,Borghesi & Vercelli Kim-Prieto et al. (2005) and Smith et al. (2005) identified thateducational attainment; employment status; social support; genetic endowment; and thesocial (Fowler & Christakis, 2008) and physical milieu are correlated with happiness andwhile this is not the case for older men in Jamaica; those variables do influence lifesatisfaction (Mroczek, & Spiro, 2005; Gwozdz, & Sousa-Poza, 2009) which indirectlyimpact health status. According to Gwozdz & Sousa-Poza (2009) life satisfaction decline with old age,which may explain why in this paper only 4 out of every 100 Jamaican older men reported 17
    • being always happy and 30 out of 100 reported being happy most of the time. Like theliterature this paper concurs that there is a correlation between life satisfaction and maritalstatus; life satisfaction and occupation; and life satisfaction and area of residence; but theywere weakly related to each other. However, it was revealed also that there was nosignificant statistical association between employment status and life satisfaction, and lifesatisfaction and income, suggesting that the variables which influence life satisfaction as wellas happiness for the elderly men are not necessarily the same as those that affect happiness orlife satisfaction of the population (Selim, 2008; Siahpush et al., 2008). Furthermore, anotherimportant finding is the disparity in factors that influence life satisfaction or health status ofolder men in Germany and Jamaica (Gwozdz, & Sousa-Poza, 2009). With the down turn in the American economy, Jamaicans have been experiencing asignificant reduction in remittances which act as an income for many families including theelderly. This will further erode the life satisfaction of elderly men as they will beincapacitated by the inability to afford basic necessities and their independence will bethreatened as they must now seek the assistance of church, friends and other social networksin order to survive. Although social networking and employment status were not found to bestatistical associated with happiness in the current work, men equate the ability to provide fortheir families and spend on particular things as they desire, as apart of their happiness.Hence, income or wealth is a good predictor of happiness for this cohort (see also, Frey &Stutzer, 2002a, 2002b; Borghesi & Vercelli, 2007; Graham, 2008), not having data on wealthhampers a possible explanation instead of many of the other variables that were tested. 18
    • The literature has provided a plethora of studies that showed the correlation betweenhappiness and health status; but this is not the case for elderly men in Jamaica. Usingstratified probability sampling technique of 2,000 elderly men, this paper found noassociation between the happiness and current health status, and vice versa. What accountsfor this disparity? While health and happiness are correlated in the general populace of theworld, other nations, and many countries outside of Jamaica, it is not the case for men ages55 years and older in Jamaica based upon men‘s unwillingness to seek openly and truthfullyabout their health. This brings into question the validity of value judgement or the self-reported health of this paper. The validity of using people‘s assessment of their life satisfaction and health is old and hasalready been resolved. Nevertheless, it will be succinctly forwarded here for those who are notcognizant of this discourse. Scholars have established that there is a statistical associationbetween subjective wellbeing (self-reported wellbeing) and objective wellbeing (Diener, 2000;Lynch, 2003) and Diener (1984) went further when he found a strong correlation between thetwo variables. Gaspart (1998) opined about the difficulty of objective quality of life (GDP percapita) and the need to use self-reported wellbeing in assessing wellbeing of people. He wrote,―So its objectivism is already contaminated by post-welfarism, opening the door to a mixedapproach, in which preferences matter as well as objective wellbeing‖ (Gaspart, 1998) whichspeaks to the necessity of using a measure that captures more to the this multidimensionalconstruct than continuing with the traditional income per capita approach. Another group ofscholars emphasized the importance of measuring wellbeing outside a welfarism and/or purelyobjectification, when they said that ―Although GDP per capita is usually used as a proxy for thequality of life in different countries, material gain is obviously only one of many aspects of life 19
    • that enhances economic wellbeing‖ (Becker, Philipson & Soares, 2004, 1) and that wellbeingdepends on both the quality and the quantity of life lived by the individual (Easterlin 2001). The discourse of subjective wellbeing using survey data cannot deny that it is based on theperson‘s judgement, and must be prone to systematic and non-systematic biases (Schwarz &Strack, 1999). In an earlier work, Diener (1984) argued that the subjective measure seemed tocontain substantial amounts of valid variance. This will not be addressed in this paper as this isnot the nature or its scope. Despite this limitation, a group of economists noted that ‗happiness orreported subjective well-being is a satisfactory empirical approximation to individual utility‘(Frey & Stutzer, 2005) and this is a rationale for its usage in wellbeing research. This paper has not only provided pertinent research information on happiness v healthstatus in elderly men in Jamaica, it also examined health status and happiness as well as othervariables such as childhood health status, life satisfaction and some other sociodemographicvariables. Life satisfaction; employment status; education; health insurance; head of household;marital status; childhood health status; church attendance; and happiness of elderly Jamaicans donot statistically influence health status. All those variables are well established in researchliterature as statistically significant correlates with health status. Studies have moved beyondthose variables being mere correlates to predictors of health status (Bourne, 2008a, 2008b;Grossman, 1972; Smith & Kington, 1997; Hambleton et al., 2005; Bourne & McGrowder, 2009).A recently published study on rural Jamaican by Bourne and McGrowder (2009) identified 12explanatory predictors of good health and another by Bourne (2008b) found 11 predictors ofwellbeing of aged Jamaicans. The aforementioned studies are different from the current as thereis a difference in regards to the measurement of health status. Those studies operationalizedhealth (or subjective wellbeing) as health conditions whereas this one used general self-reported 20
    • health status which is keeping with literature (Grossman, 1972; Smith & Kington, 1997;Hambleton et al., 2005), but departs in respects to the predictors. There is a convergence of predictors as this paper concurred with the literature thatageing is associated with lower health status; social support (Fowler & Christakis, 2008), and theplace of residence are determinants of health status. Area of residence is not only a correlate ofhealth status; but this paper found that elderly men who lived in urban areas have lower healthstatus, suggesting that healthier old men in Jamaica resided in rural areas. Functional capacity of the elderly is well established in health literature as influencinghealth status and by extension happiness (Yi & Vaupel, 2002; Bogue, 1999). The young-old(ages 60 to 64 years) are more likely to be the most functioning as the organism is just beginningthe transition into the aged arena (see for example Erber 2005; Brannon & Fiest, 2004). Thisphenomenon means that human mortality increases with age of the human adult, but that thisbecomes less progressive in advance ageing. Thus, biological ageing is a process where thehuman cells degenerate with years (i.e. the cells die with increasing age), which explains theinverse association between ageing and subjective wellbeing (Netuveli et al. 2006; Prause et al.2005). Bogue (1999:3) summarized the characteristics of three elderly cohorts (young-old – ages60 to 74; aged or old-old – 75 to 84 years and oldest old - 85+ years), when he showed that as theelderly ages from young-old to aged their health problems increased from low to moderate andthus increased to high for the oldest-old and that this is similar to their physical disability. Performance of Activities of Daily Living (ADL) is used to describe the functional statusof a person. It is used to determine a baseline level of functioning and to monitor improvementin activities of daily living (ADL) overtime. There are systems such as the Katz ADL tool thatseek to quantify these functions and obtain a numerical value. These systems are useful for the 21
    • prioritizing of care and resources. Generally though, these should be seen as rough guidelines forthe assessment of a patient‘s ability to care for themselves. Scoring the ADL findings (Katz)Independence on a given function received a score of 1 point while if dependent, 0 point wasgiven. There were 14 items (including daily activities; household chores; shopping; cooking;paying bills). The reliability of the items was very high, α = 0.801. Total scores thus could rangefrom 0-14 with lower scores indicating high dependence and higher scores indicating greaterindependence. Instrumental Activities of Daily Living (IADL) The Instrumental Activities ofDaily Living tool (IADLs; Lawton & Brody, 1969) was the basis for assessing participants‘difficulty with IADL. IADL are those activities whose accomplishment is necessary forcontinued independent residence in the community. The independent activities of daily living are more sensitive to subtle functionaldeficiencies than ADL‘s and differentiate among task performance including the amount of helpneeded to accomplish each task. Due to the fact that the study was being conducted among menonly, some tasks which are normally done by women would not apply. Thus consistent withinternational practice, the University of Wollongong‘s modified IADL functional ability scalewhich uses a scale of 5 points for men and eight for women to assess the IADL functional abilityof men in the study (Centre of Health Service Development 2001). Consequently the domains offood preparation, laundry and housekeeping were omitted in this paper with regard to theInstrumental Activities of Daily Living for older men. Scoring the IADL: IADL scores reflectthe number of areas of impairment, i.e. the number of skills/domains in which subjects aredependent. Scores range from 0-5. Higher scores thus indicate greater impairment anddependence. 22
    • Hence, Functional status is the summation of ADL and IADL. Cohen & Holliday1 statedthat correlation can be low/weak (0–0.39); moderate (0.4–0.69), or strong (0.7–1). Hence, highdependence ranges from 0 to 5.5; moderate dependence is from 5.6 to 9.7 and low dependence(ie independence) ranges from 9.8 to 14. Independence means without supervision, direction, oractive personal assistance. The performance on the functions can be further classified andanalyzed using the format below. The classification recognizes that combinations ofindependence/dependence with respect to particular functions reflect the different degrees oflevels of capability with respect to ADL. The classification outlined below (as developed basedon Katz et al 1970 and Katz et al 1993) was used to further describe the functional status of menwith regard to ADL. Based on the aforementioned discussion on ageing and health status as wellas ageing and functional capacity, ADL and IADL are strongly correlated which indicates thatageing and functional capacity should not be a separate independent variable as there would behigh multicollinearity between those two factors. Hence, ageing category was used instead offunctionality capacity as an independent variable.ConclusionThe current work has shown that happiness is not influenced by health status nor is it determinedby employment status, educational attainment; marital status; church attendance or any otherform of social networking which means that health status is not synonymous with happiness noris happiness equivalent to health status for older men in Jamaica. Happiness is not correlatedwith health status and vice versa for elderly Jamaicans, and so understanding happiness is notcomprehending health status. Happiness and health status cannot be used to proxy each other for 23
    • the elderly cohort as they are mutually exclusive events. Happiness however, is correlated withlife satisfaction and people‘s general perception about their life is a good predictor of happiness;suggesting that life satisfaction can measure happiness. A qualitative assessment is needed tounderstand elderly men‘s value system, as this will provide answers for the disparity between thetwo phenomena. In spite of the need to do further studies on the issue, research findings are nowavailable upon which better public policies can be framed from here onwards.DisclosureThe author has no disclosure to declare.ReferencesAbbe, A., Tkach, C., & Lyubomirsky, S. (2003). The art of living by dispositionally happy people. Journal of Happiness Studies, 4,385-404.Acton, G. S., & J.J. Zodda. 2005. Classification of psychopathology: Goals and methods in an empirical approach. Theory of Psychology 15:373-399.Argyle, M. (1999). Causes and Correlates of Happiness in D. Kahneman, E. Diener, and N. Schwarz eds., Well-Being: The Foundations of Hedonic Psychology, New York: Russell Sage Foundation.Becker, G.S., Philipson, T.J., & Soares, R.R. (2004). The quantity and quality of life and the evolution of world inequality. http://www.spc.uchicago.edu/prc/pdfs/becker05.pdf#search=%22preston%2C%20quality %20of%20life%22 (accessed August 22, 2006).Blanchflower, D.G., & Oswald, A.J. (2004). Wellbeing over Time in Britain and the USA. Journal of Public Economics, 88, 1359-1386.Bogue, D.J. 1999. Essays in human ecology, 4. The ecological impact of population aging. Chicago: Social Development Center.Borghesi, S., & Vercelli A. (2007). Happiness and health: two paradoxes. Paper presented at the Conference ―Policies for Happiness‖ held at the University of Siena, 14-17 June 2007) for their useful comments.Bourne, P.A., & McGrowder, D.A. (2009). Rural health in Jamaica: examining and refining the predictive factors of good health status of rural residents. Rural and Remote Health 9 (2), 1116. Available from: http://www.rrh.org.au.Bourne, P.A. (2008a). Health Determinants: Using secondary data to model predictors of well- being of Jamaicans. West Indian Medical Journal, 2008a, 57, 476-481. 24
    • Bourne, P.A. (2008b). Medical Sociology: Modelling well-being for elderly people in Jamaica. West Indian Medical Journal, 57, 596-604.Brannon, L., & Feist, J. (2007). Health psychology. An introduction to behavior and health 6th ed. Los Angeles: Thomson Wadsworth.Brickman, P., Coates, D., & Janoff-Bulman R. (1978). Lottery Winners and Accident Victims: Is Happiness Relative? Journal of Personality and Social Psychology, 36,917-927.Centre of Health Service Development, Faculty of Health and Behavioural Sciences University of Wollongong; Towards a National Measure of Functional Dependency for Home Care Services in Australia: Stage 1 report of the HACC dependency data items project 2000 updated 2001. Retrieved on January 12, 2004 from http://chsd.uow.edu.au/Publications/2001_pubs/Stage%201%20HACC%20Report_May0 1_Update.pdf.Chida Y, Steptoe A. (2008). Positive psychological well-being and mortality: a quantitative review of prospective observational studies. Psychosom Med 2008;70:741-56Cohen L, & Holliday M. 1982. Statistics for Social Sciences. London, England: Harper and Row.Crisp, R. (2005). Wellbeing. The Stanford Encyclopedia of Philosophy (Winter 2005 Edition) E. N. Zalta ed. http://plato.stanford.edu/archives/win2005/entries/wellbeing/ (accessed April 4, 2009).Diener, E. (2000). Subjective well-being: the science of happiness and a proposal for a national index. American Psychologist, 55: 34–43.Diener, E., Horwitz, J., & Emmon, R,A. (1985). Happiness of the very wealthy. Social Indicators Research, 16,263-274.Diener, E., Larson, R.J., Levine, S., & Emmon, R.A. (1999). Subjective wellbeing: Three decades of progress. Psychological Bulletin, 125, 276-302.Diener, E., Lucas, R.E., & Oishi, S. (2002). Subjective well-being: the science of happiness and life satisfaction, in C. Snyder and S. Lopez (eds), Handbook of Positive Psychology, Oxford: Oxford University Press.Diener, E., & Seligman, M.E.P. (2002). Very happy people. Psychological Science, 13, 81–84.Diener, E., Suh, M., Lucas, E., & Smith, H. (1999). Subjective well-being: Three decades of progress. Psychological Bulletin 125:276-302.Diener, E. (1984). Subjective well-being. Psychological Bulletin, 95, 542–75.Diener, E. (2000). Subjective well-being: the science of happiness and a proposal for a national index. American Psychologist, 55, 34–43.Easterlin, R.A. (2003). Building a better theory of well-being. Prepared for presentation at the Conference ―Paradoxes of Happiness in Economics‖, University of Milano-Bicocca, March21-23, 2003. http://www-rcf.usc.edu/~easterl/papers/BetterTheory.pdf (accessed April 4, 2009).Easterlin, R.A. (2001).Income and Happiness: Towards a Unified Theory. Economic Journal, 111, 465-484.Evans, C. C., M. Sherer, T. G. Nick, R. Nakase, and S. Yablon. 2005. Early impaired self- awareness, depression, and subjective wellbeing following traumatic brain injury. Journal of Head Traua Rehabilitation 20:488-500.Erber, J. 2005. Aging and older adulthood. New York: Waldsworth, Thomson Learning.Fowler JH, Christakis NA. (2008). Estimating peer effects on health in social networks: a 25
    • response to Cohen-Cole and Fletcher; and Trogdon, Nonnemaker, and Pais. J Health Econ 27:1400-5.Frey, B.S., & Stutzer, A. (2002a).What Can Economists Learn from Happiness Research? Journal of Economic Literature, XL, 402-435.Frey, B.S., & Stutzer, A. (2002b). Happiness and Economics: How the Economy and Institutions Affect Well-Being. Princeton: Princeton University Press.Frey, B.S., & Stutzer, A. (2005). Happiness Research: State and Prospects. Review of Social Economy, (LXII), 207-228. (Available: http://www.bsfrey.ch/articles/420_05.pdf, accessed April 6, 2009).Fromson, P. M. 2006. Self-discrepancies and negative affect: The moderating roles of private and public self-consciousness. Social behavior and Personality 34:333-350.Gaspart, F. (1998). Objective measures of well-being and the cooperation production problem. Social Choice and Welfare, 15, 95-112.Graham , C. 2008. Happiness and health: Lessons – A Question – For Public Policy. Health Affairs, 27:72-87.Grossman M. (1972). The demand for health - a theoretical and empirical investigation. New York: National Bureau of Economic Research.Gwozdz, W., & Sousa-Poza, A. (2009). Ageing, health and life satisfaction of the oldest old: An Analysis for Germany. Discussion Paper No. 4053, March 2009. Available from http://ftp.iza.org/dp4053.pdf (accessed July 9, 2009).Hambleton, I.R., Clarke, K., Broome, H.L., Fraser, H.S., Brathwaite, F., & Hennis, A.J. (2005). Historical and current predictors of self-reported health status among elderly persons in Barbados. Revista Panamericana de salud Públic, 17, 342-352.Harris, P. R., and O. R. Lightsey Jr. 2005. Constructive thinking as a mediator of the relationship between extraversion, neuroticism, and subjective wellbeing. European Journal of Personality 19:409-426.Huppert, F., 2006, Positive Emotions and Cognition: developmental Neuroscience and Health Perspectives, in J. Forges, ed., 2006, Hearts and Minds: Affective Influences on Social Cognition and Behaviour, Psychology Press, PhiladelphiaJackson, M., Walker, S., Forrester, T., Cruickshank, J., Wilks, R. (2003). Social and dietary determinants of body mass index in Jamaican of African. European Journal of Clinical Nutrition, 57,621-627.James, W. (1902). Varieties of Religious Experience. New York: Mentor.Kart, C.S. (1990). The realities of aging: An introduction to gerontology, 3rd ed. Boston: Allyn and Bacon.Kahneman, D. & 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.Kashdan, T. B. 2004. The assessment of subjective wellbeing (issues raised by the Oxford Happiness Questionnaire). Personality and Individual Differences 36:1225–1232.Katz, S., Downs, T.D., Cash, H.R., & Grotz, R.C. (1970). Progress in development of the index of ADL. The Gerontologist 10:20-30.Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffe MW. (1993). Studies of illness in the ages. The index of ADL: standardized measure of biological and psychosocial function. JAMA, 185 (12), 914-919. 26
    • Kim-Prieto, C., Diener, E., Tamir, M., Scollon, C., Diener M. (2005). Integrating the Diverse Definitions of Happiness: A time-sequential framework of subjective well-being. Journal of Happiness Studies 6:261-300.Lawton, MP., & Brody, EM. (1969). Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist, 9:179-86.Layard, R., 2006, Happiness: Lessons from a New Science, Penguin, London.Leung, B.W., Moneta, G.B., & 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.Lima, M.L., & Nova, R. (2006). So far so good: Subjective and social wellbeing in Portugal and Europe. Portuguese Journal of Social Science, 5, 55-33.Lynch, S.M. (2003). Cohort and Life-course patterns in the relationship between education and health: A hierarchical approach. Demography, 40,309-331.Lyubomirsky, S., King, L., & Diener, E. (2005). The benefits of frequent positive affect: Does happiness lead to success? Psychological Bulletin, 6,803-855.Lyubomirsky, S. (2001). Why are some people happier than others? The role of cognitive and motivational process in well-being. American Psychologist, 56,239-249.McConville, C., Simpson, E.E., Rae, G., Polito, A., Andriollo-Sanchez, Z., Meunier, N., Stewart- Knox, O., O‘Connor, J.M., Boussell, A.M., Cuzzolaro, & Coudray, C. (2005). Positive and negative mood in the elderly: the Zenith study. European Journal of Clinical Nutrition, 59, 22.McCullough, M.E., C.G. Bellah, S.D. Kilpatrick, & J.L. Johnson. 2001. Vengefulness: Relationships with forgiveness, rumination, wellbeing, and the big five. Personality and Social Psychology Bulletin 27:601-610.Mahon, N.E., Yarcheski, A., Rutgers, & Yarcheski, T. (2005). Happiness as related to gender and health in Early Adolescents. Clinical Nursing Research, Vol. 14, 175-190.Mroczek, DK., & Spiro, A. III. (2005). Change in Life Satisfaction During Adulthood: Findings From the Veterans Affairs Normative Aging Study. Journal of Personality and Social Psychology, 8: 189-202.Michalos, A.C., Zumbo, B.D., & Hubley, A. (2002).Health and the Quality of Life. Social Indicators Research, 51: 245-286.Netuveli, G., R.D. Wiggins, Z. Hildon, S.M. Montgomery, and D. Blane. 2006. Quality of life at older ages: evidence form the English longitudinal study on aging (wave 1). Journal of Epidemiology and Community Health 60:357-371.O‘Donnell, V., & Tait, H. (2003). Wellbeing of the non-reserves Aboriginal population. Statistics Canada Catalogue 89-589.Planning Institute of Jamaica (PIOJ), Statistical Institute of Jamaica (STATIN). (2008). Jamaica Survey of Living Conditions, 2007. PIOJ, STATIN.Prause, W., B. Saletu, G. G. Tribl, A. Rieder, A. Rosengerger, J. Bolitschek, B. Holzinger, G. Kaplhammer, H. Datschning, M. Kunze, R. Popovic, E. Graetzhofer, and J. Zeitlhofer. 2005. Effects of socio-demographic variables on health-related quality of life determined by the quality of life index—German version. Human psychopharmacology Clinical and Experimental. 20:359-365.Pressman SD, Cohen S. (2005). Does positive affect influence health? Psychol Bull, 131:925-71. 27
    • Ringen, S. (1995). Wellbeing, measurement, and preferences. Scandinavian Sociological Association, 38, 3-15.Schwarz, N., & 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.Seligman, M.P., & Csikszentmihalyi, M. (2000). Positive psychology: an introduction. American Psychologist, 55, 5–14.Selim, S. (2008). Life Satisfaction and Happiness in Turkey. Social Indicators Research 88:531- 562.Sheldon, K., & 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.Siahpush M, Spittal M, Singh GK. (2008). Happiness and life satisfaction prospectively predict self-rated health, physical health, and the presence of limiting, long-term health conditions. Am J Health Promot 23:18-26.Smith, DM., Langa, KM., Kabeto, MU., Ubel, PA. (2005). Health, Wealth, and Happiness Financial Resources Buffer Subjective Well-Being After the Onset of a Disability. American Psychological Society, 16: 663-666.Smith, J,P., & Kington, R. (1997). Demographic and economic correlates of health in old age. Demography, 34, 159-170.Statistical Institute of Jamaica. (2004). Population Census 2001 (Volume 8): Marital and Union Status. Kingston, Jamaica: Statistical Institute of Jamaica.Steptoe A, O‘Donnell K, Marmot M, Wardle J. (2008). Positive affect and psychosocial processes related to health. Br J Psychol, 99:211-7.Stutzer, A, & Frey, B.S. (2003). Reported subjective well-being: A challenge for economic theory and economic policy. Available from http://www.crema-research.ch/papers/2003- 07.pdf (accessed April 5, 2009).Veenhoven, R. (1993). Happiness in nations, subjective appreciation of in 56 nations 1946-1992. Rotterdam, Netherlands: Erasmus University.Watson, D., et al. 1999. The two general activation systems of affect: Structural findings, evolutionary considerations, and psychobiological evidence. Journal of Personality and Social Psychology 76: 820-838.Watson, D., L.A. Clark, & A. Tellegen. 1988a. Development and validation of brief measures of positive and negative affect: The PANAS Scale. Journal of Personality and Social Psychology 54:1063-1070Watson, D., L.A. Clark, & A. Tellegen. 1988b. Positive and negative affectivity and their relation to anxiety and depressive disorders. Journal of Abnormal Psychology 97:346-353.Wilks, R. (2007). Hypertension in the Jamaican Population. A presentation to the Trinidad & Tobago National Consultation on Chronic Non-Communicable Diseases. Retrieved May 19, 2008 from http://www.health.gov.tt/applicationloader.asp?app=doc_lib_details&id=28&hilite=wilksYi, Z., & Vaupel JW. (2002). Functional capacity and self-evaluation of health and life of oldest old in China. Journal of Social Issues 58:733-748. 28
    • Table 1.1: Proportion of Survey (Sample) vs. Proportion of Population Age 2001 Census (St. 2001 Census SurveyGroup Catherine) (Jamaica) (Yrs). n % n % N % 55-59 469 23.45 6577 26.7 38645 23.9 60-64 413 20.6 5179 21.1 31828 19.7 65-69 374 18.7 4391 17.8 28901 17.9 70-74 345 17.2 3594 14.6 24856 15.4 75-79 189 9.45 2402 9.78 17711 11.0 80+ 210 10.5 2399 9.77 19552 12.1 29
    • Table 1.2: Socio-demographic Characteristics of Sample: Descriptive StatisticsVariable Frequency PercentMarital Status Single 686 34.3 Married 894 44.7 Separated 112 5.6 Common law 136 6.8 Widowed 172 8.6Head of Household Self 1763 88.1 Partner 122 6.1 Children 63 3.2 Sibling/Parent 52 2.6Age group 55- 64 years 851 42.6 65 – 74 years 712 35.6 75 years and older 437 21.9House Ownership Yes 824 41.2 No 1176 58.8Employment Status Employed 511 25.6 Unemployed 412 20.6 Retired 1077 53.9Education No Formal Education 200 10.0 Primary and basic 1661 83.0 Secondary 102 5.1 Tertiary 37 1.9Self-rated Health Status Excellent 357 19.0 Good 1038 55.4 Fair 480 25.6Social Networking Yes 817 59.1 No 1183 40.9Regular Exercise Yes 282 14.1 No 1718 85.9Childhood Health status Good 1650 82.5 Poor 350 17.5Area of residence Urban 981 49.0 Rural 1019 51.0 30
    • Table 1.3: Results of Probit Analysis of Happiness and Some Sociodemographic Variables 95% Confidence Variable Std. Interval Estimate Error Lower Upper Life Satisfaction 0.816 0.203 0.417 1.215*** Employed 0.793 0.926 -1.023 2.609 Primary schooling 0.065 0.291 -0.505 0.636 Secondary and beyond 0.191 0.429 -0.649 1.031 †No formal education Health Retirement plan 0.099 0.354 -0.595 0.793 Household Head -0.009 0.308 -0.613 0.594 Married -0.046 0.212 -0.462 0.370 Separated, Divorced or Widowed -0.137 0.315 -0.754 0.481 †Never married Professional 0.007 0.288 -0.558 0.571 Current good Health Status -0.189 0.224 -0.628 0.251 Childhood health status -0.093 0.240 -0.563 0.377 Area of residence (1=Urban) -0.052 0.218 -0.478 0.375 Elderly 1 (ages 65 to 74 years) -0.238 0.225 -0.680 0.203 Elderly 2 (ages 75 years and older) -0.624 0.291 -1.193 -0.054* †Elderly (ages 55 to 64 years) Social Support 0.034 0.316 -0.586 0.654 Church attendance -0.151 0.239 -0.619 0.317 Intercept -1.459 1.042 -2.501 -0.417Log likelihood = 153.013Pearson Good of Fit test: Chi-square = 106.479, P=0.971†Reference group*p < 0.05, **p < 0.01, ***p < 0.001 31
    • Table 1.4: Results of the Probit Analysis of Health Status by Some Sociodemographic variables Variable Std. 95% Confidence Interval Estimate Error Lower Upper Life Satisfaction 0.381 0.251 -0.109 0.872 Employed 0.385 0.609 -0.809 1.579 Primary schooling -0.421 0.272 -0.956 0.113 Secondary and beyond 0.886 0.489 -0.074 1.845 †No formal education Health Retirement plan -0.456 0.388 -1.217 0.306 Household Head 0.058 0.330 -0.590 0.705 Married 0.033 0.217 -0.392 0.459 Separated, Divorced or Widowed -0.073 0.321 -0.703 0.557 †Never married Professional 0.081 0.316 -0.539 0.701 Childhood Health Status -0.414 0.246 -0.897 0.068 Area of residence (1=Urban) -0.522 0.223 -0.959 -0.085* Elderly 1 (ages 65 to 74 years) -1.067 0.228 -1.513 -0.622*** Elderly 2 (ages 75 years and older) -1.576 0.283 -2.130 -1.022*** †Elderly (ages 55 to 64 years) Social Support 0.666 0.331 0.016 1.315* Church attendance -0.052 0.243 -0.528 0.424 Intercept 0.785 0.722 0.063 1.507Log likelihood = 149.068Pearson Good of Fit test: Chi-square = 102.798, P = 0.985†Reference group*p < 0.05, **p < 0.01, ***p < 0.001 32
    • Chapter 2Happiness, life satisfaction and health status in a Caribbeannation: Using a cross-sectional surveyPaul A. Bourne, Chloe Morris, Denise Eldemire-Shearer, Christopher A.D. Charles & Neva South-BourneNot much is known about the health of older men in Jamaica and the factors that determinehappiness of these individuals. This paper examines happiness, life satisfaction and health statusof older men (55+ years) in Jamaica in order to ascertain whether they are synonymousmeasurements as well as to establish a happiness model for older men. the study used amultistage stratified sample of 2,000 elderly men (42.6% ages 55 to 64 years; 35.6% ages 65 to74 years and 21.9% of ages 75 years and older) to evaluate the psychological wellbeing (iehappiness) of this age cohort. Overall, the general happiness of older men was moderate (40.5%reported that they were happy sometimes) and that this was similar for self-reported health status(55.4% reported good health status). Using ordered probit analysis, the micro-econometrichappiness function of aged men can be explained by employment status; functional status andchurch attendance (ie religious beliefs). Happiness and life satisfaction are highly statisticallyrelated (cc = 0.833, P = 0.001),but happiness is not correlated with health status ( P = 0.767) noris life satisfaction associated with health status ( P = 0.667). This paper has provided us withmuch information on the overall quality of life of elderly men in Jamaica. It has refuted previousliterature which showed that life satisfaction, happiness and health status are synonymousmeasurements. The findings are far reaching can be used to guide future research and howsubjective wellbeing is examined, and how interventions are planned.IntroductionThis paper investigates health, happiness and satisfaction with life of older men in a middle-income developing country. Happiness, life satisfaction, and health status are among some of the 33
    • subjective indexes used to evaluate health (or wellbeing) of an individual, community orpopulation. Subjective indexes cover a wider gamut of an individual‘s life compared todiagnosed health conditions, morbidity, reproductive health and life expectancy. Jamaica hasbeen collecting data since 1989, and this has been used to measure health of the population,gender of the participants and health within area of residence. The use of illness to measurehealth is negative and does not cover health. Happiness therefore like life satisfaction and healthstatus provide a comprehensive coverage of people‘s quality of life than ill-health. The use ofobjective indexes such as diagnosed illness, gross domestic product; life expectancy andmortality are among measured that are said to be limited in scope, and justify the usage of thesubjective indexes by some scholars. Initially when happiness was put forward by Diener1 as a measure of wellbeing, it wasrigorously opposed by some scholars as subjective and so cannot be used to measure health orwellbeing. Many traditional economists believed that happiness was subjective and that thiscould not be precisely measured, and this accounted for their reservations and refusal to accept it.They believed that Gross Domestic Product per capita (GDP per capita) or income per capita wasan objective measure and one that can be precisely quantified unlike happiness, life satisfactionor other subjective indexes. This dates back to classical school of thought. Unlike traditionaleconomists, Diener, a psychologist, theorized that happiness can be used to operationalizedsubjective wellbeing1,2 and this was later adopted by some economists like Easterlin3-6, Frey andStutzer7,8 , Stutzer and Frey9 , Oswald10, Ng11,12 , Veenhoven13,14 and Blanchflower andOswald15. 34
    • Easterlin found a statistical association between happiness and income.3-6 He argued that―The relationship between happiness and income is puzzling‖3 and that people with higherincomes were happier than those with lower incomes; but that economic growth does not meanshappiness. Easterlin used happiness to operationalize subjective well-being, which was found tobe highly correlated with income. He went further when he said that ―Then, with aspirationsessentially the same those with higher income will be better able to fulfill their aspiration and,and other things being equal, on an average, feel better off‖3 Like Easterlin, all theaforementioned economists used happiness to evaluate subjective wellbeing as they accepted thathappiness is an indicator of people‘s judgement of their overall quality of life.13,14 Randomlyselecting Europeans and Americans from the 1970s to 1990s, Di Tella et al.16 using orderedprobit analysis, did not find this complex relation between income and happiness. They howevernoted that some variables such as unemployment, unemployment benefits and others areexogenous variables as they are influenced by political decisions and do influence income. Diener2 argued that well-being can be explained outside of welfare theory and/or purelyobjective utility approach, and this was supported by other scholars.17-21 Arthaud-day et al‘swork22 applied structural modeling and found that subjective well constituted of (1) cognitiveevaluations of ones life (i.e., life satisfaction or happiness); (2) positive affect; and (3) negativeaffective conditions. Unlike Arthaud-day et al, Diener2 proposed that subjective wellbeing can beoperationalized by some basic indicators such as emotional components (‗Taking all thingstogether, how happy would you say you are?‘) and cognitive components or life satisfaction(‗All things considered, how satisfied are you with your life as a whole nowadays?‘). Summers and Heston23 noted that ―…GDPPOP is an inadequate measure of countriesimmediate material well-being, even apart from the general practical and conceptual problems of 35
    • measuring countries national outputs.‖23 Generally, from that perspective, the measurement ofquality of life is, therefore, a highly economic and excludes the psychosocial factors. But, qualityof life extends beyond monetary objectification. Using data for developing countries, Camfield24in looking at well-being from a subjective vantage point noted that subjective well-beingconstitutes the existence of positive emotions and the absence of negative ones within a space ofgeneral satisfaction with life. Cummins21 argued that ‗subjective and objective measures ofmaterial well-being‘ along with the absence of illnesses, efficiency, social closeness, security,place in community, and emotional well-being means that life‘s satisfaction comprehensivelyenvelopes subjective well-being. Diener2 in an article titled ‗Subjective Well-Being: The Scienceof Happiness and a Proposal for a National Index‘ theorized that the objectification of well-beingis embodied within satisfaction of life. This explains the rationale for the use of life satisfactionand/or happiness to operationalize wellbeing instead of GDP per capita (or income per capita). In seeking to operationalize well-being, the United Nations Development Programme(UNDP) supported the inclusion of subjective measures, when they conceptualized humandevelopment as a ―process of widening people‘s choice as well as the level of achievewellbeing.‖25 Embedded within this definition is the emphasis of materialism in interpretingquality of life. Based on UNDP‘s Human Development Index it ―… is a normative measure of adesirable standard of living or a measure of the level of living‖, which speaks to the subjectivityof this valuation irrespective of the inclusion of welfarism (i.e. gross domestic product (GDP) percapita). Another economist writing on ‗objective well-being‘ summarized the matter simply bystating that ―…one can adopt a mixed approach, in which the satisfaction of subjectivepreferences is taken as valuable too.‖26 36
    • Globally, the literature on happiness and life satisfaction is well established, but extensivereview of the literature turned up one study in Jamaica that has examined life satisfaction.27 Inthis paper, the scholars found that women had a lower overall life satisfaction (72%) than men(76%; p=0.04). Employment status; education; gender; union status; church attendance; self-esteem, and current health status were determinants of life satisfaction. In Di Tella et al‘s work,they found income, employment status, interpersonal trust, health status, marital status,education, sex and inflation, the rate of change of consumer prices in the country, unemploymentbenefits, and the number of children in households was predictors of happiness. In descendingorder, they found that marital status, income and employment status had the greatest influence on 16happiness. Di Tella et al. also found that correlation between happiness and life satisfactionwas 0.56. Disaggregating happiness and life satisfaction for the sample, they found that in theUnited States‘ sample, 32.66% was very happy; 55.79% pretty happy and 11.55% not too happy.Further disaggregation of the sample by gender revealed that 31.95% of the males indicatedbeing very happy compared to 33.29% of females. For the European‘s sample, life satisfactionwas 27.29%, very satisfied; 53.72% fairly satisfied; 14.19% not very satisfied and 4.8% not at allsatisfied; with marginally more females reported very satisfied, 27.75% compared to 26.81% ofmales. No study emerged from the literature search on happiness in the Caribbean or inparticular Jamaica and none was found on happiness of elderly people (ages 60 years and older).Although there is very little or research study in the English speaking Caribbean on happiness ofthe general populace or on the elderly population, Stutzer and Frey9 have identified a fewpredictors of happiness using micro-econometric analysis: income; aspiration; andunemployment. Konow and Earley‘s study27 revealed that employment status, positive and 37
    • negative affective conditions; social support and marital status were correlated with happiness;and some of these (ie employment status, marital status, living arrangement, age, education,gender) were also recorded as being statistical associated with happiness in Blanchflower andOswald‘s study.15 Despite having identified predictors of happiness and life satisfaction,Blanchflower and Oswald‘s work found that those variables accounted for a low explanation(Pseudo R2= 0.189 and 0.0232 respectively). Using ordinary least square regression, Easterlin 3established that unemployment as well as income was predictor of happiness. Happiness is related to subjective wellbeing which incorporates the negatives andpositives of how individuals experience their lives. People in different cultures, regions and citiesperceive wellbeing differently as measured by the personal wellbeing index. Spirituality andreligiosity are important additions to personal wellbeing.31 Subjective wellbeing is significantlyinfluenced by personality traits such as extraversion, neuroticism and self esteem. Lifeexperience is also an important factor. Likewise, culture is important because of wealth, and thenormative values guiding the appropriate feelings and the perceived importance of subjectivewellbeing and the cultural tendencies of approach versus avoidance.32 Happiness is the extent towhich people favorably evaluate the overall quality of their life as a whole. As mentioned earlier,this differs from the approach the UNDP uses to evaluating poverty in human developmentwhich is arbitrary. People perceive happiness differently from the perspective of UNDP. Higherlevel of education, better healthcare and increased income does not automatically increasehappiness. Therefore, the UNDP should integrate happiness in its analysis of poverty.33Happiness is not a predictor of longevity among the sick but happiness is a predictor of longevityamong the healthy. This finding suggests that happiness cannot cure sickness but it is a buffer 34against becoming sick. . Others like Pavot and Diener35 and Watson and Clark36 have also 38
    • examined and established the importance of happiness and subjective wellbeing. . A comprehensive examination of the happiness and health status literature in theCaribbean in particular Jamaica found no empirical study that has assessed the happiness statusof older men. Concurrently, researchers have failed to evaluate health status, happiness, lifesatisfaction of older men (ages 55+ years) in spite of the fact that in 2007 they constituted 13.2%of the male population and 6.6% of the general population. This research studies happiness ofolder men (ages 55+ years) in Jamaica. Further in the same period 15.5% of the populationreported having had an illness in a 4-wwek survey period compared to 40.2% of elderly 60+years. Over a twenty year period (1988-2008), women outnumber men in seeking medical careexpect on 4 occasions, suggesting that not examining the subjective wellbeing of men is toeliminate a critical approach in understanding their health behaviour and remedy the lifeexpectancy gap between males and females (6 years). Unlike Blanchflower and Oswald whowere able to show that wellbeing has declined in United States and Great Britain over the last 25years, and that those findings were in keeping with the earlier works of Easterlin29, 30, this paperis the first of its kind and forms the platform for other works in the area. This paper will fill thegap in the literature by examining happiness, life satisfaction and health status in a singleresearch with particular reference to older men in Jamaica.MethodSample The study used primary cross-sectional survey data on men 55+ years from the parish ofSt. Catherine in 2007. The survey was submitted and approved by the University of the WestIndies Medical Faculty‘s Ethics Committee. Stratified multistage probability sampling techniquewas used to draw the sample (2,000 respondents). A132-item questionnaire was used to collect 39
    • the data. Data were collected by way of a self-administered instrument. The instrument was sub-divided into general demographic profile of the sample; past and current health status; health-seeking behaviour; retirement status; social and functional status. Data was stored, retrieved andanalyzed, using SPSS for Windows version 16.0 (SPSS Inc; Chicago, IL, USA). The Statistical Institute of Jamaica (STATIN) maintains a list of enumeration districts(ED) or census tracts. The parish of St. Catherine is divided into a number of constituenciesmade up of a number of enumeration districts (ED). The one hundred and sixty-two (162)enumeration districts in the parish of St. Catherine provided the sampling frame. Theenumeration districts were listed and numbered sequentially and selection of clusters was arrivedby the use of a sampling interval. Forty (40) enumeration districts (clusters) were subsequentlyselected with the probability of selection being proportional to population size. The sampling frame was men fifty-five years and older in the parish of St Catherine. Theparish of St. Catherine was chosen because previous data and surveys37-39 suggest that the parishhas the mix of demographic characteristics (urban, rural and age-composition) similar toJamaica.MeasuresHappiness. This is measured based on people‘s self-report on their happiness. It is a Likert scalequestion, which ranges from always to rarely happy. Health Status. This variable is measuredusing people‘s self-rate of their overall health status, which ranges from excellent to poor healthstatus. The question was ‗How would you rate your health today?‘ (1) Excellent; (2) Good; (3)Fair and (4) Poor. Education. What is [your] highest level of [education] attained? The optionswere (1) no formal education; (2) basic school; (3) primary school/all age; (4) 40
    • secondary/high/technical school; (5) vocational (ie apprenticeship/trade); (6) diploma; (7)undergraduate degree; (8) post-graduate degree. Physical Exercise. ‗Do you take time out forregular exercise?‘ (1) yes and (2) no. Type of physical exercise. ‗ What do you do in terms ofexercise?‘ Childhood illness. ‗Were you seriously ill as [a] child? (1) yes, (2) no. And, were youfrequently ill as a child? (1) yes, (2) no. If the response to either question was yes, this wascoded as poor childhood health status and if the response was no in both cases it was coded agood health status in childhood. Age group is a categorized into three sub-groups. These are (1)ages 55 to 64 years; (2) ages 65 to 74 years; and (3) ages 75 years and older (ie 75+ years). Performance of Activities of Daily Living (ADL) is used to describe the functional statusof a person. It is used to determine a baseline level of functioning and to monitor improvementin activities of daily living (ADL) overtime. There are systems such as the Katz ADL that seek toquantify these functions and obtain a numerical value. These systems are useful for theprioritizing of care and resources. Generally though, these should be seen as rough guidelines forthe assessment of a patient‘s ability to care for themselves. Scoring the ADL findings (Katz etal)40-42 Independence on a given function received a score of 1 point while if dependent, 0 pointwas given. There were 14 items (including daily activities; household chores; shopping; cooking;paying bills). The reliability of the items was very high, α = 0.801. Total scores thus could rangefrom 0-14 with lower scores indicating high dependence and higher scores indicating greaterindependence. Instrumental Activities of Daily Living (IADL). The IADL tool, Lawton &Brody43 was the basis for assessing participants‘ difficulty with IADL which are those activitieswhose accomplishment is necessary for continued independent residence in the community. Theindependent activities of daily living are more sensitive to subtle functional deficiencies thanADL‘s and differentiate among task performance including the amount of help needed to 41
    • accomplish each task. Due to the fact that the study was being conducted among men only,some tasks which are normally done by women would not apply. Thus consistent withinternational practice, the University of Wollongong‘s modified IADL functional ability scalewhich uses a scale of 5 points for men and eight for women was used to assess the IADLfunctional ability of men in the study44. Consequently the domains of food preparation, laundryand housekeeping were omitted in this paper with regard to the Instrumental Activities of DailyLiving for older men. Scoring the IADL. IADL scores reflect the number of areas of impairmenti.e. the number of skills/domains in which subjects are dependent. Scores range from 0-5. Higherscores thus indicate greater impairment and dependence. Hence, Functional status is thesummation of ADL and IADL. Cohen and Holliday45 stated that correlation can be low/weak(r=0–0.39); moderate (r=0.4–0.69), or strong (r=0.7–1). Hence, high dependence ranges from 0to 5.5; moderate dependence is from 5.6 to 9.7 and low dependence (ie independence) rangesfrom 9.8 to 14. Independence means without supervision, direction, or active personal assistance.The performance on the functions can be further classified and analyzed using the format below.The classification recognizes that combinations of independence/dependence with respect toparticular functions reflect the different degrees of levels of capability with respect to ADL. Theclassification outlined above (as developed based on Katz et al 1970 and Katz et al40-42) was usedto further describe the functional status of men with regard to ADL and IADL.43,44 Cognitive functionality (Mini-Mental Status Examination, ie MMSE) measures theMMSE assessment (Kurlowicz, & Wallace46) is probably the most widely used measure ofcognitive functions. It has been suggested that the MMSE has been being helpful in the earlydetection of Alzheimer‘s disease. Elements of the Mini-Mental Status Examination tool used inthis paper have been used internationally to assess the cognitive functional status of older 42
    • persons. Cultural and social aspects of the Jamaican culture were considered in re-designingcertain questions on the MMSE. For example on the question regarding the date of nationalindependence, date of the Queen‘s Birthday was an appropriate substitute. Hence a modifiedversion of the tool was used in this paper. The questions for this paper were (1) ‗What year isthis?‘; (2) ‗What month is this?‘; (3) ‗What day of the week is today?‘; (4) ‗How old are you?‘;(5) Name the Prime Minister of Jamaica?‘; (6) What year did Jamaica got Independence?‘; and(7) Repeat the 3 multiplications times?‘. The domains of primary interest that were measuredwere: orientation to time and the domain of registration of three words. One point was assignedto each right answer and zero for each wrong answer. MMSE Index was the summation of theeach correct answer over the 7 items (α=0.620). Cohen and Holliday45 correlation valuationswere used to categorize MMSE into low/weak (r=0–0.39); moderate (r=0.4–0.69), or strong(r=0.7–1). Hence, high MMSE ranges from 5 to 7; moderate MMSE is from 3 to 4 and lowMMSE (cognitive functionality) ranges from 0 to 2.Statistical analysis Descriptive statistics was employed to provide background information on the sample;chi-square was used to examine non-metric variables, and Ordered Probit Analysis was utilizedto establish the happiness model of older men in Jamaica. The confidence interval for the studywas 95% (ie level of significance was 5%). The exclusion criteria were 1) if more than 20% ofthe cases of a variable were missing, and 2) strong correlation among the independent variables.Cohen and Holliday45 correlation coefficients were used to establish correlation among theindependent variables. Low/weak was (0–0.39); moderate, (0.4–0.69); and strong, (0.7–1).Strong correlation among or between independent variables distort the true impact that thevariable(s) will has/have on the dependent variable. Hence, the present study will mainly report 43
    • on the statistically significant variables. The correlation matrix was examined in order to ascertain if autocorrelation (ormulticollinearity) existed between independent variables. This was used to exclude (or allow) avariable in the model. Any of the independent variables which had moderate to high correlationwas excluded from the model. The correlation between life satisfaction and happiness was 0.633;happiness and social networking (correlation coefficient = 0.12, P = 0.003); happiness andmarital status (correlation coefficient = 0.107, P = 0.026); marital status and income category(correlation coefficient =0.193, P< 0.001); social networking and marital status (r=0.205,P<0.001); social networking and age group (correlation coefficient = 0.188, P<0.001); socialnetworking and occupation (correlation coefficient =0.320, P< 0.001); social networkingeducational category (correlation coefficient =0.420, P<0.001); ADL and age cohort (correlationcoefficient =-0.813, P=0.032); income and occupation (correlation coefficient =0.7775, P <0.001); and, income and education (correlation coefficient =0.356, P<0.001); employment andeducation category (correlation coefficient =0.283, P <0.001). However, there was nocorrelation between happiness and present occupation (p=0.761); happiness and income(P=0.233); happiness and employment status (P=0.516); as well as life satisfaction andemployment status (P=0.261). Hence, life satisfaction and happiness; occupation and incomecategory will not be simultaneously used as explanatory variables.Theoretical background According to micro econometric happiness function, subjective wellbeing (ie happiness)is a function of different variables (including some demographic ones)9 [Model (1)]. Wit = + Xit + it. …………………………………………………………….. [1] 44
    • Where Wit represents subjective well-being, Xit denotes x1, x2, x3, and so on, in which x1to xn are variables – ‗sociodemographic‘, ‗environmental‘, and ‗social‘, ‗institutional‘ and‗economic conditions.‘ In this paper, the literature (ie micro econometric happiness function) will be expanded toinclude health status in childhood, current health status, life satisfaction, and area of residence bytesting this theory using elderly men in Jamaica [Model (1)]. In addition to the aforementionedmicro econometric happiness function, the study will also seek to examine health status.Variables such as happiness, life satisfaction and some demographic variables will beinvestigated simultaneously [Model (2)].Estimation Model The interests of this paper are to examine whether happiness can be predicted by healthstatus as well as employment status, self-reported childhood and current health status onhappiness of elderly men in Jamaica in addition to other socio-demographic variables.Continuing, it is also to investigate whether self-reported happiness differentiate rural and urbanolder men in Jamaica. The multivariate model used in this paper is an expansion of the literaturewhich is displayed in equations (2).HAPPit = β0 + β1HSit + β2HSi(t-1) + β3EMit+ β4FSit+ β5CFit + β6Pit +βijDij+ εi …….....[2]where HAPPit denotes happiness of person i in time period t (current period); HSit means healthstatus of person i in current time period t; HSi(t-1) denotes the childhood health status of period iprevious period (t-1); EMit is employment status of person i in current time period (t); FSit isfunctional status of individual i in current time period t; CFit is cognitive functioning ofindividual i in time period t, and Pit is physical exercise of person i in time period t. Dit = d1, d2, 45
    • d3, d4…..dn, which include sociodemographic (such as home ownership, social support, churchattendance) and socioeconomic of individual i in current time period (t). β0 indicates happiness atthe beginning of the period; β1 to βij denotes the parameter for each variable from variable 1 to j. Because the dependent variable for this paper, happiness, is a non-binary one, orderedprobit analysis was used to estimate the impact of current health status, childhood health status,including other socio-demographic variables (such as employment status, education, maritalstatus, age of elderly, social support, and church attendance) on happiness of elderly men inJamaica. Furthermore, this paper will mainly report the results of those variables that arestatistically significant (p<0.05) [Eqn. (3)].HAPPit = β0 + β3EMit+ β4FSit+ βijDij+ εi …………………………………………………...………...[3]Results: Socio-demographic Characteristics of Sample The sample was 2,000 men ages 55+ years(42.6% were 55 to 64 years; 35.6% were 65 to 74years; 21.9% 75 years and older). Fifty one percent of the sample lived in rural areas, 59.1% hadsocial network, 55.4% reported good health, 53.9% were retired, 25.6% were actively employed,58.8% did not own their homes, and 34.3% were single and 44.7% were married elderly.Majority of the sample had primary or elementary level education (83.1%); 85.9% reported thatthey do not regularly exercise; 82.5% reported good health in childhood; and 88.12% were headsof their households (Table 2.1). One half of the sample indicated that they spent Ja.$100 (US$1.45) monthly for medical expenditure; 34% of the respondents bought their prescribedmedication; 17.1% reported that they have been hospitalized since their sixth birthday and 65.8%reported that they took no medication. Of those who mentioned that they were ill duringchildhood (17.5%, n=350), 34.9% said that the illness was measles or chicken pox, 26.3% 46
    • mentioned asthma, 10.0% pneumonic fever, 8.9% polio, 6.6% accident, 4.6% jaundice, 1.7%hernia, and 5.1% indicated gastroenteritis. Twenty four percent of elderly men indicated that theywere rarely happy, 40.5% said sometimes, 31.0% mentioned often and only 4.5% reportedalways. Furthermore, 17.7% of the sample reported that they were seriously ill as children. Eight percentage of sample reported that they sought medical care whenever they are ill;25.4% knew the name of the medication that they were taking; 38.5% had a retirement healthplan; 28.4% mentioned that good health is ‗physical wellness‘, 9.5% said healthy diet, 3.7%claimed ‗psychological wellness‘, 0.7% functional ability, and 2.0% reported religious activities.In addition, 82.5% of the sample did not respond to the question on health treatment, 7.8%indicated that they used home remedy (include healers), 2.0% said hospitals and 6.2% mentionedclinics, with 1.6% said private doctors. Sixty seven percent of the sample reported doing someform of physical exercise in the survey period. Twenty-four percentage of the Jamaica older men reported that they were rarely happycompared to 5% who indicated that they were always happy (Table 2.1). Majority of the sampleindicated low functional dependence (89.6%), with 1.2% claimed high dependence on otherperson for physical activities (Table 2.1). Happiness is not significantly correlated with health status - χ2 (df=6) = 3.333, P = 0.766(Table 2.2). A significant statistical association existed between happiness and life satisfaction - χ2(df=9) = 1334.448, P = 0.001; with a strong correlation, contingency coefficient = 0.833 (Table2.3). Only 2.4% of sample that indicated rarely satisfied with life was always happy compared to60% of always satisfied with life that was always happiness. However, 1.5% of those whoindicated that they were satisfied with life sometimes were always happy (Table 2.3). 47
    • A cross-tabulation between health status and life satisfaction revealed no significantstatistical relation - χ2 (df=6) = 4.07, P = 0.667 (Table 2.4).Multivariate AnalysisUsing probit analysis, the study tested equation [2] of which happiness being the dependentvariable. Employment status, functional status and one sociodemographic variable (ie churchattendance) were found to be predictors of happiness of older men in Jamaica. Employed oldermen in Jamaica had the greatest happiness, with retired older men accounted for the leasthappiness (Table 2.5). Older men who attended church had greater happiness than those who donot attend (Table 2.5); and that functional status was negatively related to happiness in older menin Jamaica. The model [ie. Equation (2)] is a good fit for the data (χ2= 2,361.773, P <0.001). Unemployed older men‘s coefficient has a small standard error (Columns 1 & 2), whichmeans that the gap between happiness of older unemployed and retired older men is small (Table2.5). Similarly, the gap between the happiness of elderly employed men and retired men wassmall (ie standard error); and the standard error of functional status was low and indicated thatthe disparity in happiness between elderly men who had greater functional status was marginallylower.Limitations to study A single cross-sectional survey cannot be used as the only basis upon which policiesshould be altered; but it forms a platform with which we can begin to examine the health of oldermen outside of the traditional objective indexes of health. Another limitation of the study is thefact that individuals could be retired and actively involved, and this was not examined in thesurvey. In addition to the others, the study was unable to examine income‘s effect on happiness 48
    • as only 25% of the sample was employed and in hindsight no question was asked onconsumption or total expenditure which could have been used to measure income. Anotherlimitation is that participants sometimes give inaccurate information in their self reports.Discussion This paper examined the health, life satisfaction and wellbeing of older men. Theempirical research has established that happiness is a good measure of health (or subjectivewellbeing). In keeping with broader conceptualization of health, happiness is a better measure ofhealth than life expectancy, mortality, morbidity or even self-reported health conditions. Overthe last 2 decades, the Planning Institute of Jamaica and the Statistical Institute of Jamaica haverelied on self-reported health conditions, life expectancy, mortality, morbidity and health care-seeking behaviour in assessing the health status of Jamaicans. This paper found that 24 our ofevery 100 older men in Jamaica were rarely happiness; 5 out of 100 indicated a moderate healthstatus and that there was no significant statistical correlation between happiness and healthstatus; but one existed between happiness and life satisfaction. This paper highlights that healthstatus and happiness as well as health status and life satisfaction are not good predictors ofsubjective health as they are not statistical correlated. However, happiness and life satisfactionare good measures of subjective health as they are moderately related with each other. The correlation between happiness and life satisfaction was greater in this paper(correlation coefficient was 0.633) than that in Di Telli et al‘s study. The disparity between bothstudies did not cease there as substantially more people in the United States were very happy (33out of every 100) than in this sample (5 out of 100); and the figure for males was 33 out of 100.More than 100% more older men in this paper were rarely happy compared to male Americans 49
    • (11.7%). The disparity continues as 7.7 times more males in the Europe were very satisfied withlife (or always satisfied) compared to elderly males in Jamaica. On the other side of the lifesatisfaction spectrum (ie rarely satisfied or not at all satisfied), 6.8 times more elderly males inJamaica reported rarely satisfied compared to European males. 47 Subramanian et al.‘s work found that people with physical disabilities had similarlevels of happiness as fully functional people. An interesting conclusion of this paper, which concurs with the literature, is thecorrelation between happiness and employment status. The literature showed that theunemployed men had lower happiness than employed people15, and this went further as it foundthat the retired elderly men were less happy than the employed; but greater than that for theunemployed. Apart of the explanation for this is may be embedded in psychological state of menpost employment which includes 1) the lost social networks, 2) joblessness, 3) the reducedincome, and lowered levels of self-respect. Happiness, according to Easterlin6 is associated withwellbeing, and so does ill-being (for example depression, anxiety, dissatisfaction). Easterlin6argued that material resources have the capacity to improve someone‘s choices, comfort level,state of happiness and leisure, which militates against static wellbeing. The reverse is true asretirement means not having access to income from employment, and thereby reduces people‘scapacity to purchase material and other resources. Outsides of those realities, self-respect andsocial relationships are linked to employment, and a group of scholars found that the impact of 48unemployment is even greater than the loss income, re-emphasizing the negativepsychological state which accompanies unemployment as well as retirement. This offers someexplanation for the negative relation between unemployment and life satisfaction, and 50
    • unemployment and happiness as an aspect to people‘s quality of life is reduced and these are notcaptured in life expectancy measurement. If retirement comes with other social involvement, theeffects of unemployment will mitigate against and this may not eliminate the loss ofunemployment as it may not offset the degree of socio-economic lost job. Two economists studied the ‗impact of wealth and income on subjective wellbeing andill-being‘; they found that employed people had a higher life and financial satisfaction than theirunemployed counterparts49. Using linear regression analysis, researchers47 found that theemployed had a coefficient of 0.77 in life satisfaction compared to unemployed -3.00; and in thecase of financial satisfaction it was 5.52 and -11.52 respectively. Another study provides furtherexplanations for lower happiness among retired and unemployed persons than employedindividuals. The Cornel Study of Retirement ―estimated that the average retired person‘s incomedeclined to 56 percent of pre-retirement income‖50 Palmore50 argued that ‗tax advantage‘,‗housing subsidies‘, ‗Medicare‘ and ‗income tax‘ exemptions offset this. However, for the retiredperson in Jamaica, there is no such thing as housing subsidy, and the National Drug for theelderly programme coverage is minimal and thereby goes not offset the income fromemployment. Men substantially tie their success with the ability to provide and this is howimportant income and employment are. Hence, by not paying income tax and receiving socialand other types of assistances, this deteriorates the psychological state of men and accounts forthe lowered happiness. The inverse correlation between subjective wellbeing and unemploymentextends beyond that relation to unemployment causing depression, anger, anxiety, loss self-esteem and disruption in social life. A group of researchers found that even after controlling forfall in income, unemployment inversely influence wellbeing.51 51
    • There is little debate within the public arena about the increasing decline of the labourforce participation rate of aged Jamaicans. In 1980, the labour force participation rate (in %) was46.4% and it is estimated to be 26.6% in 2007. This represents a 43% reduction in the number ofaged persons ≥ 65 years who were actively involved in the labour force. When the labour forceparticipation rate is decomposed by gender, the figures reveal a more telling disparity. As forfemales, in 1980, there were 30.4% of women actively involved within the labour force, but it isestimated to be 13.8% in 2007, which is a 55% reduction in the number of employed females.With respect to males‘ involvement in the labour force, it is projected to fall to 41.4% in 2007,which is coming from 65.3% in 1980. The labour force participation rate for men will fall by23% compared to that of females that will decline by 55%. This is within the context of femalesliving longer than their male counterparts, and that the retirement age for females is 60 years andnot 65 years. Therefore, if we are to extrapolate a reduced 5 years for females, the labour forceparticipation rate will increase further by at least a percentage point. With retirement and unemployment at older ages (60 years and older for women and 65years and older for men), the family and other social network must replace this lost income.Statistics from the Planning Institute of Jamaica and the Statistical Institute of Jamaica52 showedthat 26.6% of Jamaica received remittances and that the rate rose by 57% (to 41.8%), whichemphasizes the role of the family and social support in supplementing income of man peopleincluding the retired and unemployed elderly men. Eldemire53 agreed with this finding, when sheopined that the loss of financial resources (ie income or employment) result in changes in thelifestyle practices of older peoples as retirement result of changes in their financial base.Unemployment or retirement means that those people must now use their past savings(dissavings) or social support to meet current food and other expenditures. This means that 52
    • financial inadequacies will prevent the individual from accessing food and nutritional needs aswell as the inability to meet utilities and other expenses. The issue of resource insufficiency affects the ability and capacity of the poor elderly andother older unemployed and retired men from accessing the quality of goods and servicescomparable to the rich that are better able to add value to wellbeing and by extension theirhappiness with life. This paper disagrees with Di Tella et al.‘s work16 which found the leasthappiness for the unemployed; but both research agree that the employed had the greatest levelof happiness, indicating that these are constant across America and some European nations aswell as in developing states like Jamaica. According to Kart55, religious guidelines aid wellbeing through healthy behaviouralhabits such as smoking, drinking of alcohol, and even diet. Researchers found that a positiveassociation exists between religion and wellbeing.55, 56 Using church attendance to measurereligious status of older men, this work supports the literature that happier people attend churchthan those who do not. The relationship was even stronger for men than for women, and that thisassociation was influenced by denominational affiliation. Graham et al‘s study57 found thatblood pressure for highly religious male heads of households in Evan County was low. Thefindings of this research did not dissipate when controlled for age, obesity, cigarette smoking,and socioeconomic status. A study on the Mormons in Utah revealed that cancer rates werelower (by 80%) for those who adhere to Church doctrine than those with weaker adherence.58 Aged individuals experience changes in sensory processes, perception, motor skill andproblem-solving ability. Their perception, self-esteem, drives, mental health status, and emotionsare frequently altered3,48,59-62 because of the psychological and physiological changes caused 53
    • through psychopathological conditions of ageing. People‘s cognitive responses to ordinary andextraordinary situational events in live are associated with different typology of wellbeing. 60 It isfound that happier people are more optimistic and as such conceptualize life‘s experiences in apositive manner. Studies revealed that positive moods and emotions is associated with wellbeing61 as the individual is able to think, feel and act in ways that foster resource building and 62involvement with particular goal materialization. This situation is later internalized, causingthe individual to be self-confident from which follows a series of positive attitudes that guidesfurther actions.63 Positive mood is not limited to active responses by individual, but a studyshowed that ―counting one‘s blessings,‖ ―committing acts of kindness‖, recognizing and usingsignature strengths, ―remembering oneself at one‘s best‖, and ―working on personal goals‖ allpositively influence wellbeing. An interesting finding of this paper is the explanatory power of the micro-econometrichappiness equation. The micro-econometric happiness equation of this paper was 32%, which isgreater that in Blanchflower and Oswald‘s work15 (Pseudo R2=4.4% for men in the UnitedStates). Although Di Tella et al‘s work16 was not on older men, they found that majority of menin the United States were pretty happy (56 out of every 100) which was similar for older men inJamaica (41 out of every 100). Only 12 out of every 100 men in the United States reported being‗not too happy‘ compared to 24 out of every 100 older men in Jamaica (ie. ‗rarely happy). Thework of Di Tella et al. used data from the 1970‘s to the 1990‘s and the present study used datafor 2007, so the disparity may be wider or narrower in 2007 for both nations. The literature empirically established that happiness is correlated with health status; butno study found a strong relation between those two variables. Easterlin 19 found that since World 54
    • War II in developed nations, the association between those aforementioned variables is negativeand even non-existence. This paper concurs with Easterlin as no significant correlation wasfound between the variables in question. This paper provides some critical findings in the understanding of older men in Jamaica.Happiness is not statistical correlated with health status as well as life satisfaction and healthstatus, while life satisfaction and happiness are good measures of subjective health (iewellbeing). Interestingly therefore is that not all three subjective indexes (life satisfaction,happiness and health status) are good measures of each other. Employed older men are happierthan unemployed ones; and that spirituality increases happiness and by extension life satisfactionof older men in Jamaica. This paper contradicts the literature that life satisfaction, happiness andhealth status are synonymous measures. Although the present research shows that the afore-mentioned measures are no all synonymous, the limitation of only using older men does notinvalidate the findings. Thus, this adds information to the current literature but the issue as towhether this hold true for the same cohort of females and the younger population are stillunresolved and need further examination.ConclusionIn sum, happiness is strongly related to life satisfaction but not to health status, and lifesatisfaction is not statistically associated with health status, suggesting that older men make adistinction between happiness as well as life satisfaction and health status. This denotes thatsatisfaction with life and happiness are good proxy for each other, but neither life satisfaction norhappiness are associated with health status. The present study highlight a differential in the threeidentified variable as older Jamaicans generally view health as illness and so happiness and life 55
    • satisfaction is a more holistic measure than health status. Thus, happiness or life satisfactioncannot be used as independent variable in each other‘s model. Health is a narrower measure forquality of life than life satisfaction or happiness. Inspite of the broad definition of health as wasforwarded by WHO in the late 1940s, health for older men in Jamaica is still narrowlyconceptualized and cannot be used to measure quality of life (or subjective wellbeing) likehappiness or life satisfaction. There is also the issue of gender where the literature suggest that less women are apart ofthe labor force than men. This situation, the feminists argue, is due to the glass ceiling in thesociety which denies Jamaican women their rights and opportunities because of their gender. Therole of the glass and grey ceilings on the wellbeing of older Jamaican women should beresearched. This is another double burden in addition to the well known double burden ofprofessional work and housework that constrains the professional and economic success ofwomen and hence their wellbeing. The findings are far reaching can be used to influence patientcare outcome as well as other policy intervention programmes.References 1. Diener E. Subjective well-being. Psychological Bulletin 1984; 95: 542–75. 2. Diener E. Subjective well-being: the science of happiness and a proposal for a national index. Am Psychologist 2000; 55: 34–43 3. Easterlin RA. Income and happiness: Towards a unified theory. The Economic Journal 2001; 111:465-484. 4. Easterlin RA. Life Cycle Welfare: Evidence and Conjecture. Journal of Socio-Economics 2001; 30:31-61. 5. Easterlin RA. How Beneficent Is the Market? A Look at the Modern History of Mortality, the Reluctant Economist. Cambridge: Cambridge University Press 2004; 101- 38. 6. Easterlin RA. Building a better theory of well-being. Prepared for presentation at the Conference Paradoxes of Happiness in Economics, University of Milano-Bicocca, March 21-23, 2003. 56
    • 7. Frey BS, Stutzer A. Happiness, Economy and Institutions. Economic Journal 2000; 110:918-938.8. Frey BS, Stutzer A. Happiness and Economics. Princeton University Press; 2002.9. Stutzer A, Frey BS. 2003. Reported subjective well-being: A challenge for economic theory and economic policy. Working paper No. 07. Center for Research in Economics, Management and the Arts; 200310. Ng YK. Happiness Surveys: Some Comparability Issues and an Exploratory Survey Based on Just Perceivable Increments. Social Indicators Research 1996; 38:1-27.11. Ng YK. A Case for Happiness, Cardinalism and Interpersonal Comparability. Economic Journal 1997; 107:1848-1858.12. Oswald AJ. Happiness and Economic Performance. Economic Journal 1997; 107:1815- 1831.13. Veenhoven R. Is Happiness Relative. Social Indicators Research 1991; 24:1-34.14. Veenhoven R. Happiness in Nations: Subjective Appreciation of Life in 56 Nations, 1946-1992. Erasmus University Press, Rotterdam; 1993.15. Blanchflower DG, Oswald AJ. Well-Being Over Time In Britain And The USA. Journal of Public Economics, 2004, 88(7-8,Jul):1359-138616. Di Tella R, MacCulloch RJ, Oswald AJ. The macroeconomics of happiness. Review of Economics and Statistics 2003;85:809-827.17. Liang J. Dimensions of the Life Satisfaction Index A: A structural formulation. Journal of Gerontology, 1984; 39:613-622.18. Kimball M, Willis R. Utility and happiness; 2005. Available at: www.stanford.edu/group/SITE/papers2005/Kimball.05.doc. Accessed on: August 31, 2006.19. Diener E, Suh M, Lucas E, Smith H. Subjective well-being: Three decades of progress. Psychological Bulletin 1999; 125:276-302.20. Diener E, Suh E. Measuring quality of life: Economic, social subjective indicators. Social Indicators Research1997; 40:189-216.21. Cummins R. Self-rated quality of life scales for people with an intellectual disability: a review. Journal of Applied Research in Intellectual Disabilities 1997; 10:199–216.22. Arthaud-day ML, Rode JC, Mooney CH, Near JP. The Subjective Well-being Construct: A Test of its Convergent, Discriminant, and Factorial Validity. Social Indicators Research, 2005; 74(3):445-476.23. Summers R, Heston A. Standard of Living: SLPOP An Alternative Measure of Nations Current Material Well-Being. CICUP 95-5. Available at: http://pwt.econ.upenn.edu/papers/standard_of_living.pdf. Accessed on: January 24, 2006.24. Camfield L. Using subjective measures of wellbeing in developing countries. Glasgow, Scotland: University of Strathclyde; 2003.25. United Nations Development Programme. Human Development Report, 1997. New York, United States: UNDP; 1997.26. Gaspart F. Objective measures of well-being and the cooperation production problem. Social Choice and Welfare 1998; 15 (1):95-112.27. Hutchinson G, Simeon DT, Bain BC, Wyatt GE, Tucker MB, LeFranc E. Social and Health determinants of well-being and life satisfaction in Jamaica. International Journal 57
    • of Social Psychiatry 2004; 50(1):43-53.28. Konow J, Earley J. The Hedonistic Paradox: Is Homo-Economicus Happier? Mimeo, Loyola Marymount University, Dept. of Psychology; 1999.29. Easterlin RA. Does Economic Growth Improve the Human Lot? Some Empirical Evidence in Nations and Households in Economic Growth: Essays in Honour of Moses Abramowitz, Ed David PA, Reder MW, Academic Press, New York and London; 1974.30. Easterlin RA. Will Raising the Incomes of All Increase the Happiness of All? Journal of Economic Behavior and Organization1995; 27:35-47.31. Wills E. Spirituality and subjective wellbeing: Evidence for a new domain in the personal wellbeing index. Journal of Happiness Studies 2009; 10: 49-69.32. Diener E, Oishi S, Lucas RE. Personality, culture and subjective wellbeing: Emotional and cognitive evaluations of life. Annual Review of Psychology 2003; 54:403-425..33. Schimmel J. Development as happiness: The subjective perception of happiness and UNDP‘s analysis of poverty, wealth and development. Journal of Happiness Studies 2009; 10:93-111.34. Veenhoven R. Healthy happiness: Effects of happiness on physical health and the consequences of preventive health care. Journal of Happiness Studies 2008; 9:449-469.35. Pavot W, Diener E. Review of the Satisfaction with Life Scales. Psychological Assessment 1993; 5:164-172.36. Watson D, Clark LA. Self Versus Peer Ratings of Specific Emotional Traits: Evidence of Convergent and Discriminant Validity. Journal of Personality and Social Psychology 1991; 60:927-940.37. Statistical Institute of Jamaica. Population Census 2001 (Volume 8): Marital and Union Status. Kingston, Jamaica: Statistical Institute of Jamaica; 2004.38. Wilks R. Hypertension in the Jamaican Population. A presentation to the Trinidad & Tobago National Consultation on Chronic Non-Communicable Diseases, September 2007.39. Jackson M, Walker S, Forrester T, Cruickshank J, Wilks R. Social and dietary determinants of body mass index in Jamaican of African. European Journal of Clinical Nutrition 2003; 57:621-627.40. Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffe MW. Studies of illness in the ages. The index of ADL: standardized measure of biological and psychosocial function. JAMA, 1993; 185 (12):914-919.41. Katz, D.L., Brunner, R.L., St. Jeor, S.T. et al. Dietary fat consumption in a cohort of American adults, 1985-1991: covariates, secular trends, and compliance with guidelines, American Journal of Health Promotion, 1998; 12 382- 390.42. Katz, S., Down, T.D., Cash, H.R., & Grotz, R.C. Progress in the development of the index of ADL. The Gerontologist, 1970;10(1), 20-30.43. Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist. 1969; 9(3):179-86.44. Centre of Health Service Development, Faculty of Health and Behavioural Sciences University of Wollongong; Towards a National Measure of Functional Dependency for 58
    • Home Care Services in Australia: Stage 1 report of the HACC dependency data items project 2000 updated 2001.45. Cohen L, Holliday M. Statistics for Social Sciences. London, England: Harper and Row, 1982.46. Kurlowicz L, Wallace C. The Mini Mental State Examination (MMSE) Number 3, Series. Hartford Institute of Geriatric Medicine; 199947. Subramanian SV, Kin D, Kawachi I. Covariation in the socioeconomic determinants of happiness: A multivariate multilevel analysis of individuals and communities in the USA. Journal of Epidemiology and Community health 2005; 59:664-669.48. Winkelmann L, Winkelmann R. Why are the unemployed so unhappy? Evidence from panel data. Economics 1998; 65:1-15.49. Wooden M, Headey B. The effects of wealth and income on subjective well-being and ill-being. Australia: Melbourne Institute of Applied Economic and Social Research; 2004.50. Palmore E. Social patterns in normal aging: Findings from the Duke longitudinal study. United States of America: Duke University Press; 1981.51. Clark AE, Frijters P, Shields MA. Income and happiness: evidence, explanations and economic implication. Working paper No. 5. National Center for Econometric Research; 2006.52. Planning Institute of Jamaica, (PIOJ), Statistical Institute of Jamaica (STATIN). Jamaica Survey of Living Conditions, 2007. Kingston: PIOJ, STATIN; 2008.53. Eldemire D. The Elderly and the Family: The Jamaican Experience. Bulletin of Eastern Caribbean Affairs, 1994; 19:31-46.54. WHO. World report on violence and health. Geneva, Switzerland: WHO; 2002.55. Kart CS. The Realities of Aging: An introduction to gerontology, 3rd. Boston, United States: Allyn and Bacon; 1990.56. Moody HR. Is religion good for your health? Gerontologist 2006:147-149.57. Graham TW, Kaplan BH, Cornoni-Huntley JC, James SA, Becker C, Hames CG, Heyden S. Frequency of church attendance and blood pressure elevation. Journal of Behavioral Medicine 1978; 1:37-43.58. Gardner JW, Lyon JL. Cancer in Utah Mormon men by lay priesthood level. American Journal of Epidemiology 1982; 116:243-257.59. Diener E, Larson RJ, Levine S, Emmons RA. Intensity and frequency: Dimensions underlying positive and negative affect. Journal of Personality and Social Psychology, 1985; 48:1253-1265.60. Lyubomirsky S. Why are some people happier than others? The role of cognitive and motivational process in wellbeing. American Psychologist 2001; 56:239-249.61. Leung BW, Moneta G, McBride-Chang C. Think positively and feel positively: Optimism and life satisfaction in late life. International Journal of Aging and human development 2005; 61:335-365.62. Lyubomirsky S, King L, Diener E. The benefits of frequent positive affect: Does happiness lead to success? Psychological Bulletin 2005; 6, 803-855. 59
    • 63. Sheldon K, Lyubomirsky S. How to increase and sustain positive emotion: The effects of expressing gratitude and visualizing best possible selves. Journal of Positive Psychology 2006; 1:73-82. 60
    • Table 2.1: Socio-demographic Characteristics of SampleVariable Frequency PercentCognitive Functionality Low 19 1.0 Moderate 99 4.9 High 1882 94.1Functional Status High dependence 24 1.2 Moderate dependence 184 9.2 Low dependence 1792 89.6Age group 55- 64 years 851 42.5 65 – 74 years 712 35.6 75 years and older 437 21.9House Ownership Yes 824 41.2 No 1176 58.8Employment Status Employed 511 25.5 Unemployed 412 20.6 Retired 1077 53.9Happiness Rarely 480 24.0 Sometimes 810 40.5 Most times 620 31.0 Always 90 4.5Self-rated Health Status Excellent 357 19.0 Good 1038 55.4 Fair 480 25.6Social Networking Yes 817 59.1 No 1183 40.9Regular Exercise Yes 282 14.1 No 1718 85.9Childhood Health status Good 1650 82.5 Poor 350 17.5Area of residence Urban 981 49.0 Rural 1019 51.0 61
    • Table 2.2. Happiness and Health StatusHappiness Health status Excellent Good Fair (Moderate) Total n (%) n (%) n (%) n (%)Rarely 86 (24.1) 261 (25.1) 107 (22.3) 454 (24.2)Sometimes 137 (38.4) 424 (40.8) 202 (42.1) 763 (40.7)Most times 117 (32.8) 313 (30.2) 148 (30.8) 578 (30.8)Always 17 (4.7) 40 (3.9) 23 (4.8) 80 (4.3)Total 357 1038 480 1875χ2 (df=6) = 3.333, P = 0.766 62
    • Table 2.3. Happiness and life satisfaction Life Satisfaction Happiness Rarely Sometimes Most times Always Total Rarely 348 (52.9) 82 (12.2) 40 (6.7) 10 (14.3) 480 (24.0) 172 (26.2) 466 (69.1) 160 (26.7) 12 (17.1) 810 (40.5) Sometimes 122 (18.5) 116 (17.2) 376 (62.9) 6 (8.6) 620 (31.0) Most times 16 (2.4) 10 (1.5) 22 (3.7) 42 (60.0) 90 (4.5) Always Total 658 674 598 70 2000Χ2 (df = 9) = 1334.448, P = 0.001, contingency coefficient = 0.833 63
    • Table 2.4. Health status and life satisfaction Life Satisfaction Health status Rarely Sometimes Most times Always Total Excellent 113 (18.4) 112 (17.5) 121 (21.7) 11 (17.7) 357 (19.0) 346 (56.3) 358 (55.8) 299 (53.7) 35 (56.5) 1038 (55.4) Good 156 (25.4) 171 (26.7) 137 (24.6) 16 (25.8) 480 (25.6) Fair Total 615 641 557 62 1875χ2 (df = 6) = 4.07, P = 0.667 64
    • Table 2.5: Happiness Equation for Older Men in Jamaica (Ordered Probit Regression)Dependent variable: ReportedHappiness Coefficient Z P CI (95%) Unemployed 0.164 2.386 0.017 0.029 - 0.300 Employed 0.213 3.411 0.001 0.091 - 0.335 Functional status Index -0.035 -2.779 0.005 -0.060 - -0.010 Logged Cognitive functioning Index 0.005 0.037 0.970 -0.232 - 0.241 Dummy Home Dwelling -0.080 -1.404 0.160 -0.193 - 0.032 Dummy Brother Alive -0.103 -1.296 0.195 -0.259 - 0.053 Dummy Sister Alive 0.019 0.283 0.777 -0.114 - 0.153 Dummy Exercise 0.012 0.190 0.850 -0.114 - 0.138 Dummy Mother Alive -0.019 -0.266 0.790 -0.160 - 0.122 Dummy Father Alive -0.076 -0.888 0.374 -0.244 - 0.092 Dummy Have Children 0.005 0.035 0.972 -0.264 - 0.273 Dummy Education 0.105 1.037 0.300 -0.093 - 0.303 Church Attendance 0.192 2.574 0.010 0.046 - 0.338 Social Support 0.154 1.871 0.061 -0.007 - 0.315 Urban Area -0.033 -0.632 0.528 -0.136 - 0.070 Childhood Health Status -0.022 -0.365 0.715 -0.141 - 0.097 Current Health Status -0.019 -0.296 0.767 -0.148 - 0.109 Intercept -0.719 -2.422 0.015 -1.016 - -0.422Pearson Goodness of fit Test - Chi-square = 2,361.773, P < 0.001n = 1,873Pseudo R2 = 0.320Log likelihood = 755.268 65
    • Chapter 3A cross-sectional survey of the health status, life satisfaction andhappiness of older men in Jamaica - associations betweenquestionnaire scores Paul A. Bourne, Chloe Morris & Denise Eldemire-ShearerEmpirical evidences have shown that happiness, life satisfaction and health status are stronglycorrelated with each other. In Jamaica, we continue to collect data on health status to guidepolicies and intervention programmes, but are these wise? This paper aims to fill the gap in theliterature by examining life satisfaction, health status, and happiness in order to ascertainwhether they are equivalent concepts in Jamaica as well as the coverage of the estimates. Thispaper used a cross-sectional survey of 2000 men 55 years and older from the parish of St.Catherine in 2007. Data were stored, retrieved and analysed using SPSS for Window version15.0 (SPSS Inc; Chicago, IL, USA). Ordinal logistic regression techniques were utilized toexamine determinants of happiness, life satisfaction and health status. Happiness was correlatedwith life satisfaction - Pseudo r-squared = 0.311, -2LL = 810.36, χ2 = 161.60, P < 0.0001. Lifesatisfaction was determined by happiness - Pseudo r-squared = 0.321, -2LL = 1069.30, χ2 =178.53, P < 0.0001. Health status was correlated with health status age, income, education andarea of residence - Pseudo r-squared = 0.313, -2LL = 810.36, χ2 = 161.60, P < 0.0001. Thispaper refuted the empirical finding that there is an association between self-reported happinessand health status, but one between life satisfaction and happiness. This shows the geopoliticaldifferences as well as age in determining these associations.IntroductionFor many centuries, health was measured on the further extreme of the illness pendulum. Healththerefore meant that people were not experiencing physical illnesses (or ailments). This approachwas negative in scope [1], but the advantage of this measure was its precision in objectification. 66
    • Illness (or ill-health) denotes being diagnosed with a particular pathogen which caused thepresent state. It follows that the hospital system, technology, the study of medicine and treatmentof ill-health was fashioned around this biomedical approach. The biomedical approach (ormodel) was more than dominant in medicine, technology, health care system and treatment of ill-health, but people used this as a definition of their wellbeing (or ill-being). Then in the 1940s, theWorld Health Organization recognizing the uni-dimensional nature of this measure forwarded aconceptual definition of health that argued for the inclusion of social, economic andpsychological conditions in the study of health. This was documented in the Preamble to theWHO‘s Constitution in 1946 [2]. Engel, a psychiatrist, apparently adopted the broad conceptualframework offered by the WHO, when he forwarded a ‗biopsychosocial model‘ in the treatmentof mentally ill patient [3-6]. He opined that the people are as such body as they are social,psychological and economic being. This means that patient care should not be solely about thebiological conditions of the ill-patient, but on the psychosocial and economic components. Many decades later, many scholars continue to use morbidities and mortality in thediscussion of health and health outcome [7-12]. This is also the practice by Latin America andCaribbean scholars [13-25]. Again the dominance of morbidities and mortality studies are owingthe (1) structure of the world around the biomedical model, (2) objectivity of those measures and(3) training of many scholars that knowledge through the objective science is superior tosubjective (or ―soft‖) science. This is reinforced by Bok who opined that the WHO‘sconcepualisation of health is too broad and so can be objectively measured and operationalizedfor researchers to use with the element of subjectivity and by this reducing the objectivity of themeasure. While the WHO‘s conceptual definition of health includes an element of subjectivity,this in no way diminish the quality of science or information that is obtained from people. The 67
    • WHO introduced wellbeing in the discussion of health measurement, and this is an expansionfrom the negative approach to the conceptualisation of health. Embodied in wellbeing is measure of people living standard or general life, whichextends beyond illness (or ill-health) [2, 26, 27]. The dominance of positivism or quantitativescholars like the arguments raise in health opined that wellbeing must be measure usingquantifiable approach such as income, expenditure, consumption, Gross Domestic Product or percapita income [28-30]. In a material entitled ‗Objective measures of wellbeing and thecooperation production problem‘, Gaspart [28] provided arguments that support the rationalebehind the objectification of wellbeing. His premise for objective quality of life is embeddedwithin the difficulty as it relates to consistency of measurement when subjectivity is the constructof operationalization. This approach takes precedence because an objective measurement ofconcept is of exactness as non-objectification; therefore, the former receives priority over anysubjective preferences. He claimed that for wellbeing to be comparable across individuals,population and communities, there is a need for empiricism. According to WHO, health is multifaceted. If ―Health is state of complete physical,mental and social well, and not merely being the absence of disease or infirmity‖ [2], thensubjectivity must be an aspect of its measurement. In order to forward an understanding of whatconstitutes wellbeing or ill being, a system must be instituted that will allow us to coalesce ameasure that will unearth peoples‘ sense of overall quality of life from either economic-welfarism [31] or psychological theories [32-35]. The discourse on people‘s assessment of theirlives was driven by their experiences including cognitive judgements and affective reactions[36]. This meant that the study of wellbeing could now expand to include subjective measures 68
    • such as self-rated health, life satisfaction, and happiness [37]. Wilson [37] found that happierpeople were healthier, well-educated, well-paid, extroverted, optimistic, worry-free, religious,married, and of high self-esteem among other positive psychological conditions. One scholaropined that satisfaction with life and positive affective conditions were among subjectivewellbeing as happiness [36]. The uses of subjective indexes such as happiness, life satisfaction,perceived quality of life or wellbeing have been examined by even some economists [38-44].The economists have only concurred with what psychologists have been postulating for years[32-35]. An economist in the 1970 utilized another subjective index (i.e. self-reported health statusor health status) to measure health [45]. Ringen [46] in a paper entitled ‗Wellbeing,measurement, and Preferences‘ argued that non-welfarist approaches to measuring wellbeing arepossible despite its subjectivity. The direct approach for wellbeing computation through theutility function according to Ringen is not a better quantification as against the indirect method(i.e. using social indicators). The stance taken was purely from the vantage point that utility is afunction ‗not of goods and preferences‘ but of products and ‗taste‘. The constitution ofwellbeing is based on choices. Choices are a function of individual assets and options. With thispremise, Ringen forwarded arguments which show that people‘s choices are sometimes‗irrational‘, which is the make for the departure from empiricism. Many empirical studies have been done on the using particular subjective indexes such ashappiness, self-reported health status and/or health conditions to measure health or wellbeing. Inthe Caribbean Hambleton et al. [47] utilized health status and health conditions and found that astrong correlation between both variables. Another group of Caribbean scholars used self- 69
    • esteem, life satisfaction, and health status to assess wellbeing, but that these were not all tested inone multivariate analysis [48]. They used illnesses (i.e. acute and chronic) to measure health.Concurrently, it was revealed that acute illnesses were not correlated with wellbeing but therewas a statistical correlation between chronic illness and wellbeing. Using wellbeing and lifesatisfaction as dependent variable, they found that illnesses were not correlated with thedependent variable. In a non-Caribbean clinical gerontology study, the researchers found thatneither self-rated health nor illness (i.e. chronic, neurological or surgical) was correlated withphysical action on fear of falling [49]. There are also studies on happiness and health status [50].However in Jamaica 2007 was the first time in 2 decades (1988-2008) that the Planning Instituteand the Statistical Institute began collection data on health status and health conditions. Inprevious years, they collected data on illnesses, but is health and illness wide enough conceptthat measure wellbeing. This paper aims to fill the gap in the literature by examining threehypotheses (1) factors of life satisfaction, (2) determinants of health status, (3) variables that areassociated with happiness, in order to ascertain whether life satisfaction, health status andhappiness are equivalent concepts in Jamaica as well as the coverage of the estimates. Thisresearch will use primary cross-sectional survey data on older men (ages 55+ years) to assess theaforementioned issue.Method and MeasureThe study used primary cross-sectional survey data on men 55 years and older from the parish ofSt. Catherine in 2007; it also generalizable to the island. The survey was submitted and approvedby the University of the West Indies Medical Faculty‘s Ethics Committee. Stratified multistageprobability sampling technique was used to draw the sample (2,000 respondents). A132-item 70
    • questionnaire was used to collect the data. The instrument was sub-divided into generaldemographic profile of the sample; past and Current Good Health Status; health-seekingbehaviour; retirement status; social and functional status. The Statistical Institute of Jamaica (STATIN) maintains a list of enumeration districts(ED) or census tracts. The parish of St. Catherine is divided into a number of constituenciesmade up of a number of enumeration districts (ED). The one hundred and sixty-two (162)enumeration districts in the parish of St. Catherine provided the sampling frame. Theenumeration districts were listed and numbered sequentially and selection of clusters was arrivedby the use of a sampling interval. Forty (40) enumeration districts (clusters) were subsequentlyselected with the probability of selection being proportional to population size (Table 3.1). The enumeration districts in the parish of St. Catherine provided the sampling frame andthe sample size determined with the help of the Statistical Institute of Jamaica (STATIN). Theenumeration districts were listed and single-stage cluster sampling was used to select the sample.The enumeration districts were numbered sequentially and selection of clusters was arrived at bycalculating a sampling interval. From a randomly selected starting point, forty (40) enumerationdistricts (clusters) were subsequently selected with the probability of selection being proportionalto population size. It was determined that 50 older men in each enumeration district would beinterviewed yielding a sample size of 2000. The parish of St. Catherine had approximately 233,052 males, (preliminary census data2001) of which 33,674 males were 55+ years. STATIN maintains maps with enumerationdistricts or census tracts which included the selected EDs and access routes and had references tothe selected site of a starting point household within each ED. The starting point was determined 71
    • by randomly selecting a household with a man 55 years and over from the list of persons in theED. With this information the interviewers would travel in a north-easterly or closest to north-easterly direction beginning with the first selected household, and would conduct interview untilthe requisite number of interviews for that ED was completed. (North-East was randomlyselected by STATIN as the direction of travel from the starting point). Where the selected household was found to be subsequently devoid of an older man (dueto out-migration or death), an adjacent household was canvassed. Where households had a man55+ years as a resident and he was not at home a call-back form was left indicating a proposedtime that the interviewer would return which would not be longer than two days after the initialvisit. In households where there was more than one man 55 years old and over, then all wereincluded in the survey. The sample population does not only speak to the parish of St. Catherine, it isgeneralizable to the island of Jamaica. The sampling frame was men fifty-five years and older inthe parish of St Catherine. The parish of St. Catherine was chosen as previous data and surveys[13, 17, 27] suggest that it has the mix of demographic characteristics (urban, rural and age-composition) which typify Jamaica.MeasuresHappiness. This is measured based on people‘s self-report on their happiness. It is a Likert scalequestion, which ranges from always to rarely happy.Current Health Status. This variable is measured using people‘s self-rate of their overall healthstatus, which ranges from excellent to poor health status. The question was ‗How would you rateyour health today?‘ (1) Excellent; (2) Good; (3) Fair and (4) Poor. 72
    • Life satisfaction is a Likert scale variable which is measured from ‗Generally, are you satisfiedwith your life?‘ The options were (1) rarely, (2) sometimes, (3) most times, and (4) always.Social network is self-reported involvement in church; civic organization; social clubs; orcommunity groups. This is a binary variable, where 1=social network, 0=otherwise.Education. What is [your] highest level of [education] attained? The options were (1) no formaleducation; (2) basic school; (3) primary school/all age; (4) secondary/high/technical school; (5)vocational (ie apprenticeship/trade); (6) diploma; (7) undergraduate degree; (8) post-graduatedegree. Performance of Activities of Daily Living (ADL) is used to describe the functional statusof a person. It is used to determine a baseline level of functioning and to monitor improvementin activities of daily living (ADL) overtime [51, 52]. Scoring the ADL findings (Katz)Independence on a given function received a score of 1 point while if dependent, 0 point wasgiven. There were 6 items (―eating‖ refers to feeding oneself; ―dressing‖ denotes getting clothesand getting dressed, including typing shoes; ―transferring‖ means to get in and out of bed as wellas in and out of a chair; ―using toilet‖ refers to going to the toilet and cleaning afterwards;―bathing‖ denotes to sponge bath, shower, tub bath, or washing body with a wet towel;―continence‖ denotes to control of urination and bowel movement). The reliability of the itemswas high, as Cronbach alpha was 0.696. Total scores thus could range from 0 to 6 with lowerscores indicating low independence (ie. high dependence) and larger scores indicating higherindependence. If there was a score of 0 to 2 (ie none to 2 of the six ADL activities was chosen),the older person was classified as low independence; if 3 to 4 of the activities were selected, the 73
    • older man was classified as moderately independent and if 5 to 6 items were selected the olderwas classified as highly independent. Instrumental Activities of Daily Living IADL. The Instrumental Activities of DailyLiving tool [53] was the basis for assessing participants‘ difficulty with IADL. IADL are thoseactivities whose accomplishment is necessary for continued independent residence in thecommunity. The independent activities of daily living are more sensitive to subtle functionaldeficiencies than ADL‘s and differentiate among task performance including the amount of helpneeded to accomplish each task. Hence, IADL for older men in this paper used the 8-itemchoices as is used for women. These are preparing meals; shopping; management medication;money management; transportation; telephone and laundry. Scoring the IADL. IADL scoresreflect the number of areas of impairment i.e. the number of skills/domains in which subjects aredependent. The data were coded as 1 if fully independent to 4 if lowly independent. Scores rangefrom 0 to 8, with higher scores indicating higher dependence and lower scores greaterindependence (ie low dependence). If none to 3 activities were selected, the older person wasclassified as high dependence; if 4 to 6 activities were selected the elder was classified asmoderately dependent and if 7 to 8 items were selected the elder was classified as highlydependent. The Cronbach alpha for the 8 item scales was 0.648.The classification outlined below(as developed based on Katz [51] and Katz et al [52]) was used to further describe the functionalstatus of men with regard to ADL.Statistical AnalysesData were stored, retrieved and analysed using SPSS for Window version 15.0 (SPSS Inc;Chicago, IL, USA). For this paper descriptive statistics (frequency, percentages) were employedto provide background information on the sample; and chi-square was used to examine non- 74
    • metric variables. Logistic regression was used to examine a binary dependent variable (iephysical exercise) and some socio-demographic variables (such as employment status, currenthealth status, and health status in childhood, number of bother and/or sister (s) alive). Level ofsignificance was p<0.05 and the only exclusion criteria was if more than 20% of the cases of avariable were missing. Using Cohen and Holliday [54] correlation coefficients – low, < 0, 4,moderate, 0.5-0.69; high, 0.7 – 1.0 - were used in the present study to exclude (or allow) avariable. Where collinearity existed (strong correlation), variables were entered independentlyinto the model to determine which one should be retained during the final model construction.This was used to ascertain the variables‘ contribution to the predictive power of the model andthe goodness of fit [55]. To derive accurate tests of statistical significance, the researcher usedSUDDAN statistical software (Research Triangle Institute, Research Triangle Park, NC), andthis adjusted for the survey‘s complex sampling design.ModelIn order to examine the effect of many variables on a single dependent variable, the researcherused multivariate analysis to test a single model. Using the literature this paper investigates thecorrelates of social networking of older Jamaicans within the context of the available data. Theproposed model that this research seeks to evaluate is displayed (Eqn1):HAPPi = ƒ(,Hti,LSi , ,ARi , Ai, EDi, MSi , Pi , HHi, ADL, IADL, εi)..........................................[1]LSi = ƒ(,Hti SNi , HAPPi , ,ARi , Ai, EDi , MSi , Pi , HHi , ADL, IADL, εi)...............................[2]Hti = ƒ(HAPPi ,LSi , ,ARi , Ai, EDi , MSi , Pi , HHi, ADL, IADL, εi)..........................................[3] 75
    • Where happiness of person i, HAPPi; current health status of person i, Ht; life satisfaction ofperson i, LSi; area of residence of person i, ARi; age group of respondent i, Ai; educational levelof person i, EDi; marital status of person i, MSi; number of person in household of person i, Pi;head of household of person i, HHi , ADL, IADL and an error term of person i, εi.Results: Demographic CharacteristicOf the sampled respondents (n=2,000), 74.2% indicated that they had good health in theirchildhood; 74.4% reported good current health status; 51.0% lived in rural areas; 3.5% weremostly satisfied with life; 10.4% had moderate to high functional dependence; 89.6% had lowfunctional dependence (ie independence); 21.9% were ages 75 years and older; 35.6% were ages645 to 74 years and 42.6% reported ages 55 to 64 years. In addition, 94.1% had high cognitivefunctionality, 43.1% reported that they were depressed, 67.3% reported that they do some kind ofphysical exercise and 24.0% indicated being rarely happy, 4.5% mentioned that they were happymost time and 71.5% claimed occasional happiness. One half of the sample indicated that they spent Ja.$100 (USD1.45) monthly for medicalexpenditure; 34% of the respondents bought their prescribed medication; 17.1% reported thatthey have been hospitalized since their sixth birthday and 65.8% reported that they took nomedication. Of those who mentioned that they were ill during childhood (17.5%, n=350), 34.9%said that the illness was measles or chicken pox, 26.3% mentioned asthma, 10.0% pneumonicfever, 8.9% polio, 6.6% accident, 4.6% jaundice, 1.7% hernia, and 5.1% indicatedgastroenteritis. Twenty four percent of elderly men indicated that they were rarely happy, 40.5%said sometimes, 31.0% mentioned often and only 4.5% reported always. Furthermore, 17.7% ofthe sample reported that they were seriously ill in their children. 76
    • Multivariate analysesTable 3.2 presents information on determinants of happiness. Of the 10 variables that were testedin the model, only one was correlated with happiness – life satisfaction - Pseudo r-squared =0.311, -2LL = 810.36, Model χ2 = 161.60, P < 0.0001. Furthermore, the model was a good fit forthe data - χ2 = 767.67, P < 0.0001.Table 3.3 shows information that was tested which examined life satisfaction and somevariables. Happiness was the only determinant of life satisfaction of 10 variables that weretested in the model - Pseudo r-squared = 0.321, -2LL = 1069.30, Model χ2 = 178.53, P < 0.0001.The model was a good fit for the data - χ2 = 2294.26, P < 0.0001.Table 3.4 highlights information that examined possible determinants of health status. Foursocial determined emerged as correlated with health status - Pseudo r-squared = 0.313, -2LL =810.36, Model χ2 = 161.60, P < 0.0001. The model was found to be a good fit for the data - χ2 =767.67, P < 0.0001. The determinants of the model were age, income, education and area ofresidence.Limitation of studyThe sample used for the current research is older men and cannot be used to represent males,older females, females or Jamaicans. 77
    • DiscussionThis paper revealed that older men in Jamaica perceived health status narrower than lifesatisfaction and happiness. While happiness and life satisfaction are determinants of each other,neither of the two variables is correlated with health status. Health status is determined by socialfactors such as age, income, education, and area of residence, but these were not determinants ofhappiness or life satisfaction. The findings showed that happiness accounted for 32.1% of thevariability in life satisfaction, and that life satisfaction accounted for 31.1% of the variance inhappiness of older men, suggesting that more than 30% of respondents‘ happiness or lifesatisfaction can be explained by either life satisfaction or happiness. The disparity between theaforementioned figures indicated that happiness is a strong predictor of life satisfaction that islife satisfaction of happiness of older men. The study also indicated that the more older men arehappier, the more likely that they are satisfied with life and vice versa. The present research highlighted the dominance of illness in men‘s perception of healthand there health status is synonymous with illness and not the borrower concept with which theterm denotes in the literature. In a study by Ross and Mirowsky [56] measured health as―...physical functioning and perceived health. Physical functioning assesses physical mobilityand functioning in daily activities‖ which emphasises the biological conditions (or the biologicalmodel) and not the intended broad concept of health that WHO offered in 1948. This extendseven to the Caribbean as Hambleton et al‘s work [47] found that 88% of the variability in healthstatus of elderly Barbadians was accounted for by illness. From the empirical findings, it can beextrapolated that illness are health status are synonymous concepts and that is limited to oldermen. In a study of oldest-old (ie. Ages 85+ years) in China, Liu and Zhang [57] defined from theLikert scale connotation of good-to-very poor health, which denotes that the respondents would 78
    • interpret self-rated health status within the perspective of illness continuum. This can beextrapolated from the findings as illness were strong correlated with self-rated health status andthis reinforced the issue of health being the opposite of illness and illness denotes ill-health orpoor health status, which highlights the dominance of ill-health in health research. In a study inRawalpindi and Islamabad, Pakistan, Ali and de Muynck [58] found that street boys soughthealth care when illnesses are severe, and this speaks to their perception of health. Health is onthe extreme of the illness pendulum, and that it is not conceptualised as broader that illness. Iffollows that illness is synonymous with ill-health which appears to be constant across the globe. If health is to be in keeping with broader conceptual framework written in the Preambleto the Constitution of WHO, then could life satisfaction or happiness be used measure thisconstruct. The WHO used wellbeing in defining health, which is well-being – more that nothaving an illness. The literature showed that health is associated with happiness, but this is notthe case for older men in Jamaica. Diener [36] noted that research had found that there was not asubstantial correlation between happiness and health, but what the current research revealed isthat not experiencing illness is not associated with happiness or life satisfaction. The presentresults even more refuted a study which found a strong correlation between health status andhappiness (r = 0.85) [58]. Older men‘s happiness or life satisfaction extends to their quality oflife experiences which include aspirations, self-esteem, optimism job satisfaction, desires, virtueand/or holiness. It is for those reasons why ADL and IADL are not correlated with happiness andlife satisfaction as old age of itself is an attainment for many people and this mean that othersthings now becomes important and not merely working, walking, seeing or ill-health. The dominance of illness in conceptualising health is such that wellbeing should be thenew thrust. This could be measure by way of happiness or life satisfaction and not use health as 79
    • this goes back to the illness or health conditions and not the intended broader concept with whichthe WHO outlined in the Preamble to its Constitution. Happiness is the degree to which peoplejudge their overall quality of life as favourable [34, 60, 61]. According to Konow and Earley[62], happiness was correlated with unemployment, positive and negative life-events, socialnetworks and intimate friendships. This paper on older men therefore from within the context ofthe literature provides the explanation why happiness was strongly correlated with lifesatisfaction as both subjective indexes are broader than health status and incorporate many aspectof life. Hence, the finding that very happy older men are highly likely to be very satisfied withlife and vice versa suggests that heart disease, hypertension, digestive disorders and headachesare temporal and as such in assess ones quality of life, they are lowly value and do not contributeto this overall measure of wellbeing.ConclusionSelf-rated (or self-assessed, self-evaluated, self-reported) health which is referred to as healthstatus is a narrow concept in measuring health with the broad ambit of the WHO‘s definition ofhealth. This paper refuted the empirical finding that self-reported happiness depends onperceived health status for older men in Jamaica. This paper highlight the critical fact that theintervention and prevention programmes can be tailored to fit one nation based on the finding ofanother political locality. The determinants of happiness such as income and social factors aswere found in the literature were not factors of happiness or life satisfaction of older men inJamaica, which underlines the fact that the social factors can create differential between nationand within nations in measuring a particular phenomenon. Just like how cultures differ, people‘s 80
    • perception also differs and this justifies why public health should rely on research findingswithin the geographically defined space with which it intends to apply the interventioncampaign. Life satisfaction and happiness are broader construct than health status to measurequality of life for older men in Jamaica. Inspite of the limitation this paper highlights the need forfurther research on the population in order to establish how health data should be collected in thefuture as happiness and life satisfaction appears to be more comprehensive a subjective index inassessing wellbeing than health status. Despite the limitation, health is a comprehensive concept,and so it is imperative that longitudinal studies be carried out to establish whether socioeconomiccharacteristics such as income, marital status, employment, education and others are parametersof happiness, and life satisfaction of Jamaican as well as if the findings of this paper are potent tothe population as this should provide a new paradigm in the assessment of health.References[1]. Brannon L, Feist J. Health psychology. An introduction to behavior and health, 6th ed. Los Angeles: Wadsworth; 2007.[2]. 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 World Health Organization. Basic Documents, 15th ed. Geneva, Switzerland: WHO; 1948.[3]. Engel G. The biopsychosocial model and the education of health professionals. Annals of the New York Academy of Sciences 1978; 310: 169-181.[4]. Engel G. A unified concept of health and disease. Perspectives in Biology and Medicine 1960; 3:459-485.[5]. Engel G. The care of the patient: art or science? Johns Hopkins Medical Journal 1977; 140:222-232.[6]. Engel GL. The clinical application of the biopsychosocial model. American Journal of Psychiatry 1980; 137:535-544.[7]. Sheela J, Jayamala M. Health condition of the elderly women: a need to enhance their wellbeing. IJSAS 2008; 1(1): 1-18. 81
    • [8]. Worlh Health Organization. Commission on social determinants of health priority public health conditions knowledge network, (CSDH). Scoping paper: priority public health conditions. Washington DC: CSDH; 2007. [9]. Ronsmans C, Graham WJ. Maternal mortality: who, when, where, and why. Lancet 2006; 368(9542):1189-200.[10]. Lamb VL, Siegel JS. Health demography. In: Siegel JS, Swanson DA, editors. The methods and material of demography, 2nd. California: Elsevier; 2004: pp. 341-370.[11]. Low W-Y, Chirk-Jenn NG, Choo, W-Y, Hui-Meng T. How do men perceive erectile dysfunction and its treatment: a qualitative study on opinions of men? The Aging Male; 2006; 9: 175-80.[12]. Duke J, Leventhal H, Brownlee S, Leventhal E. Giving up and replacing activities in response to illness. J of Gerontology: Psychological Sciences 2002; 57B (4):P367-P376.[13]. Wilks R. Hypertension in the Jamaican population. A presentation to the Trinidad & Tobago National Consultation on Chronic Non-Communicable Diseases. Summit, Trinidad and Tobago; 2007.[14]. Planning Institute of Jamaica (PIOJ) & Statistical Institute Statistical Institute of Jamaica, (STATIN). Jamaica Survey of Living Conditions, 1988-2007. Kingston: PIOJ & STATIN; 1989-2008.[15]. 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.[16]. Jamaican Ministry of Health (MoHJ). Annual Report 2006-2007. Kingston: MoHJ; 2007- 2008.[17]. Statistical Institute of Jamaica. Demographic Statistics, 1970-2007. Kingston, Jamaica;1971-2008.[18]. Wilks R, Younger N, Mullings J, Zohoori N, Figueroa P, Tulloch-Reid M. et al. Factors affecting study efficiency and item non-response in health surveys in developing countries: the Jamaica national healthy lifestyle survey. BMC Medical Research Methodology 2007, 7:1-14.[19]. Lindo J. Jamaican perinatal mortality survey, 2003. Kingston: Jamaica Ministry of Health 2006:1-40.[20]. McCarthy JE, Evans-Gilbert T. Descriptive epidemiology of mortality and morbidity of health-indicator diseases in hospitalized children from western Jamaica. Am J Trop Med Hyg. 2009; 80:596-600.[21]. Domenach H, Guengant J. Infant mortality and fertility in the Caribbean basin. Cah Orstom (Sci Hum.). 1984; 20:265-72.[22]. Desai P, Hanna B, Melville B, Wint B. Infant mortality rates in three parishes of western Jamaica, 1980. West Indian Med J. 1983; 32:83-87.[23]. Rodriquez FV, Lopez NB, Choonara I. Child health in Cuba. Arch Dis Child 2002; 93:991-3.[24]. Forrester T, Cooper RS, Weatherall D. Emergence of Western diseases in the tropical world: the experience with chronic cardiovascular diseases. British Med Bulletin 1998; 54(2):463-473. 82
    • [25]. Blake G, Hanchard B, Mitchell K, Simpson D, Waugh N, Wolff C, Samuels E. Jamaica cancer mortality statistics, 1999. West Indian Med J 2002; 51(2):64-67.[26]. 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).[27]. Jackson M, Walker S, Forrester T, Cruickshank J, Wilks R. Social and dietary determinants of body mass index in Jamaican of African. European Journal of Clinical Nutrition 2003; 57, 621-627.[28]. Gaspart F. Objective measures of wellbeing and the cooperation production problem. Social Choice and Welfare 1998; 15, 1:95-112.[29]. Lipsey RG, Chrystal KA. Economics, 11th ed. Oxford: Oxford University Press; 2007.[30]. Hanson JL. A textbook of economics. 7th ed. London: MacDonald and Evans;1986.[31]. Becker GS, Philipson TJ, Soares RR. The quantity and quality of life and the evolution of world inequality [Internet] 2004. [cited 2006 Aug 22]. Available from http://www.spc.uchicago.edu/prc/pdfs/becker05.pdf#search=%22preston%20quality%20 of%20life%22.[32]. Diener E, Suh E. Measuring quality of life: economic, social subjective indicators. Social Indicators Research 1997; 40:189-216.[33]. Diener E. Subjective wellbeing: the science of happiness and a proposal for a national index. American Psychological Association 2000; 55: 34-43.[34]. Kashdan TB. The assessment of subjective wellbeing (issues raised by the Oxford Happiness Questionnaire) Personality and Individual Differences 2004; 36:1225–1232.[35]. Wooden M, Headey B. The effects of wealth and income on subjective wellbeing and ill- being. Melbourne: Melbourne Institute of Applied Economic and Social Research [Internet]. 2004 [cited, 2006 Jun 29]. Available from http://melbourneinstitute.com/wp/wp2004n03.pdf.[36]. Diener E. Subjective well-being. Psychological Bulletin 1984; 95: 542–75.[37]. Wilson W. Correlates of avowed happiness. Psychological Bulletin 1967; 67:294-306.[38]. Di Tella R, MacCulloch R, Oswald AJ. The Macroeconomics of happiness. Review of Economics and Statistics 2003;85:809-827.[39]. Blanchflower DG, Oswald AJ. 2004. Well-being over time in Britain and the USA. J of Public Economics 2004; 88:1359-1386.[40]. Gardner J, Oswald AJ. Money and mental well-being: a longitudinal study of medium- sized lottery winner. Journal of Health Economics 2007; 26:49-60.[41]. Borghesi S, Vercelli A. Happiness and health: two paradoxes. DEPFID Working papers; 2008.[42]. Easterlin RA. Income and happiness: towards a unified theory. Economic J. 2001; 111:465-484.[43]. Frey BS, Stutzer A. Does marriage make people happy, or do happy people get married. Journal of Socioeconomic 2006; 35(2):326-347.[44]. Gardner J, Oswald AJ. Do divorcing couples become happier by breaking up. Journal of the Royal Statistical Society: Series A 2006; 169:319-336.[45]. Grossman M. The demand for health – a theoretical and empirical investigation. New York: National Bureau of Economic Research; 1972. 83
    • [46]. Ringen S. Wellbeing, measurement, and preferences. Scandinavian Sociological Association 1995; 38, 3-15.[47]. 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.[48]. 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.[49]. Yeung FKC, Chou K-L, Wong ECH. Characteristics associated with fear of falling in Hong Kong Chinese Elderly Residing in Care and Attention Homes. Clinical gerontologist 2006; 29(3):83-98.[50]. Graham C. Happiness and health: lessons – a question – for public policy. Health Affairs 2008; 27:72-87.[51]. Katz S, Downs TD, Cash HR, Grotz RC. Progress in development of the index of ADL. The Gerontologist 1970; 10:20-30.[52]. Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffe MW. Studies of illness in the ages. The index of ADL: standardized measure of biological and psychosocial function. JAMA 1993; 185 (12), 914-919.[53]. Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist 1969; 9:179-86.[54]. Cohen L, Holliday M. Statistics for Social Sciences. London, England: Harper and Row, 1982.[55]. Polit DF. Data analysis and statistics for nursing research. Stamford: Appleton and Lange Publisher; 1996.[56]. Ross CE, Mirowsky J. Refining the association between education and health: the effects of quantity, credential, and selectivity. Demography 1999; 36(4):445-460.[57]. Liu G, Zhang Z. Sociodemographic differentials of the self-rated health of the oldest-old Chinese. Population Research and Policy Review 2004; 23:117-133.[58]. Ali M, de Muynck A. Illness incidence and health seeking behaviour among street children in Rawalpindi and Islamabad, Pakistan – a qualitative study. Child: Care, Health and Development 2005; 31(5):525-532.[59]. Kahneman D, Riis J. Living and thinking about it, two perspectives. In: Huppert FA, Kaverne B, Baylis N. The science of well-being. Oxford: Oxford University Press; 2005.[60]. Veenhoven R. Is happiness relative? Social indicators Research 1991; 24:1-34.[61]. Veenhoven R. Happiness in nations: subjective appreciation of life in 56 nations, 1946- 1992. Rotterdam: Erasmus University Press 1993.[62]. Konow J, Earley J. The hedonistic paradox: is homo-economicus happier: mimeo. Loyola Marymount University, Dept of Psychology; 1999. 84
    • Table 3.1: Proportion of Survey (Sample) vs. Proportion of Population Age 2001 Census (St. 2001 Census SurveyGroup Catherine) (Jamaica) (yrs). n % n % N % 55-59 469 23.45 6577 26.7 38645 23.9 60-64 413 20.6 5179 21.1 31828 19.7 65-69 374 18.7 4391 17.8 28901 17.9 70-74 345 17.2 3594 14.6 24856 15.4 75-79 189 9.45 2402 9.78 17711 11.0 80+ 210 10.5 2399 9.77 19552 12.1 85
    • Table 3.2. Parameter estimates of happiness of older men in Jamaica Std. Estimate Error CI (95%) Variable PRarely happy -4.376 1.002 0.000 -6.339, -2.412Sometimes happy -2.148 0.991 0.030 -4.091, -.205Most times happy 0.669 0.981 0.495 -1.254, 2.591Age -0.183 0.128 0.151 -0.433, 0.067Income 0.030 0.077 0.694 -0.120, 0.181 0.103 0.117 0.380 -0.127, 0.332ADLIADL -0.079 0.048 0.101 -0.173, 0.015Head of household -0.089 0.124 0.474 -0.331, 0.154 No of people in household -0.008 0.044 0.860 -0.094, 0.078Tertiary education =1 0.131 0.098 0.184 -0.062, 0.324Single -0.064 0.417 0.877 -0.881, 0.752Married -0.030 0.411 0.943 -0.836, 0.777Separated 0.414 0.539 0.442 -0.642, 1.470Common-law 0.530 0.502 0.291 -0.454, 1.513Widowed 0 Urban 0.125 0.173 0.472 -0.215, 0.464Rural 0Life Satisfaction rarely=1 -3.854 0.481 0.000 -4.797, -2.911Life Satisfaction sometimes =2 -2.800 0.473 0.000 -3.727, -1.873Life Satisfaction most times =3 -1.193 0.463 0.010 -2.100, -.287Life satisfaction always = 4 0Excellent health status -0.251 0.288 0.384 -0.816, 0.314Good health status -0.230 0.248 0.353 -0.716, 0.255Fair health status 0Pseudo r-squared = 0.311-2LL = 810.36Model χ2 = 161.60, P < 0.0001Goodness of fit χ2 = 767.67, P < 0.0001 86
    • Table 3.3. Parameter estimates of life satisfaction of older men in Jamaica Std. P CI (95%) Variable Estimate ErrorLife Satisfaction rarely=1 -3.157 1.021 0.002 -5.159, -1.156Life Satisfaction sometimes =2 -1.481 1.018 0.146 -3.477, 0.515Life Satisfaction most times =3 1.428 1.002 0.154 -0.536, 3.393Age 0.002 0.130 0.990 -0.253, 0.256Income 0.034 0.078 0.662 -0.119, 0.188ADL -0.006 0.118 0.957 -0.237, 0.225IADL -0.019 0.049 0.703 -0.115, 0.078Head of household -0.037 0.126 0.766 -0.284, 0.209No of people in household 0.007 0.044 0.879 -0.080, 0.094Tertiary education =1 0.131 0.098 0.184 -0.062, 0.324Single 0.753 0.441 0.088 -0.111, 1.616Married 0.763 0.436 0.080 -0.092, 1.618Separated 0.694 0.553 0.209 -0.389, 1.777Common-law 0.825 0.525 0.116 -0.204, 1.853Widowed 0Urban -0.122 0.176 0.488 -0.466, 0.222Rural 0Rarely happy -5.012 0.500 0.000 -5.993, -4.032Sometimes happy -3.075 0.463 0.000 -3.983, -2.167Most times happy -2.078 0.460 0.000 -2.979, -1.177Always happy 0Excellent health status 0.317 0.290 0.275 -0.252, 0.886Good health status 0.209 0.251 0.405 -0.283, 0.700Fair health status 0Pseudo r-squared = 0.321-2LL = 1069.30Model χ2 = 178.53, P < 0.0001Goodness of fit χ2 = 2294.26, P < 0.0001 87
    • Table 3.4. Parameter estimates of health status of older men Std. P CI (95%) Variable Estimate ErrorExcellent health status 0.409 0.996 0.681 -1.543, 2.361Good health status 3.371 1.011 0.001 1.389, 5.354Age 0.287 0.131 0.029 0.030, 0.544Income 0.685 0.080 0.000 0.528, 0.842ADL -0.006 0.121 0.963 -0.243, 0.231IADL -0.049 0.050 0.332 -0.148, 0.050Head of household -0.054 0.128 0.675 -0.304, 0.197 No of people in household 0.017 0.045 0.710 -0.072, 0.106 Tertiary education =1 -0.733 0.107 0.000 -0.942, -0.525 Single -0.302 0.438 0.490 -1.160, 0.556 Married -0.455 0.433 0.293 -1.304, 0.393 Separated 0.107 0.563 0.849 -0.996, 1.210 Common-law -0.591 0.525 0.260 -1.621, 0.438 Widowed 0 Urban 0.407 0.180 0.023 0.055, 0.759 Rural 0 Rarely happy -0.173 0.505 0.732 -1.163, 0.817 Sometimes happy 0.130 0.491 0.791 -0.832, 1.092 Most times happy 0.151 0.501 0.763 -0.831, 1.133 Always happy 0 Life Satisfaction rarely=1 0.182 0.515 0.724 -0.827, 1.191 Life Satisfaction sometimes =2 0.196 0.519 0.705 -0.822, 1.214 Life Satisfaction most times =3 -0.238 0.525 0.651 -1.268, 0.792 Life Satisfaction always=4 0Pseudo r-squared = 0.313-2LL = 810.36Model χ2 = 161.60, P < 0.0001Goodness of fit χ2 = 767.67, P < 0.0001 88
    • Chapter 4Good Health Status of Older and Oldest Elderly in Jamaica: Are theredifferences between rural and urban areas? Paul Andrew BourneThe aim of this paper was to examine the good health status of older and oldest elderlyJamaicans as well as to determine predictors of this health status. A sub-sample of 1,069respondents (42.4 percent men and 57.6 percent women) who indicated being 75 years and olderwere used for this paper. This is extracted from a larger nationally cross-sectional survey of25,018 respondents in 2002. The stratified multistage probability sampling technique was usedto draw the survey respondents, which reflects the socio-demographic characteristic of theJamaican population, and makes the sample generalizable on the population. A self-administered questionnaire was used to collect the data from the sample; and the interviewerswere trained to collect data. The data were entered, stored and retrieved in SPSS 16.0.Descriptive statistics were used to examine the demographic characteristics of the sample; chi-square was used to investigate non-metric variables, and logistic regression was the multivariatetechnique chosen to determine predictors of good health status. Two factors were found to bestatistically significant predictors of good health status of older and oldest elderly respondents.These were area of residence and sex of respondents. Older and oldest elderly men reported agreater good health status than old and oldest elderly women (OR=1.410; 95% CI: 1.048-1.897).On the other hand, there was no statistical difference between the self-reported diagnosed(chronic) recurring illness and age cohort of the sample. Rural older and oldest elderlyrespondents indicated the lowest good health status (OR=1.00) compared to other residents(urban: OR=1.670; 95% CI: 1.071-2.606; and other town dwellers: OR=1.847; 95% CI: 1.327-2.572). Good health of this age cohort is not influenced by income or social standing, and thereis a need to examine lifestyle risk factors; disease indicators and psychological conditions, as thismay provide more answers to the good health of Jamaicans 75 years and older. A quantitativeassessment has provided us with answers, but it is clear from the findings that more informationis needed on this age cohort. The researcher recommends the use of qualitative methodologies toprovide in-depth understanding of those factors that determine good health of this age cohort. 89
    • INTRODUCTIONGlobally, statistics revealed that the growth rate for people 80 years and older was 3.9 percent(2000-2005) and that this was twice more than that for elderly 60 years and over. Comparatively,the average annual rate of growth for the population 80 years and older was 4.0 percent for LatinAmerica and the Caribbean, which was 1.4 times more than that for the population 60+ years [1].For the Caribbean, the average annual growth rate for the population 80+ years was 0.7 timesless than the younger elderly. Moreover, the annual rate of growth for the population of Jamaicasince 2003 is between 0.50 and 0.45, which is less than the rate of growth for the population 60 +years (1.2 percent) and 80+ years (2.0 percent). People are not only living longer in theCaribbean, but traditional health indicators such as total fertility rate, crude birth and death rates,infant and maternal mortality have been relatively stable since 1996. For some time now, Caribbean nations such as Barbados, Cuba, Dominica, Guadeloupe,Jamaica, Martinique and Trinidad and Tobago have been experiencing demographic transition[1-5]. This is a shifting of the population from younger ages to older ones (ages 60 years andolder or elderly) owing to reduced child and adult mortality, better public health andenvironmental conditions, higher standard of living and a reduction in the population under 15years. Those countries have in excess of 8 percent (2007) of their population 60 years and older[1-5]. Some demographers argue that population ageing occurs when 8 percent and more of acountry‘s population are elderly [6]. Population ageing in the Caribbean is similar to theexperiences of the rest of the world, but it is more rapid, with a high degree of poverty andsignificant gender differences and inequalities. Another noticeable aspect of the ageing process isthe average annual rate of growth of the population 80 years and older in comparison with 60+years. 90
    • Undoubtedly ageing is a biological process, and continues throughout one‘s lifetime.Over the lifespan of an individual he/she shifts from one birthday to the next, and equally so isthe case for morbidity, health status and quality of life. Health literature has shown thatbiological ageing is correlated with increased morbidity, mortality and poor health status [7, 8],which explains the health disparity (including functional and working capacity) between youngerand older ages (60+ years). This justifies the rationale for the WHO‘s disability adjusted lifeexpectancy (DALE or healthy life expectancy) [9]. Life expectancy that has been widely usedby demographers to assess the health status of a population is computed from mortality data, anda critical assumption is that all people subscribe to the same mortality patterns. Embedded in thisconstruct is the fact that living means good health status. This, however, is not the case, aspeople can be alive but not enjoying their lived years, because of ailments which are not life-threatening but debilitating health conditions. This gave rise to the WHO‘s recognition that theemphasis should not be on life expectancy but on healthy life expectancy. Here, it argued for thediscounting of life expectancy for the number of years lived with disabilities or illnesses. The elderly have a greater probability of facing health conditions compared to people ofyoung ages owing to their biological composition, which implies that the older an elderly personbecomes, the less likely it is that he/she will have good health. The WHO [1] calculated thatdeveloping countries‘ life expectancy should be discounted by 9 years, and this should be 8.4years for men and 9.5 years for women in Jamaica. Although life expectancy has doubled formen and women in Jamaica over the last 100 years [2, 10], people are living longer with moredisabilities and health conditions. According to WHO [11], ―In developing countries, their(elderly – ages 60 years and older) situation is generally much less widely-known and their needsand contributions have been largely invisible.‖ This is not the case in Jamaica, as Bourne [3, 10, 91
    • 12], Eldemire [13-20], and others have [21-27] extensively reviewed different aspects of the lifeof people and/or elderly women and men. Although those studies have been done, an extensivereview of health literature in Jamaica found no study that has investigated determinants of goodhealth status of the older and oldest elderly Jamaicans. Hence, the aim of this paper is to examinefactors that explain good health status of the older elderly (ages 75 to 84 years) and the oldestelderly (ages 85+ years) in Jamaica.METHODSThe sub-sample for this paper was 1,069 older and oldest elderly respondents (ages of 75 yearsand older) extracted from a nationally representative cross-sectional survey of 25,018 Jamaicans(Jamaica Survey of Living Status, JSLC). The survey was drawn using stratified randomsampling. This design was a two-stage stratified random sampling design where there was aPrimary Sampling Unit (PSU) and a selection of dwellings from the primary units. The PSU isan Enumeration District (ED), which constitutes of a minimum of 100 dwellings in rural areasand 150 in urban areas. An ED is an independent geographic unit that shares a commonboundary. 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 samplingframe from which a Master Sample of dwelling was compiled, which in turn provided thesampling frame for the labour force. Ten percent was selected for the survey (JSLC). This paper used JSLC 2002 which was conducted by the Statistical Institute of Jamaica(STATIN) and the Planning Institute of Jamaica (PIOJ) between June and October 2002. Theresearchers chose this survey based on the fact that it was the second largest sample size for thesurvey in its history (since 1988 to 1998), and in that year the survey contained questions on 92
    • crime and victimization and the physical environment, unlike previous years. A self-administered questionnaire was used to collect the data, which were stored and analyzed usingSPSS for Windows 16.0. The questionnaire was modelled from the World Bank‘s LivingStandards Measurement Study (LSMS) household survey. There are some modifications to theLSMS, as JSLC is more focused on policy impacts. The questionnaire covered areas such associo-demographic, economic and wealth variables, crime and victimization, social welfare,health status, health services, nutrition, housing, immunization of infants and physicalenvironment. The non-response rate for the survey was 27.7%. Descriptive statistics such as mean, standard deviation (SD), frequency and percentagewere used to analyze the socio-demographic characteristics of the sample. Chi-square was usedto examine the association between non-metric variables, and an Analysis of Variance(ANOVA) was used to test the relationships between metric and non-dichotomous categoricalvariables. Logistic regression examined the relationship between the dependent variable andsome predisposed independent (explanatory) variables, because the dependent variable was abinary 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, Oddsratio and confidence interval (95% CI). The predictive power of the model was tested using theOmnibus Test of Model, and Hosmer and Lemeshow (28) was used to examine goodness of fitof the model. The correlation matrix was examined in order to ascertain whether autocorrelation(or multicollinearity) existed between variables. Based on Cohen and Holliday (29) correlationcan be low (weak) - from 0 to 0.39; moderate – 0.4-0.69, and strong – 0.7-1.0. This was used toexclude (or allow) a variable in the model. Wald statistics were used to determine the magnitude 93
    • (or contribution) of each statistically significant variable in comparison with the others, and theOdds Ratio (OR) for the interpreting of each significant variable. Multivariate regression framework [10,12] was utilized to assess the relative importanceof various demographic, socio-economic characteristics, physical environment and psychologicalcharacteristics, in determining the health status of Jamaicans; and this has also been employedoutside of Jamaica [30,31]. This approach allowed for the analysis of a number of variablessimultaneously. Secondly, the dependent variable is a binary dichotomous one and this statistictechnique has been utilized in the past to do similar studies. Having identified the determinantsof health status from previous studies, using logistic regression techniques, final models werebuilt for women in general as well as for each of the geographical sub-regions (rural, peri-urbanand urban areas) using only those predictors that independently predict the outcome. A p-valueof 0.05 was used to for all tests of significance. The proposed model which this paper seeks to evaluate is the health status of Bourne [10,12] which was used previously to model health status of Jamaican.Hi = ƒ(Wi, HHi, Pmci, Ci, MRi, ARi, EDi, SSi, CRi, (∑NAi, PAi), Mi, Fi, CHi, At, Xi, Ai, HIi, LLi, Eni, Yi, Vi,εi) (1) Health status of person i Hi , is a function of Wi is the two wealthiest quintiles of personi. 1 if yes, 0 if two poorest quintiles; HHi is household head of person i. 1 if yes, 0 if otherwise;Pmci is cost of medical care of person i, in US dollars; Ci is average consumption per person inhousehold, in Jamaican dollars; MRi is marital status of person i; ARi is area of residence ofperson i; EDi is educational level of person i; SSi is having social support of person i. 1 if, yes;and 0 if no; CRi is crowding of person i, in numbers; (∑NAi, PAi) is a psychological statuswhich is the summation of negative affective status of person i, NAi where values are in 94
    • continuous numbers; and, PAi is positive affective psychological status of person i, where valuesare in continuous numbers; Mi is number of men in household of person i; Fi is number ofwomen in household of person i; CHi is number of children below the age of 14 years of personi; At is asset owned of person i, in continuous numbers; Xi is gender of respondent i; Ai is age ofperson i, in continuous numbers; HIi is ownership of private health insurance ; LLi is livingarrangement where 1= living with family members or relative, and 0=otherwise; Eni is physicalenvironment of person i. 1 if affected by flood, landslides, soil erosion, 0 if no; Yi is averageincome per person in household (this variable is measured by total expenditure, and Vi is crimeof person i, where values are continuous numbers, and εi is the residual error.Using data on older and oldest elderly Jamaicans, this paper found that self-reported health statuscan be predicted by two variables [Eqn. (2)]Hi = ƒ(ARi, Xi, εi) (2)MeasuresSelf-reported Health Status is self-assessed illness (cold, diarrhoea, asthma attack, hypertension,diabetes mellitus or any other illnesses) reported by respondents in the last 4 weeks of thesurvey period. Good Health Status is a dummy variable, where 1=good health (not reporting anailment, injury or dysfunction) and 0=poor health (self-reported illness, injury or ailment).Household crowding is the average number of persons living in a room excluding kitchen,bathroom and verandah. Physical Environment is the summation of responses as reported byrespondents on suffering the effects of landsides, property damage due to rains, flooding; or soilerosion in the last 4 weeks of the survey period. Psychological Conditions are the psychologicalstate of an individual, and this is sub-divided into positive and negative affective psychological 95
    • status. Positive Affective Psychological Status refers to the number of responses that are hopefuland optimistic about the future and life generally. Negative Affective Psychological Status refersto the number of respondents having lost a breadwinner and/or family member, experienced lossof property, been made redundant, or failed to meet household and other obligations. Age is thenumber of years lived, which is also referred to as age at last birthday. This is a continuousvariable, ranging from 15 to 100 years. Age is classified into three groups: young respondentsaged 15 to 30 years, older adults 31 to 59 years, and elderly 60 years and older. Crime andVictimization Index (Crime Index) measures the number of cases and severity of crimescommitted against a person or his/her family members, but not against property. Using Cohenand Holliday‘s [29] correlation guideline, low crime was from 0 to 34; moderate from 35 to 61,and high from 62 to 88. Older elderly is defined as the chronological age of 75 years to 84 years.Oldest elderly is the chronological age of 85 years and older. Social support (or network) denotesdifferent social networks in which the individual is involved (1= membership of and/or visits tocivic organizations or having friends that visit one‘s home or with whom one is able to network,0=otherwise).RESULTS: Demographic Characteristic of SampleThe sample was 1,069 respondents (42.5 percent men and 57.6 percent women), of which therewere 74.2 percent older elderly and 25.8 percent oldest elderly. Forty-three percent wereclassified as either poor or poorest; 71 percent were never married (included common-law),separated, divorced or widowed; 5 percent had private health insurance coverage; 8 percentreceived some form of retirement; 68 percent lived in rural areas compared to 32 dwelling inurban areas (of this 21 percent lived in other towns and 11 in cities); 67 percent had at most 96
    • primary level education, of which 2 percent reported tertiary level education; 48.3 percentindicated that they had good health compared to 51.7 percent with poor health status; 41 percentreported having suffered the effects of soil erosion, landslide or some other form of naturaldisaster. Crimes affecting the sample were very low (1.12 ± 0.84); 52.1 percent reported visits toprivate health care facilities compared to 47.9 percent public health care facilities, meanconsumption per person in household was US$699.13 ± US$627.64; 55.7 percent of respondentsindicated that they had social support; 20.7 percent lived alone; 35.5 percent were living withgrandchildren, and 29.2 percent of the sample was married. On further examination of some of the aforementioned variables by age cohort,interesting results came to light (Table 4.1). The findings revealed that there was no statisticaldifference between the reported good health status of older elderly respondents (48.7%)compared to that of the oldest elderly respondents (45.5%), p = 0.385. The same thing wasfound with private health insurance coverage for older elderly respondents compared to oldestelderly respondents (p = 0.184). However, a statistical correlation was found between sex ofrespondents and age cohort (p = 0.003). Fifty-five and one tenth percent of older elderlyrespondents were females compared to 44.9 percent of the oldest elderly. More of therespondents dwelled in rural areas, with there being no statistical difference between olderelderly and oldest elderly respondents (p = 0.121). A high percentage of the sample owned theirown home (87.2 percent), and there was no statistical difference between the older elderly (87.7percent) and oldest elderly (85.5 percent) (Table 4.1). The crime index showed that this affected more urban than rural elderly respondents(urban 1.61 ± 7.53; rural 0.74 ± 3.02) (p = 0.007) (Table 4.2). The findings revealed that povertywas 2.2 times greater in rural than in urban areas (12.4 percent of urban residents were below the 97
    • poverty line); higher level education was greater in urban than rural areas; private healthinsurance coverage was 5.2 times greater for urban residents compared to rural residents (2.0percent); self-reported good health was greater for urban (58.9 percent) than rural respondents(43.5 percent) (Table 4.2). Also retirement income was 2.4 times more for urban respondentsthan for rural respondents (5.7 percent). Table 4.3 revealed that there was a statistical correlation between health insurancecoverage and retirement income (p = 0.001). Respondents who reported receiving retirementincome were 5.8 times more likely to have reported private health insurance coverage than theelderly who had not reported having received retirement income (Table 4.3). Of the sample (N=1,069), 41.3 percent answered the question of ―Is your illnessdiagnosed as (chronic) recurring illness?‖ Of this number, 97.1 percent indicated a diagnosed(chronic) recurring ailment. A cross tabulation of diagnosed (chronic) recurring illness and agecohort of respondents showed no statistical correlation (p = 0.509). Notwithstanding theaforementioned p value, 75.5 percent of those who responded to this question reported diabetesmellitus, hypertension and arthritis, with 37.3 percent having hypertension and 21.9 percentdiabetes mellitus (Table 4.4). The number of respondents who indicated hypertension, diabetesand arthritis of the sample was 31.3 percent (n=335); with 15.4 percent hypertension, 9.1 percentdiabetes mellitus and 6.8 percent arthritis. With respect to those who indicated being diagnosed (chronic) recurring ailment, 42.2percent of women reported hypertension compared to 29.9 percent of men; 5.7 percent of menhad asthma compared to 1.9 percent of women; 24.6 percent of women reported diabetes 98
    • mellitus compared to 17.8 percent of men; and 21.3 percent of men reported arthritis comparedto 13.4 percent of women (Table 4.5).RESULTS: Multivariate AnalysisPredicting Good Health Status of Older and Oldest Elderly Jamaicans. Two factors were foundto be statistically significant predictors of good health status of older and oldest elderlyrespondents. These were area of residence and sex of respondents. The model had a statisticallysignificant predictive power (chi-square = 37.258, p=0.001; Hosmer and Lemeshow goodness offit chi-square=5.785, p= 0.671). In addition, it was revealed that overall 58.39% of the data werecorrectly classified: 69.6% of those who indicated poor health status and 45.7% of those whoindicated good health status (Table 4.6). Based on Table 4.6, older and oldest elderly men reported a greater good health statusthan older and oldest elderly women (OR=1.410; 95% CI: 1.048-1.897). Rural older and oldestelderly respondents indicated the lowest good health status (OR=1.00) compared to otherresidents (urban: OR=1.670; 95% CI: 1.071-2.606; and other town dwellers: OR=1.847; 95% CI:1.327-2.572). None of the other factors such as consumption, social support, crowding, healthinsurance coverage, cost of medical care, education, age of respondents, and the physicalenvironment predicted good health status of older and oldest elderly respondents (p > 0.05).DISCUSSIONThis paper has shown that the health status of older and oldest elderly in Jamaica is relativelymoderate, as 48 out of every 100 older and oldest elderly reported good health status. It wasfound that there was no statistical difference between the self-reported good health status of olderpeople (ages 75 – 84 years) and oldest elderly (ages 85 years and older). Nine of every 100 99
    • older-to-oldest elderly had diabetes mellitus; 15 out of every 100 hypertension and 7 out of every100 had arthritis. In addition, there was a statistical correlation between good health status andarea of residence, or self-reported (chronic) recurring illness and age cohort. Furthermore, thedata showed that older and oldest elderly Jamaicans who dwelled in rural area had the lowestself-reported good health compared to those who resided in other towns and urban areas.Continuing, those who resided in other towns reported the greatest good health status.Approximately, twice more women reported being diagnosed with (chronic) recurring illnesscompared to men. Eldemire [32] opined that ageing population is associated with increased disability, and ifthis is so then there should be more illness with ageing. This paper does not concur withEldemire findings, that as people age (older to oldest elderly) they would report more disabilities.This approach emphasizes the longevity of the cells, in relation to the number of years theorganism can live. Thus, in this construction the human body (an organism) is valued based onphysical appearance and/or state of the cells. Embedded in this apparatus is the geneticcomposition of the survivor. Gompertz‘s law in Gavriolov and Gavrilova [7] demonstrates the fundamentalquantitative theory of ageing and mortality of certain species (the examples here are as follows –humans, human lice, rats, mice, fruit flies, and flour beetles). Gompertz‘s law went further toestablish that human mortality increases twofold with every 8 years of an adult life, which meansthat ageing increases in geometric progression. This phenomenon means that human mortalityincreases with the age of the human adult, but that this becomes less progressive in advancedageing. Thus, biological ageing is a process where the human cells degenerate with years (i.e.the cells die with increasing age), which is explored in evolutionary biology [33, 34]. But 100
    • studies have shown that using the evolutionary theory for ―late-life mortality plateaus‖ failedbecause of the unrealistic set of assumptions on which the theory is based [35-38]. The reliability theory, on the other hand, is a better fitted explanation for the ageing ofhumans than that argued by Gompertz‘s law, as the ‗failing law‘ speaks to the deterioration ofhuman organisms with age [7] as well as the non-ageing term. The latter, based on Gavrilov andGavrilova [7], can occur because of accidents and acute infection, which are called ―extrinsiccauses of death. While Gompertz‘s law speaks to mortality in the ageing organism due to age-related degenerative illnesses such as heart diseases and cancers, a part of the reliability functionis Gompertz‘s function as well as the non-ageing component. This paper did not find a statisticaldifference between self-reported diagnosed (chronic) recurring illness and older and oldestelderly elderly; this can be as a result of the data. Despite the fact that people are the best judgeof what affects them, there is a clear disparity here between biological ageing theorists‘ findingsand the self-reported results of older and oldest elderly Jamaicans. The World Health Organization [39, 40] put forward a position that there is a disparitybetween contracting many diseases and the gender constitution of an individual. One healthpsychologist, Rice [41], in concurring with WHO, argued that differences in death and illnessesare the result of differential risks acquired from functions, stress, life styles and ‗preventativehealth practices‘. Rice believed that this health difference between the sexes is due to social support.Other scholars explained that it is owing to epidemiological trends [42], i.e. lifestyle practicesjustify the advantages that women enjoy compared to men concerning health status. This paperfound that older and oldest elderly men had superior good health status to that of women, with 101
    • men being 1.4 times more likely to report good health than women. A survey done by Rudkinfound that women have lower levels of economic wellbeing than men [43], and this is one of thejustifications for the latter group reporting superior good health status. This finding is furthersanctioned by Havenman et al [44] whose study revealed that retired men‘s wellbeing was higherthan that of their female counterparts, because men usually received more material resources,and more retirement benefits compared to women ages 65 years and older. Thus, with menreceiving more than women and having more durable possessions than women, their generalsatisfaction with life (including health) will be better than their women counterparts. There is aparadox here, as Bourne showed from statistics [3, 10] that the life expectancy of women inJamaica has been at least 3 years (1880-1882) to 6 years (2002-2004) longer, yet they have alower good health status. A part of the gender health disparity that was put forward is owing to the culture. Amongthe gender roles ascribed to Caribbean males are the protection of the family, children, wife orgirlfriend, and parents. The man is expected to handle the laborious tasks such as lifting heavyitems, pruning trees and hedges and taking out the garbage, while maintaining a specialprotective role for his parents, in particular his mother. A Caribbean male finds it impossible totolerate someone criticizing his mother or belittling her, without becoming abusive or evenconfrontational. It is not that Caribbean males take a minimalistic role in regard to the family,but it is primarily the gender specification of these societies along with task specialization.Another cultural bias that emerged from the laborious tasks they are expected to undertake isillness. Illness is an indicator of weakness and lowered masculinity, which explains men‘sunwillingness to seek preventative care, visit health facilities and report illness. This then 102
    • accounts for the lowered good health status of women and the greater one reported by men.Despite this reality, let us examine particular health conditions. Women have a higher propensity than men to contract particular conditions such asdepression, osteoporosis and osteoarthritis [39, 45]. Herzog [45] noted that ―… it appears thatolder women are more likely to be impaired by their health problems, while older men are morelikely to die from them.‖ A study by Schoen et al. [46] found that a group of adolescentsrevealed something different from that which was reported by WHO. The researchers found thatmales are more likely than females to feel stressed; ‗overwhelmed‘ or ‗depressed‘, and theyattributed this to men‘s limited social networks. Other researchers have agreed with Schoen et althat men in general tend to be more stressed and less healthy than females, and further arguedthat men can use denial, distraction, alcoholism and other social strategies to conceal their illnessor disabilities [47-50]. On the other hand, Herzog [45] in Physical and Mental Health in OlderWomen, using studies from a number of experts, wrote that females had higher rates ofdepression than their male counterparts. Data for the Caribbean showed that hypertension and arthritis are morbidities thatsignificantly plague both men and women [26]. This paper revealed that diabetes mellitus wasthe leading cause of illness among older and oldest elderly in Jamaica, followed by hypertensionand arthritis, which differs from a past study [17] that had hypertension as the leading cause ofmorbidity of the elderly (43.4 percent), followed by arthritis (39.8 percent) and diabetes mellitus(10.2 percent). When reported illness was cross tabulated by sex of older and oldest elderlyrespondents, the findings showed that 1.4 percent more women had diabetes mellitus than menand this was the same for hypertensive older and oldest elderly Jamaicans. On the other hand, 103
    • there were 1.6 times more old and oldest elderly Jamaican men with self-reported arthritis thanwomen. These chronic non-communicable diseases continue to interface within the functionallives of the elderly, which means that they are indeed living longer but are faced with lowerlevels of good health than young adults (ages 15 to 29 years) and middle-aged adults (ages 30 to59 years). However, there was no statistical difference between self-reported ill and older andoldest elderly age cohorts in this paper, suggesting that health disparity is not between olderelderly and oldest elderly Jamaicans, but rather between older and oldest elderly and other agecohorts, such as young adults and middle-aged adults. Bourne‘s study [10] of 3,009 elderlyJamaicans (ages 60 years and older) found a low general wellbeing of respondents (3.9 out of 14± 2.3) which concurs with this paper. This paper has refined the aforementioned one, byshowing that there is no statistical difference between the self-reported health status of older andoldest elderly Jamaicans; but it did not examine the young old (ages 60 to 74 years) and so it isunable to state whether there was a difference between young old and old and oldest elderlyrespondents. The old and oldest elderly are less likely to be productively employed in the labour forcethan middle-aged adults. This does not mean that they cannot be actively engaged in many otheractivities. Old and oldest elderly Jamaicans are involved in social work, home gardening, andactively engaged in extended family functions such as the rearing of grand-children. In this paper36 out of every 100 old and oldest elderly reported that their grandchildren lived with them. InJamaica, the extended family is still cohesive [20] and this paper showed that this has notchanged, as approximately 54 out of every 100 persons were either married or in common-lawunions; but 8 out of every 10 old and oldest elderly were not living alone, suggesting that theextended family is still alive in 2002. 104
    • In 1997, Statistics from the Planning Institute of Jamaica and the Statistical Institute ofJamaica [51] revealed that 54.3 percent of elderly (ages 60 years and over) lived in rural areas,and this paper showed that approximately 7 out of every 10 old and oldest elderly lived in ruralareas, compared to 6 out of 10 for those 60 years and older of the population. In addition, 20 outof every 100 Jamaicans were below the poverty line, compared to 25 out of every 100 in ruralJamaica. Given that the elderly substantially lived in rural areas and that poverty for this groupwas 10.2 percent (in 2007), it is not surprising that the old and oldest elderly in this area ofresidence had a lower level of good health status than the urban old and oldest elderly inJamaica. It should be noted here that studies have shown that income was related to good health(52, 53), but this is not the case for this paper (old and oldest elderly Jamaicans). Poverty leads to ill-health, suggesting that the poor are less likely to have superior ‗goodhealth status‘ to those in middle to upper classes [54]. Murray [54] opined that the interrelationbetween poverty and health is expressed in poor nutrition, improper sanitation and water qualityand inadequate housing, and these contribute to a lower health status. Other studies [55-57] haverefined this relationship by showing that persistent poverty affects health and even mortality, aswell as accounting for much of the malnutrition in developing countries [58]. Poverty and poorhealth is not only outside of the Caribbean as a study conducted in Jamaica [59] revealed that theleast health was reported by those in the lower class. This is not the case for the old and oldestelderly Jamaicans, as there was no statistical difference between the various social standings (i.e.lower, middle and upper classes) and good health status. The rationale for this is embedded in thedefinition of health, which means that health is tied to the living by more than difficulties ofhypertension, diabetes mellitus and arthritis. Those conditions are not viewed as poor health, asthey are permanent conditions, and therefore may not be construed as such. 105
    • In studies done on elderly Jamaicans (ages 60+ years), physical environment, age, thenumber of males, females and children in a household, education, consumption, health insuranceand cost of medical care were significantly related to good health [3,4,10], as is also the case inBarbados [30], Canada [60] and the United States [61]. However, those variables are not relatedto good health for the old and oldest elderly population in Jamaica, suggesting that variables arenot what account for good health in old and oldest elderly respondents. In Bourne studies onelderly Jamaicans generally [3, 4, 10], it was revealed that crowding, marital status, area ofresidence, physical environment and gender accounted for the majority of the explanatory powerof good health, and that only crowding and marital status were not included in this paper,indicating that good health for ages 75 years and older was not due to identified variables orthose affecting 60+ years and older. Embedded in this figure is that most of the variables thatwere predictors of good health of elderly were more explanations of young elderly (60 to 74years) than the older and oldest elderly elderly. The validity of using people‘s assessment of their life satisfaction and health is old and hasalready been resolved. Nevertheless, it will be succinctly put forward here for those who are notcognizant of this discourse. Scholars have established that there is a statistical associationbetween subjective wellbeing (self-reported wellbeing) and objective wellbeing [62-68], andDiener went further when he found a strong correlation between the two variables [68]. Gaspart[63] opined on the difficulty of objective quality of life (GDP per capita) and the need to useself-reported wellbeing in assessing the wellbeing of people. He wrote, ―So its objectivism isalready contaminated by post-welfarism, opening the door to a mixed approach, in whichpreferences matter as well as objective wellbeing‖ [63], which speaks to the necessity of using ameasure that approximates more to this multidimensional construct, rather than continuing with 106
    • the traditional income per capita approach. Another group of scholars emphasized theimportance of measuring wellbeing outside of welfarism and/or pure objectification, when theysaid that ―Although GDP per capita is usually used as a proxy for the quality of life in differentcountries, material gain is obviously only one of many aspects of life that enhance economicwellbeing‖ [69] and that wellbeing depends on both the quality and the quantity of life lived bythe individual [70]. Another study found that self-rated health was a strong predictor ofmortality, and remained the same even when controlled for physical health [64]. As such, self-rated health encompasses a more extensive coverage of health (such as physical status; cognitive,emotional and social health) that are in keeping with old age than the objective health, which aresubtle and difficult to measure objectively using physical health assessment. CONCLUSIONS In summary, we now have a better understanding of those factors that account for olderand oldest elderly good health. While the data were well fitted for the model, the explanatorypower was low for those identified predictive factors. This means that the good health of this agecohort is not influenced by income, social standing and many other factors that predict healthstatus for the general populace, and that there is a need to examine lifestyle risk factors, cultureand the meaning system of this group, as those variables may provide more answers to the goodhealth of Jamaicans 75 years and older. This quantitative assessment has provided us withpertinent answers, but it is clear from the findings that more information is needed on this agecohort and that this can be had by qualitative methodology. The researcher recommends the useof qualitative methodologies to provide in-depth understanding of the culture and meaningsystem of this cohort as they can provide valuable insight into some of the determinants of goodhealth. 107
    • ACKNOWLEDGEMENT The author would like to thank the Data Bank in the Sir Arthur Lewis Institute of Social and Economic Studies, the University of the West Indies, Mona, Jamaica for making the dataset (Jamaica Survey of Living Conditions, 2002) available. It was used for this paper. REFERENCES [1]. United Nations. World Population Ageing 1950-2050. New York: United Nations; 2002. [2]. Eldemire-Shearer D. Ageing- A New Challenge to Health Care in the New Millennium. West Indian Medical J 2001; 50:95-9. [3]. Bourne PA. Growing Old in Jamaica: Population Ageing and Senior Citizens‘ Wellbeing. Kingston: Community Health and Psychiatry, Faculty of Medical Sciences, the University of the West Indies, Mona, Jamaica; 2009 [4]. Bourne PA. Determinants of well-being of the Jamaican Elderly. Unpublished Thesis, Department of Sociology, Psychology and Social Work, the University of the West Indies, Mona, Kingston; 2007. [5]. Castellόn RH. Population Ageing in Cuba. Malta: International Institute on Ageing, United Nations; 1994 [6]. Gavrilov LA, Heuveline P. Aging of Population. Quoted in the Encyclopedia of Population P. Demeny and G. McNicol, Eds. New York: Macmillan; 2003. [7]. Gavrilov LA, Gavrilova NS. The reliability theory of aging and longevity. J theor Biol 2001; 213:527-45. [8]. Gavrilov LA, Gavrilova NS. The biology of life Span: A Quantitative Approach. New York: Harwood Academic Publisher; 1991. [9]. WHO. WHO Issues New Healthy Life Expectancy Rankings: Japan Number One in New ‗Healthy Life‘ System? Washington D.C. & Geneva: WHO; 2000.[10]. Bourne PA. Medical Sociology: Modelling Well-being for elderly People in Jamaica. West Indian Med J 2008; 57(6):596-04.[11]. WHO. Older persons in emergencies: An Active Ageing Perspective. Geneva: WHO; 2008[12]. Bourne PA. Health Determinants: Using Secondary Data to Model Predictors of Wellbeing of Jamaicans. West Indian Med J 2008; 57:476-81.[13]. Eldemire D. The Jamaican elderly: A socioeconomic perspective and policy implications. Soci & Economic Studies 1997; 46: 175-93.[14]. Eldemire D. Older women: A situational analysis, Jamaica 1996. New York: United Nations Division for the Advancement of Women; 1996.[15]. Eldemire D. A situational analysis of the Jamaican elderly, 1992. Kingston: Planning Institute of Jamaica; 1995.[16]. Eldemire D. The elderly in Jamaica: A gender and development perspective. In Robert, 108
    • J.H., Kitts, J., and L.J. Arsenault, eds. Gender, health, and sustainable development. Perspective from Asia and the Caribbean. Proceedings of workshops held in Singapore, 23-26 January 1995 and in Bridgetown, Barbados, 6-9 December 1994. Ottawa: International Development Research Centre; 1995.[17]. Eldemire D. The elderly and the family: The Jamaican experience. Bulletin of Eastern Caribbean Affairs 1994; 19:31-46.[18]. Eldemire D. The elderly – A Jamaican perspective. Grell, Gerald A. C. (ed). 1987. The elderly in the Caribbean: Proceedings of continuing medical education symposium. Kingston, Jamaica: University Printery; 1987.[19]. Eldemire D. The clinical‘s approach to the elderly patient. G. Grell. ed. 1987. The elderly in the Caribbean: Proceedings of continuing medical education symposium. Kingston, Jamaica: University Printery; 1987.[20]. Eldemire D. Health care in Jamaica. World Health Forum 1995; 16:344-347.[21]. Morrison E. Diabetes and hypertension: Twin trouble. Cajanus 2000; 33:61-63.[22]. Barrett V. Analysis of the Jamaica government‘s policy (1981 – 1986) on institutional and community programmes for the elderly. Kingston: B.Sc. Public Administration, University of the West Indies, Mona; 1987.[23]. Eldemire-Shearer D, Paul TJ, Morris C. Ageing Males – An Emerging Area of Concern. West Indian Med J 2002; 51:139-42.[24]. Anthony BJ. 1999. Nutritional assessment of the elderly. Cajanus 32:201-216.[25]. Blue Cross of Jamaica. The Jamaican handbook for the elderly. Kingston, Jamaica: L.M.H. Publishing; 2001.[26]. Caribbean Food and Nutrition Institute. Health of the elderly. Cajanus 1999; 32:217-240.[27]. Morgan O, Ed. Health Issues in the Caribbean. Kingston: Ian Randle; 2005[28]. Homer D, Lemeshow S. Applied logistic regression, 2nd ed. John Wiley & Sons Inc., New York; 2000.[29]. Cohen L, Holliday M. Statistics for Social Sciences. London, England: Harper & Row; 1982.[30]. Hambleton IR, Clarke K, Broome HL, et al. Historical and current predictors of self- reported health status among elderly persons in Barbados. Revista Panamericana de Salud Pública 2005; 17(5-6):342-52.[31]. Grossman M. The demand for health - a theoretical and empirical investigation. New York: National Bureau of Economic Research, 1972.[32]. Eldemire-Shearer D. Ageing- A New Challenge to Health Care in the New Millennium. West Indian Med J 2001; 50:95-9.[33]. Medawar PB. Old age and natural death. Mod. Q. 2:30-49. [Reprinted in the Uniqueness of the Individual (Medawar PB, Ed. 1958). New York: Basic Books, 1946; 17-43.[34]. Charlesworth B. Evolution in Age-structured Populations, 2nd Ed. Cambridge: Cambridge University Press; 1994.[35]. Mueller L, Rose MR. Evolutionary theory predicts late-life mortality plateaus. Proc. Natl Acad. Sci. 1996; 93:15 253.[36]. Charlesworth B, Partridge L. 1997. Ageing: Leveling of the grim reaper. Curr. Biol. 7:R440-R442; 1997.[37]. Pletcher SD, Curtsinger JW. Mortality plateaus and the evolution of senescence: why are old-age mortality rates so low? Evolution 1998; 52: 454-64. 109
    • [38]. Wachter KW. Evolutionary demographic models for mortality plateaus. Proc. Natl Acad. Sci. 1999; 96:10544-7.[39]. WHO. Ageing and Health, Epidemiology. WHO, Regional Office in Africa; 2005. Available from: http://www.afro.who.int/ageingandhealth/epidemiology.html (accessed March 30, 2009)[40]. WHO. Healthy Ageing: Practical pointers on keeping well. Regional Office for the Western Pacific, Manila, Philippines: WHO; 2005. Available from: http://wpro.who.int (accessed March 30, 2009)[41]. Rice PL. Health psychology. CA, USA: Brooks/Cole Publishing; 1998.[42]. Rodin, J., and Ickovic, J.R. 1990. Women‘s health: Review and research agenda as we approach the 21st century. Am Psychologist, 45:1018-34.[43]. Rudkin L. Gender differences in economic well-being among the elderly of Java. Demography 1993; 30:209-26.[44]. Havenman R, Holden K, Wilson K, Wolfe B. Social security, age of retirement, and economic well-being: Inter-temporal and demographic patterns among retired-worker beneficiaries. Demography 2003; 40:369-94.[45]. Herzog AR. 1989. Physical and Mental Health in Older Women: Selected Research Issues and Data Sources. In: Hendricks, Jon A, ed. 1989. Health and Economic Status of Older Women: Research Issues and Data Sources. New York, USA: Baywood; 1989.[46]. Schoen C, Davis K, DesRoches C, Shekhdar A. The health of adolescent boys: Commonwealth Fund survey findings. New York: Commonwealth Fund; 1998.[47]. Friedman HS ed. Hostility, coping, and health. Washington, DC: Am Psychological Association; 1991.[48]. Kopp MS, Skrabski A, Szedmak S. Why do women suffer more and live longer? Psychosomatic Med 1998;60:92-135.[49]. Weidner G, Collins RL. Gender, coping, and health. In H.W. Krohne, Ed. Attention and avoidance (p. 241-65). Seattle, WA: Hogrefe & Huber; 1993.[50]. 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). Thousand Oaks, CA: Sage Publications; 1987.[51]. Planning Institute of Jamaica (PIOJ), Statistical Institute of Jamaica (STATIN). Jamaica Survey of Living Conditions, 2007. Kingston: PIOJ & STATIN; 2008.[52]. Marmot M. The influence of Income on Health: Views of an Epidemiologist: Does money really matter? Or is it a maker for something else? Health Affairs 2003; 21: 31- 46.[53]. Stronks K, Van De Mheen, Van Den Bos J, MacKenbach JP. The Interrelationship between Income, Health and Employment Status. Int J of Epid 1997; 26:592-600.[54]. Murray S. Poverty and health. Canadian Med Association J 2006;174:923[55]. Lynch JW, Kaplan GA, Shema SJ. Cumulative impact of sustained economic hardship on physical cognitive, psychological, and social functioning. New England J of Med 1997; 337:1889–95.[56]. Menchik PL. Economic status as a determinant of mortality among black and white older men: Does poverty kill? Population Studies 1993;47:427–36.[57]. Zick CD, Ken RS. 1991. Marital transitions, poverty and gender differences in mortality. J of Marriage & the Family 1991; 53: 327–36. 110
    • [58]. Muller O, Krawinkel M. Malnutrition and health in developing countries. Canadian Med Association J 2005; 173:279-86.[59]. Powell LA, Bourne P, Waller L. Probing Jamaica‘s Political culture, vol 1: Main Trends in the July-August 2006, Leadership and Governance Survey. Kingston: Centre for Leadership and Governance, Department of Government, University of the West Indies, Mona, Jamaica; 2007.[60]. Moore EG, Rosenberg MW, McGuinness D. Growing old in Canada: Demographic and geographic perspectives. Ontario: Nelson; 1997.[61]. Smith JP, Kington R. Demographic and Economic Correlates of Health in Old Age. Demography 1997; 34:159-70.[62]. Diener E. Subjective well-being: the science of happiness and a proposal for a national index. Am Psychologist 2000; 55: 34–43[63]. Gaspart F. Objective measures of well-being and the cooperation production problem. Soc Choice & Welfare 1998;15(1):95-112.[64]. Idler EL, Benyami Y. Self-rated health and mortality: A review of twenty-seven community studies. J of Health and Soc Behavior 1997; 38: 21-37.[65]. Jylha M, Guralnik JM, Ferrucci L, Jokela J, Heikkinen E. Is self-rated health comparable across cultures and genders. J of Gerontology 1998; 53B:S144-S15.[66]. Larson R. Thirty years of research on the subjective well-being of older Americans. J of Gerontology 1978;33(1):109-25.[67]. Zimmer A, Natividad JN, Lin Hui-Sheng, Chayovan N. A cross-national examination of the determinants of self-assessed health. J of Health and Soc Behavior 2000; 41:465-81.[68]. Diener E. Subjective well-being. Psychological Bulletin 1984; 95: 542–75.[69]. Becker GS, Philipson TJ, Soares RR. The quantity and quality of life and the evolution of world inequality; 2004. Available from: http://www.spc.uchicago.edu/prc/pdfs/becker05.pdf#search=%22preston%2C%20quality %20of%20life%22 (accessed August 22, 2006).[70]. Easterlin RA. Income and Happiness: Towards a Unified Theory. Economic J 2001; 111; 473: 465-84 111
    • Table 4.1. Sociodemographic Characteristics of Sample by Old and Oldest Elderly CohortsVariable Older Elderly Oldest Elderly P value n (%) n (%)Sex 0.003 Male 356 (44.9) 97 (35.1) Female 437 (55.1) 179 (64.9)Health Insurance No 742 (95.0) 256 (96.6) 0.184 Yes 39 (5.0) 9 (3.4)Good Health Status 0.385 No 403 (51.3) 140 (52.6) Yes 382 (48.7) 126 (47.4)Education 0.170 Primary and below 491 (65.2) 171 (70.7) Secondary 241 (32.0) 68 (28.1) Tertiary 21 (2.8) 3 (1.2)Area of residence 0.121 Urban 259 (32.7) 79 (28.6) Rural 534 (67.3) 197 (71.4)House Tenure 0.613 Rent free 61 (7.7) 25 (9.1) Rented 36 (4.5) 15 (5.5) Owned 696 (87.8) 235 (85.5) 112
    • Table 4.2. Sociodemographic Characteristics of Sample by Urban-rural AreasVariable Urban Rural p value n (%) n (%)Good Health Status 0.001 No 137 (41.1) 406 (56.5) Yes 196 (58.9) 312 (43.5)Retirement Income 0.001 No 292 (86.4) 689 (94.3) Yes 46 (13.6) 42 (5.7)Gender 0.185 Male 136 (40.2) 317 (43.4) Female 202 (59.8) 414 (56.6)Marital status 0.282 Married 97 (29.4) 207 (29.1) Never married (include common law) 80 (24.2) 175 (24.6) Divorced 10 (3.0) 8 (1.1) Separated 6 (1.8) 18 (2.3) Widowed 135 (41.5) 305 (42.9)Age group 0.214 Older Elderly 259 (76.6) 534 (73.1) Oldest Elderly 79 (23.4) 197 (26.9)Utilization of Health Facilities 0.293 Private 39 (55.7) 119 (51.1) Public 31 (44.3) 114 (48.9)Private Health Insurance coverage 0.001 No 296 (89.7) 702 (98.0) Yes 34 (10.3) 14 (2.0)Education 0.001 Primary and below 196 (61.4) 466 (68.9) Secondary 105 (32.9) 204 (30.2) Tertiary 18 (5.6) 6 (0.9)Social class 0.001 Poorest 42 (12.4) 197 (26.9) Poor 45 (13.3) 171 (23.4) Low Middle 59 (17.5) 136 (18.6) Upper Middle 77 (22.8) 117 (16.0) Wealthiest 115 (34.0) 110 (15.0)Per capita consumption* Mean (SD) US$1,820.23 US$1,263.21 0.001 ($1,399.19) ($1,187.49)Crowding Mean (SD) 1.05 (0.85) 1.15 (0.83) 0.071Crime Index Mean (SD) 1.61 (7.53) 0.74 (3.02) 0.007Living Alone 75 (22.2) 146 (20.0) 0.405*US$1= Ja.$50.97 113
    • Table 4.3. Health Insurance by Retirement Income Retirement Income No Yes TotalHealth Insurance Coverage No 96.7 81.0 100.0 Yes 3.3 19.0 4.6Total 962 84 1,046χ 2 (1) =4.610, p value = 0.001 114
    • Table 4.4. Chronic (recurring) Illness by Age Cohort Age Cohort Older Elderly Oldest elderly TotalChronic Illness Cold 3.9 2.8 3.6 Diarrhoea 1.2 2.8 1.6 Asthma 3.9 1.9 3.4 Hypertension 23.4 17.6 21.9 Diabetes 37.1 38.0 37.3 Arthritis 16.5 16.7 16.5 Other 11.7 15.7 12.7 No 2.4 4.6 2.9Total 334 108 442χ 2 (7) =6.269, p value = 0.509 115
    • Table 4.5. Chronic (recurring) Illness by Gender Gender Male Female TotalChronic Illness Cold 4.6 3.0 3.6 Diarrhoea 1.7 1.5 1.6 Asthma 5.7 1.9 3.4 Hypertension 17.8 24.6 21.9 Diabetes 29.9 42.2 37.3 Arthritis 21.3 13.4 16.5 Other 16.7 10.1 12.7 No 2.3 3.4 2.9Total 174 268 442χ 2 (7) =19.908, p value = 0.006 116
    • Table 4.6. Logistic Regression on Good Health of Old and Oldest Elderly Jamaicans andSome Explanatory Variables, N=958 Std Wald Odds 95.0% C.I. Variables Coefficient Error Statistics p value Ratio Lower Upper Average Consumption 0.000 0.000 0.334 0.563 1.000 1.000 1.000 Environment 0.103 0.143 0.517 0.472 1.108 0.837 1.468 Other Towns 0.614 0.169 13.213 0.000 1.847 1.327 2.572 Urban 0.513 0.227 5.115 0.024 1.670 1.071 2.606 †Rural area 1.000 Social support -0.165 0.134 1.513 0.219 0.848 0.652 1.103 Sex 0.343 0.151 5.145 0.023 1.410 1.048 1.897 Number of male 0.008 0.074 0.012 0.914 1.008 0.872 1.165 Number of female 0.084 0.076 1.227 0.268 1.088 0.937 1.262 Number of children 0.050 0.062 0.644 0.422 1.051 0.930 1.188 Age -0.019 0.012 2.501 0.114 0.981 0.957 1.005 Middle Quintile 0.023 0.188 0.015 0.901 1.024 0.709 1.478 Wealthiest Quintiles 0.088 0.205 0.185 0.668 1.092 0.731 1.631 †Poorest-poor quintiles 1.000 Health Insurance 0.241 0.326 0.549 0.459 1.273 0.672 2.411 Cost of medical care 0.000 0.000 0.203 0.652 1.000 1.000 1.000 Primary Education 0.180 0.142 1.592 0.207 1.197 0.905 1.582 - Constant 0.774 1.024 0.572 0.450 2.168Nagelkerke R-square=5.0%-2 Log likelihood = 1325.803Hosmer and Lemeshow chi-square=5.785; P=0.671Model: Omnibus Test - chi-square=37.258, p=0.001Overall correct classification = 58.3%Correct classification of cases of poor health status =69.6%Correct classification of cases of good health status = 45.7%†Reference group 117
    • Chapter 5Decomposing Mortality Rates and Examining Health Status ofthe Elderly in Jamaica Paul A. Bourne, Donovan A. McGrowder and Tazhmoye V. CrawfordPopulation ageing in Jamaica follows a global trend where the number of persons aged 60 andover is increasing. This paper investigated age-specific death rates, mortality sex ratio and healthstatus of the elderly in Jamaica aged 55 years and over. The study utilized secondary datapublished by the Statistical Institute of Jamaica on mortality and secondary cross-sectionalprobability survey data were used to model poor health status in elderly residents. The findingsrevealed that there is increased life expectancy. In 2005, the age-specific mortality rate forelderly 75 years and older was 4.4 times more than that of the crude death rate for thepopulation; 9.4 times more than that of age-specific death rate at ages 55 to 59 years and thatdisparity narrows at the elderly gets older. The mortality sex ratio revealed that between 115 to120 males die for every 100 females. More men die between the ages of 55 and 75, than men 75years and older. As Jamaicans become older than 55 years their poor health status significantlyincreased. Poor health status was accounted for significantly by hypertension, diabetes mellitus,and arthritis. Eight factors determine poor health status of elderly Jamaicans. Some of thesefactors are retirement income (OR = 1.461, 95%CI:1.001, 2.131); cost of medical care (OR =1.144, 95%CI = 1.073, 1.220); area of residence (other towns – OR = 0.754, 95%CI = 0.597,0.953); marital status (separated – OR = 1.901, 95%CI = 1.479, 2.445; married – OR = 1.406,95%CI = 1.103, 1.792); education (secondary – OR = 1.206, 95%CI = 1.001, 1.451; tertiary leveleducation – OR = 0.492, 95%CI = 0.281, 0.861), and number of men in household (OR = 0.987,95%CI = 0.806, 0.998). This paper provides valuable information about the mortality rates andhealth status of elderly residents in Jamaica. High mortality rates for avoidable and preventablediseases and potential years of life lost are major public health concerns, especially for regionalhealthcare providers. 118
    • INTRODUCTIONPopulation ageing offers many challenges that impact on every dimension of life includingfamily, economy, health services, education, and the general fabric of a society [1]. Manycountries in the Caribbean have already begun to recognize the need to mainstream ageing intotheir comprehensive long-term development policies and programmes while others are re-examining already existing approaches to enhance welfare and well-being of not only theirelderly but also to prepare the younger generations for their later years [2]. Birth cohorts of theelderly in Latin America and the Caribbean who reach age 60 years and above after 1990 areunique in that they are largely the product of medical interventions that increased childhoodsurvival largely in the absence of significant improvements in standards of living. It is estimatedthat between 50 to 70 percent of the mortality decline that took place after 1945 was associatedwith medical interventions [3,4]. The remaining decline was probably associated with betterstandards of living, increased knowledge about exposure and resistance to illnesses, and assortedother factors. Furthermore, a large fraction of these gains were concentrated early in the life ofindividuals, between birth and age five (5) or 10. Worldwide life expectancy of the elderly is increasingly becoming higher for femalesthan for their male counterparts. In developed countries, an average female life expectancy atbirth of at least 80 years has become the norm. The average gap in life expectancy between thesexes is roughly seven (7) years in developed countries, but can be as great as 13 years in parts ofthe former Soviet Union as a result of unusually high levels [5]. Changes in overall lifeexpectancy in developing regions of the world have been more uniform. Given the small averagegender gap in life expectancy relative to developed nations, most demographers expect to see a 119
    • widening of the female/male difference in upcoming decades, along the lines of the historicaltrend in industrialized nations [6]. One factor that may promote such a widening is education,which is positively related to survival. As women ―catch up‖ to men in terms of educationalattainment, we might expect to see relative improvements in survival and health status [7].Greater male exposure to risk factors such as tobacco use, alcohol consumption, andoccupational hazards often are cited as a source of higher male mortality rates than female [8]. The World Health Organization (WHO) in its World Health Report 2003 [9] states thatpopulation ageing and changes in the distribution of risk factors have accelerated the epidemic ofnon-communicable diseases in many developing countries. While non-communicable andlifestyle related diseases used to be the plight of the developed world, they are increasinglybecoming major health threats for people in developing countries. Cardiovascular disease is byfar the leading cause of death at older ages in developing countries, although the impact ofcommunicable diseases remains considerable [10]. There is evidence that the prevalence ofdiabetes is highest in people over 65 years of age, with the highest incidence also occurring inthis age group [11]. The burden of diabetes in the older population is set to increase even furtherbecause of demographic change, the rising incidence of diabetes in all age groups [12] and thelonger survival of people who are diagnosed at a younger age [13]. Diabetes affects mortalityand numerous studies have highlighted the reduced life expectancy associated with a diagnosisof diabetes [14], with mortality found to be almost 4-fold [15] and even as high as 9-fold [16] inolder diabetics compared with non-diabetics. In developed countries, the health and social status of the elderly has received a fairamount of attention [17]. With the Caribbean, some progress has been made in terms of researchon the elderly since Braithwaite [18] when he noted that data on the Caribbean elderly were 120
    • extremely limited. With the continuing aging of the population in the Caribbean, gerontologicalresearch has devoted increasing attention to those at very advanced ages [19] and in recent years,there has been increasing interest in issues relating to health of the elderly in the Caribbean.Patterns of mortality at the most advanced ages are of interest in their own right, indicatingvariation in health status and well-being among this group. Moreover, differences in mortalityand trends in them may give clues about the likelihood of a further extension of life expectancy[20]. In Jamaica as is the same for most of the Caribbean, there are increasing numbers ofpersons living 60 years and some people are even living beyond the life expectancy of theirperspective nations. Eldemire [21] noted that the elderly in Jamaica represents 10% of thepopulation, and that they were for the most part mentally competent and physically independent.With a calculated life expectancy of 75.5 years [22], the burden on the healthcare system can beexpected to increase. While we acknowledge the increasing longevity of the Jamaicanpopulation, many elderly have low socio-economic status and continue to experience a numberof other social as well as medical problems which influence their health status and can cause pre-mature mortality. For the last decade (1998-2007), statistics on mortality in Jamaica revealed thattwo-thirds of the annual deaths were people 60 years and older [23]. Given those issues andowing to the seemingly critical nature of mortality on ageing, this paper investigated lifeexpectancy at birth of Jamaicans by gender, mortality sex ratios and age-specific mortality ratesof adults 55 years and over. Aspects of the health status of these adults are investigated as well aschronic communicable and non-communicable diseases of persons with poor health status. Thepaper also examined factors which can predict poor health status in elderly persons (ages 55years and older) in Jamaica. 121
    • METHODThis paper utilized secondary data on mortality published by the Statistical Institute of Jamaica(STATIN). The data are collected by the Registrar General Department (RGD). The mortalitydata published by STATIN is a modification of the RGD‘s figures. This is in keeping withcoverage errors identified by some scholars who examined the RGD‘s data on mortality. There have been many postulations that RGD‘s data are not correctly reflecting a goodcoverage of deaths, and births in the country. This discourse has extended beyond demographersand epidemiologists in Jamaica to the United Nations. In keeping with the above-mentionedrequisition from different scholars, STATIN have used the findings published in different studies[24, 25] as they found under-registration in fetal, infant and maternal deaths in the country [26].In 1996, researchers revealed that the RGD data on deaths had an 84.8% coverage rate and 2years later the figure raised to 89.6%, which means a moderate coverage of data according to theWorld Health Organization – the ICD classification. It noted that 90% of completeness of deathregistration was said to be high quality data; and 70-89% was medium quality data [23].Consequently, STATIN adjust RGD‘s mortality data to reflect 100% coverage. This paper employed the published data within STATIN‘s demographic statistics afterthe adjustment of the RGD‘s figure. The mortality data that were used in this paper was onselected ages – ages 55 years and over. This research sought to decomposed mortality data atolder ages in Jamaica in comparison to total deaths in a calendar year, examining any trends inmortality pattern in since 1998. 122
    • In addition to the aforementioned secondary data, cross-sectional survey data were alsoutilized to examine health status and self-reported recurring (chronic) dysfunctions as diagnosedby a medical practitioner. The sub-sample for this paper was 3,748 persons (ages of 55 to 100years) extracted from a nationally representative cross-sectional survey of 25,018 Jamaicans, theJamaica Survey of Living Status (JSLC). This paper used JSLC 2002 which was conducted by STATIN and Planning Institute ofJamaica (PIOJ) between June and October 2002. The researchers selected this survey because itwas the second largest sample size for the survey in its history (since 1988 to 1998), and in thatyear, the survey had questions on crime and victimization, and the physical environment unlikeprevious years. A self-administered questionnaire was used to collect the data, which was storedand analyzed using SPSS for Windows 16.0. The questionnaire was modeled from the WorldBank‘s Living Standards Measurement Study (LSMS) household survey. There were somemodifications to the LSMS as JSLC was more focused on policy impacts. The questionnairecovered questions such as: socio-demographic, economic and wealth, crime and victimization,social welfare, health status and services, nutrition, housing, immunization of infants andphysical environment. The non-response rate for the survey was 27.7%. Hence, of the intendedsample, 72.3% of the respondents answered the survey questions. Descriptive statistics such as mean, standard deviation (SD), frequency and percentagewere used to analyze the socio-demographic characteristics of the sample. Chi-square was usedto examine association between non-metric variables; an Analysis of Variance (ANOVA) wasused to evaluate the relationships between metric and non-dichotomous categorical variables. Toexamine the predictors of poor health status, logistic regression was performed as the dependent 123
    • variable was a binary one (self-reported health status, with 1 if good health status was reportedand 0 if poor health). Results were presented using un-standardized B-coefficients, Wald statistics, odds ratioand confidence interval (95% CI). The predictive power of the model was tested using OmnibusTest of Model and Hosmer and Lemeshow [27] was used to examine goodness of fit of themodel. The correlation matrix was examined in order to ascertain whether autocorrelation (ormulti-collinearity) existed between variables. Based on Cohen and Holliday [28], correlation canbe low (weak), from 0 to 0.39; moderate, 0.4 to 0.69, and strong, 0.7 to 1.0. This was used toexclude (or allow) a variable in the model. Wald statistics was used to determine the magnitude(or contribution) of each statistically significant variables in comparison with the others, and theodds ratio (OR) for interpreting each significant variables.MeasureRetirement income is a dummy variable where 1= having reported receiving public or privatepensions, 0 = otherwise. Durable goods index is the summation of all consumer goods owed byhousehold members that are within the household. Average consumption expenditure is the totalamount of money spent on consumption and non-consumption goods divided by the number ofpeople in the household. Crowding is the total number of people in the household divided by thetotal number of rooms in the dwelling excluding verandah, kitchen and bathroom. Social class -this variable was measured based on income quintile. The upper classes were those in thewealthy quintiles (quintiles 4 and 5); middle class was quintile 3 and poor those in lowerquintiles (quintiles 1 and 2). Poor health status (self-reported illness or self-reporteddysfunction): The question was asked: ―Is this a diagnosed recurring illness?‖ The answering 124
    • options are: yes, cold; yes, diarrhoea; yes, asthma; yes, diabetes; yes, hypertension; yes, arthritis;yes, other; and no. A binary variable was later created from this construct (1 = yes, 0 =otherwise) in order to use this in the logistic regression. Social supports represent differentsocial networks with which the individual is involved (1 = membership of and/or visits to civicorganizations or having friends who visit ones home or with whom one is able to network,0 = otherwise). Psychological conditions are the psychological state of an individual, and this issubdivided into positive and negative affective psychological conditions. Positive affectivepsychological condition is the number of responses with regard to being hopeful, optimisticabout the future and life generally. Negative affective psychological condition is number ofresponses from a person on having lost a breadwinner and/or family member, having lostproperty, being made redundant, or failing to meet household and other obligations. where ki represents the frequency with which an individual witnessed or experienced a crime, where i denote 0, 1 and 2, inwhich 0 indicates not witnessing or experiencing a crime, 1 means witnessing 1 to 2, and 2symbolizes seeing 3 or more crimes. Tj denotes the degree of the different typologies of crimewitnessed 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 orraped. The summation of the frequency of crime by the degree of the incident ranges from 0 anda maximum of 51. 125
    • RESULTSThe sample comprised of 3,748 respondents who were 55 years and older (48.2% men and51.8% women), with mean age being 68.87 years (SD = 9.67 years). Approximately 8% of thesample had private health insurance compared to 92% who do not have private health insurancecoverage. Two-thirds of the sample resided in rural areas compared to 22% in peri-urban areasand 12% in urban areas. Marginally more of the respondents had social support (55%); 19%lived alone; 60% had at most primary level education; 4% had tertiary level education and 60%reported good health status. Forty-two percent of the sample was married; the medianconsumption per person per household was US$551.96, and the mean number of visits to healthcare practitioners was 1.74 (SD =1.47). The mean crowding was 1.00 person (SD = 1.00 person).Thirty-seven percentage points of sample was poor, of which 18% were below the poverty linecompared to 43% who were at least wealthy of which 23% were in the wealthiest social class(Table 5.1). In 1998, 18.8 Jamaicans for every 1,000 Jamaicans died. Over a 9-year period (1998-2007), the crude death rate fell to 17.8 per 1,000 Jamaicans (Table 5.2). Although the crudedeath rates for Jamaicans ages 55 years and older fell for the same aforementioned period, it was1.94 times more for older respondents than for the population in 1998 and the rate fell to 1.85times in 2005. Table 5.2 revealed that as Jamaicans age beyond 59 years, the age-specific deathrate increases and this is significant for those 75 years and older. For Jamaicans 75 years andolder, in 1998, the age-specific death rate was 7.8 times more than the age-specific death for ages55 to 59 years, and the figure increased to 9.3 times in 2005. Since 1998 (to 2005), mortality atolder age (75 years and over) has been fluctuating, with the only relatively stable period beingfrom 1998 to 2001. However, there was a precipitous fall in 2004 over 1998 (by 13.0%). 126
    • The age-specific death rates for the population and older ages do not provide a thoroughunderstanding of the sex disparity in mortality. The sex disparity in mortality is capture in lifeexpectancy data (Table 5.3). In 1880-1882, life expectancy for females was 2.78 years morethan that of males and 122 years later (2002-2004), the disparity has increased to 5.81 years.Once again this is for the population, and does not provide an understanding of mortalitydisparity at older ages for the sexes. The mortality sex ratio revealed that between 115 to 120 males die for every 100 females.On decomposing these figures, it was revealed that more men die between the ages of 55 and 75,than men 75 years and older (Table 5.4). Of the mortality statistics at older ages, mortality sexratio increased in ages 65 to 69 years (7.62%) unlike any other old age cohorts (Figure 6.1) for2005 over 2004. Mortality sex ratio at older ages has been declining with the exception of theincrease in the aforementioned age cohort. Consequently, the lowest reduction in mortality sexratio was at ages 75 years and beyond (2.58%). The largest decline was for ages 55 to 59 years(5.95%) followed by 60-64 years (5.67%). There was a negative correlation between good health status and age group ofrespondents (χ2 = 171.799, p = 0.001). Table 5.5 revealed that while about 76% of Jamaicansaged 55 to 59 years reported good health status, this percentage decreased as the age of therespondents increased and averaged 48.3% of those aged 75 years and over. It was found that32% of the sample reported that they were diagnosed with a chronic illness by a medicalpractitioner. Ninety-six percent of those who indicated that they had chronic illness werediagnosed with this condition compared to 3.8% who claimed that their illness (chronic) was notdiagnosed by a health practitioner. Most of the respondents who indicated being diagnosed with 127
    • a chronic illness had hypertension (37.6%) compared to 22.0% having diabetes mellitus, 15.3%having arthritis, 12.5% reported other and 2.7% reported asthma (Table 5.6). There was nostatistical correlation between diagnosed chronic illness and age cohort of respondents (χ2 =24.46, p = 0.657). In examining predictors of poor health status of elderly Jamaicans, eight factors werestatistically associated with poor health status of elderly Jamaicans. The factors explain 10.6% ofthe variability in poor health of sample (Table 5.7). The model had a moderate statisticalsignificant predictive power (χ2 = 190.47, p = 0.001; Hosmer and Lemeshow goodness of fit χ2 =7.92, p = 0.441). Overall, 67.1% (n = 1,580) of the data were correctly classified: 89.4% (n =1,338) indicated good health status and 28.1%, poor health status (n = 242). The factors that determine poor health status of elderly Jamaicans are retirement income(OR = 1.461, 95%CI:1.001, 2.131); cost of medical care (OR = 1.144, 95%CI = 1.073, 1.220);area of residence (other towns - OR = 0.754, 95%CI = 0.597, 0.953); marital status (separated –OR = 1.901, 95%CI = 1.479, 2.445; married – OR = 1.406, 95%CI = 1.103, 1.792); education(secondary - OR = 1.206, 95%CI = 1.001, 1.451; tertiary level education - OR = 0.492, 95%CI =0.281, 0.861); psychological conditions (negative affective condition - OR = 1.035, 95%CI =1.004, 1.068; positive affective condition - OR = 0.945, 95%CI = 0.909, 0.983); number of menin household (OR = 0.987, 95%CI = 0.806, 0.998), and durable goods (OR = 0.953, 95%CI =0.914, 0.994; Table 5.7). 128
    • DISCUSSIONLife expectancy between 1880 and 2004 clearly indicates a gradual upward progression and thatthe disparity of lived years between the sexes was greatest for 2002 to 2004. Females continue tohave a higher life expectancy than males and the gap between the life expectancy of males andfemales widened from 2.78 years in 1880-1884 to 5.81 years in 2002-2004. This indicates thatwhile the Jamaican population is ageing, on an average mortality for women is falling comparedto men. A study carried out in 1995, showed that there were 110,430 males and 130,020 femalesin Jamaica in the 60 years and older group, representing 9.42% of the population [29]. Anotherstudy reported that in the years 1996 -1998, and 2002–2004, there was a significant increase inlife expectancy and in the average life span of the country‘s population [30]. Furthermore, it wasalso found that Jamaican males born in the earlier period (1996-1998), can expect to live 69.98years, and females can look forward to live 75.58 years. Jamaican males born in 2002-2004 canexpect to live 71.26 years compared with their female counterpart who can look forward to 77.07years [30]. The positive trend in life expectancy is indicating that the proportion of the elderly inthe Jamaican population is increasing. The increase in life expectancy can be explained by:increase in the number of births, reduction in infant mortality, decrease in premature deaths,decrease in mortality rate, the elimination of most infectious diseases and improved health care[31]. The gains reported in recent years in mean life expectancy at various age groups has nodoubt contributed to the common view that major breakthroughs in medicine that reduce deathsfrom the major chronic diseases will now produce significant reductions in mortality of olderpersons and consequent prolongation in life expectancy. Improvements in healthcare and 129
    • increased accessibility to healthcare equally play a role in the increased life expectancy [32] aswell as sanitation, good quality water and better nutritional intake of foods by people. Other supporting studies carried out in the Caribbean show that persons at age 60 canexpect to live another 20 years, with the highest value for Barbadian and Cuban women (22.5years) and the lowest value for men from Haiti and Guyana (less than 16 years additional years)[33]. In terms of health-adjusted life expectancy rates, a person at age 60 in the Caribbean shouldbe able to spend on the average two thirds of his/her life expectancy in good health [33].Furthermore, the difference between life expectancy at birth for men and women in theCaribbean is presently 5.5 years, but the gap appears to narrow with increasing age, with adifference of 2.5 years at age 60 and less than one year at age 80 [33]. A possible explanation forthese gender-specific differences in life expectancy could be the fact that women seem to begenerally more health conscious than men and consequently consult medical professionals morefrequently than men. The results of this paper showed that the mortality sex ratio of the elderly fluctuates in thevarious age groups although it increases from 1998 to 2004 in the 55 to 59 age group anddecreases in the 65 to 69 age group. Overall, most of the years showed a marginal increase in themortality sex ratio in the population, and there was a significant decrease in the 75 years andover group compared with the 70 – 74 age group. This suggests that the mortality rate of femalesrelative to males increased significantly in the 75 years and over. This emphasized that the deathrates themselves are higher for males as for females at the same ages and this differential isslightly increasing possibly as a result of increased in the mortality rates for females 75 years andover. 130
    • There is evidence suggesting that self-reported health is an indicator of general healthwith good construct validity [34] and is a respectably powerful predictor of mortality risks [35],disability [36] and morbidity [37], though these properties vary somewhat with national orcultural contexts [35]. The results of this paper showed that the majority of those sampledreported themselves to be experiencing fair to good health, with thirty seven percent reportingbad health. Another key observation is that with increasing age of the respondents, less reportedgood heath suggesting that the elderly becomes older, there is decreased health status. Theseresults compare very favourably with results coming out of Dominica [38] and Trinidad [39]. Inreviews of the literature, Benyamini & Idler [40] and Idler & Benyamini [35], showed that inmost studies conducted since the 1980s, the elderly people who self-rated their health as badpresented greater incidence of death than did those who considered it to be excellent. Amongelderly people, self-rated health may present greater sensitivity for men than for women. Sincewomen live longer than men and experience more years with diseases and incapacities, they tendto rate their health more negatively than do men, but do not necessarily die because of this, overthe short term. Thus, negative self-rated health expressed by women may be more associatedwith quality of life. On the other hand, when men rate their health negatively, they present agreater risk of succumbing to a fatal event [41]. This research revealed that elderly men were42.5% less likely to report poor health status than elderly women and that this is in keeping withthe literature. In a study of the elderly in Latin America and Caribbean countries, self reported healthstatus shows large inter-country variability and more muted heterogeneity due to gender and age[42]. The authors found that women and the very old are more likely to declare themselves inbad health. In addition, the mean number of self reported chronic conditions increases with age 131
    • and is higher for females than it is for males. In this paper, the prevalent rate of chronic diseaseswas 31%. This is less than the 80% reported in a study in Trinidad [39]. The main chronicillnesses reported by the respondents in this paper were hypertension, diabetes and arthritis. Thisis in keeping with the study by Rawlins et al [39] and other Caribbean studies on this age group[43, 44]. Furthermore, a study conducted on elderly Jamaicans showed that this age cohort wasmainly affected by chronic non-communicable diseases [45]. In 1991, cardiovascular diseasesfollowed by diabetes mellitus and neoplasms were the diseases for which Jamaicans 65 yearsolder were most often hospitalized. Although we did not examine hospitalization data for thispaper, interestingly and indirectly the findings somewhat concurs with the 1991 study. Thefindings in this paper revealed that hypertension is the leading cause of reported disease followedby diabetes mellitus. The 1994 Jamaica Survey of Living Conditions [46] indicates that personsover 60 years old exhibited the highest prevalence of protracted illness. Additionally, 81.5% ofthe ill or injured sought medical care from private institutions. Females were more likely thanmales to seek medical care, and are partially explained in the fact that they were more willing todeclare that they were ill and this is the first sign of recognition that there is an ill-health matterthat needs to be addressed through medical attention. Diabetes mellitus is one of the leading causes of morbidity and mortality among personsaged 65 and older [47]. About 20% of persons in this age group are estimated to have diabetes,with another 25% in pre-diabetic stages [48]. Moreover, because diabetes can be asymptomaticfor many years, about 50% of older individuals with diabetes are thought to be undiagnosed [49].In Jamaica, diabetes-related deaths in 1994 had increased 147% over the 1980 level andrepresented the third leading cause of loss of years of potential life among women and tenth 132
    • among men [50]. There is evidence that this is due to the low rates of awareness, treatment andcontrol among patients with hypertension and diabetes [51, 52]. Hypertension was the main non-communicable cause of poor health in the sample, and ismore common among women and the elderly in Jamaica [53]. It is known to be a major riskfactor for the development of diabetic renal disease, and hyperglycaemia also has a role in thedevelopment of diabetic nephropathy [54]. Hypertension is one of the most important treatablecauses of morbidity and mortality and accounts for a large proportion of cardiovascular diseasesin elderly [55]. Studies from developed countries have reported prevalence of raised bloodpressure among elderly to vary from 60% to 80% [56]. One of the findings of this paper was that married and separated elderly adults haveincreased odds of reporting poor health. This is not so unexpected given the context of Jamaicawhere most of the respondents in the sample are from the rural area. Statistics for Jamaica in2007 showed that the prevalence of rural poverty was 15.3% which was 2.5 times more than thatin urban areas and 3.8 times more than in peri-urban areas [57]. With more elderly Jamaicansresiding in rural areas, and poverty being significant higher in those geographical areas, thosewho are married would have social support from their partners, but would be more economicchallenged in providing food and the addition responsibility of medical care on occasions whenillness affects them or their partner. Due to their low socio-economic status coupled with ageingand the possibility of unemployment, they will be highly unlikely to afford and access healthcare as well as to take care of the other spouse. These findings are contrary to other research thathas documented a positive relationship between longer life, good health status and marriagewhich likely can be attributed to the heightened financial well-being that accompanies being 133
    • married [58]. In addition to possibly low socio-economic status, elders who are separated mayrequire more help than those who are married. Another finding is that the number of men in a household has significantly lower odds ofreporting health care. In Jamaica some men have greater economic stability based on their levelof employment, income and material resources, which is significantly greater than women. Thismeans that these men are more likely to have accumulated more in their working years thanwomen. This increased their ability to provide for themselves and their household in later life.Ageing is a rural phenomenon in Jamaica as more elderly resides there. Furthermore, there is asub-culture in rural areas that men are the head of the household and are responsible to work,while a woman‘s responsibilities include the rearing of children and household domestication.Hence, households with more men have a greater probability of more economic resources thanthose with more women. Although the sub-culture in rural areas is that men‘s responsibility is forfinancial resources, this is not dominant in urban areas. Men are paid more than women and mayhave access to more financial resources. This then explains the finding for why more elderly menin a household being an advantage to that dwelling than one with more women as they have thecapacity to absorb the financial challenges in later life. One indicator that can be used to evaluate how people are responding (or not responding)to life‘s challenges is their psychological state. According to Diener [59], there is a correlationbetween one‘s psychological state and subjective wellbeing; this suggests that psychologicalconditions influence health status. Diener and Emmons [60] refined psychological conditionsinto negative and positive affective psychological conditions and argued that each plays adifferent role in affecting wellbeing. They opined that being optimistic about life directinfluences wellbeing, and negative emotions and pessimism affect one‘s wellbeing indirectly. 134
    • This was concurred in a later finding that showed the significant direct association betweenhappiness (ie positive affective condition) and subjective wellbeing [61]. Lyubomirsky [61]identified ‗comfortable income‘, ‗robust health‘, supportive marriage‘, and ‗lack of tragedy‘ or‗trauma‘ in the lives of people as factors that distinguish happy from unhappy people, which wasearlier noted in a study by Diener, Suh, Lucas and Smith [62]. Negative and positive affectiveconditions based on those scholars do influence subjective wellbeing differently, and so must betaken into consideration in the study of health status. This paper concurs with the literature as itfound a direct correlation between negative affective psychological conditions and poor healthstatus, and an inverse significant association with positive affective conditions and poor healthstatus. Interestingly, the study revealed that the strength of both phenomena was stronger forpositive than negative affective condition. Embedded therein is how positive conditions willsignificant reverse poor health status of the elderly and the decreasing role of negative conditionson health status.CONCLUSIONThe life expectancy of Jamaicans is increasing and the gender gap has widened in recent years.Majority of the respondents in the sample had good health, and those with poor health statuswere more likely to report having hypertension followed by diabetes mellitus. High mortalityrates for avoidable and preventable diseases and potential years of life lost are major publichealth concerns, especially for regional health planners and healthcare providers. These diseasesare often considered to be a manifestation of lifestyle choices, though it must be recognized that 135
    • choices are greatly affected by social, cultural and economic factors. The prevalence of chronicdiseases and levels of disability in older people can be reduced with appropriate healthpromotion and strategies to prevent non-communicable diseases. This research provides valuableinformation on mortality and health status which can help planners to specifically and adequatelyaddress the health needs of the elderly in Jamaica.REFERENCES1. Pelaez M. Building the foundations for health in old age in the Americas. Rev Panam Salud Publica / Pan Am J Public Health 2005; 17(5-6): 299-302.2. Commission for Latin America and the Caribbean (ECLAC)/ Caribbean Development and Cooperation Committee (CDCC). Population ageing in the Caribbean: An inventory of policies, programmes and future challenges, Port of Spain, Trinidad and Tobago, 2004.3. Palloni A, Wyrick R. Mortality decline in Latin America: Changes in the structures of causes of deaths, 1950-1975. Social Biology 1981; 28: 187-216.4. Preston SH. Mortality patterns in national populations with special reference to recorded causes of death. New York: Academic Press, 1976.5. Crimmins, E, Hayward M, Saito Y. Differentials in active life expectancy in the older population of the United States. Journal of Gerontology: Social Sciences 1996; 51B(3): S111-120.6. Palloni A, Pinto-Agiurre C, Pelaez M. Demographic and health conditions of ageing in Latin America and the Caribbean. International Journal of Epidemiology 2002; 31: 762-771.7. Liu X, Hermalin, Yi-Li-Chuang. The effect of education on mortality among older Taiwanese and its pathways. Journal of Gerontology: Social Sciences 1998; 53B (2): S71-82.8. Statistics Canada. Health Reports, 1997; 9(1): 1, Ottawa. U.S. Bureau of the Census, 1998.9. World Health Organization (2003). World Health Report. Shaping the future, Geneva Young, Mary E. Health problems and policies for older women: An emerging issue in developing 136
    • countries; in: World Bank, Human Resources Development and Operations Policy (HRO) Working Papers, May, 1994.10. Murray, CL, Lopez A, eds. The Global Burden of Disease, World Health Organization, Geneva, 1996.11. Ubink-Veltmaat LJ, Bilo HJG, Groenier KH, Houweling ST, Rischen RO, Meyboom-de Jong B. Prevalence, incidence and mortality of type 2 diabetes mellitus revisited: a prospective population-based study in The Netherlands (ZODIAC-1). Eur J Epidemiol 2003; 18: 793-800.12. Wild S, Sicree R, Roglic G, King H, Green A. Global prevalence of diabetes: estimates for the year 2000 and projections for 2030. Diabetes Care 2004; 27: 1047-53.13. Wilson P, Anderson K, Kannel W. Epidemiology of diabetes mellitus in the elderly. The Framingham study. Am J Med 1986; 80(Suppl. 5a): 3-9.14. Gu K, Cowie C, Harris M. Mortality in adults with and without diabetes in a national cohort of the U.S. population, 1971–1993. Diabetes Care 1998; 21: 1138-45.15. Damsgaard EM, Froland A, Mogensen CE. Over-mortality as related to age and gender in patients with established non-insulin-dependent diabetes mellitus. J Diabetes Complications 1997; 11: 77-82.16. Sasaki A, Uehara M, Horiuchi N, Hasegawa K, Shimizu T. A 15-year follow up study of patients with non-insulin-dependent diabetes mellitus (NIDDM) in Osaka, Japan. Factors predictive of the prognosis of diabetic patients. Diabetes Res Clin Pract 1997; 36: 41-7.17. Rogers RG. The effects of family composition, health and social support linkage on mortality. Journal of Health and Social Behaviour 1996; 37: 326-8.18. Braithwaite S. The elderly in Barbados: problems and policies. Bull Pan Am Health Org 1990; 24: 314-29.19. M Manton KG, Stallard E, Tolley HD. Limits to human life expectancy: evidence, prospects, and implications. Population and Development Review 1991; 17: 603-637.20. Suzman RM, Willis DP, Manton KG (Eds.). The oldest old. New York: Oxford University Press, 1992.21. Eldemire D. An epidemiological study of the Jamaican elderly. PhD Thesis. The University of the West Indies, Jamaica, 1993. 137
    • 22. Plan of Action on Health and Ageing: Older Adults in the Americas 1992-2000 Washington, PAHO, 1999.23. Statistical Institute of Jamaica. Demographic Statistics, 2007. Kingston: STATIN; 2008.24. Desai P, Hanna B, Melville B, Wint B. Infant mortality rates in three parishes of western Jamaica, 1980. West lnd Med J 1983; 32: 83-87.25. McCaw-Binns A, Fox K, Foster-Williams K, Ashley DE, Irons B. Registration of Births, Stillbirths and Infant Deaths in Jamaica. International J of Epidemiology. 1996; 25:807-813.26. Mathers C, Ma Fat D, Inoue M, Rao C. Counting the dead and what they died form: An assessment of the global status of cause of death data. Bulletin of the World Health Organization March 2005: 83:172-173.27. Homer D, Lemeshow S. Applied logistic regression, 2nd edn. John Wiley & Sons Inc., New York, 2000.28. Cohen L, Holliday M. Statistics for Social Sciences. London, England: Harper and Row; 1982.29. Pan Organization Health Organization. Health in the Americas. Older population and health systems: A profile of Jamaica; 1998. Washington DC: PAHO; 1998.30. Clarke E. Population trends and challenges in Jamaica. Journal of Aging and Emerging Economies 2009; 1:24–32.31. Medvedev AZ. Negative trends in life expectancy in the USSR, 1964 – 1983. The Gerontologist 1985; 25: 201-8.32. Myers G. Cross-national trends in mortality rate among the elderly. The Gerontologist 1978; 18: 441-8.33. Population ageing in the Caribbean: Longevity and quality of life. LC/CAR/L.26, December 2004. www.monitoringris.org/documents/tools_reg/uneclac1.pdf34. Smith J. Measuring health and economic status of older adults in developing countries. Gerontologist 1994; 34: 491-6.35. Idler EL, Benjamin Y. Self-rated health and mortality: A Review of Twenty-seven Community Studies. Journal of Health and Social Behavior 1997; 38: 21-37.36. Iddler EL, Kasl S. Self-ratings of health: Do they also predict change in functional ability? Journal of Gerontology 1995; 50B (6): S344-S353. 138
    • 37. Schechter S, Beatty P, Willis GB. Asking survey respondents about health status: Judgment and response issues, in N. Schwarz, D. Park, B. Knauper and S. Sudman [ed.]: Cognition, Aging, and Self-Reports. Ann Arbor, Michigan: Taylor and Francis, 1998.38. Luteijn B. Health status of the elderly in the Marigot Health District, Dominica. West Indian Medical Journal 1996; 45(Suppl.2): 31.39. Rawlins JM, Simeon DT, Ramdath DD, Chadee DD. The elderly in Trinidad: Health, social and economic status and issues of loneliness. West Indian Medical Journal 2008; 57: 589 – 595.40. Benyamini Y, Idler E. Community studies reporting association between self-rated health and mortality: additional studies, 1995 to 1998. Res Aging 1999; 21:392-401.41. Lebrão ML, Duarte YAO, organizadores. SABE - Saúde, Bem-Estar e Envelhecimento: o projecto SABE no Municipio de Sao Paulo: uma abordagem inicia Brasilia (DF): projeto SABE no Município de Sao Paulo: uma abordagem inicial. Brasília (DF): Organização Pan- Americana da Saude; 2003. Disponivel em. http://www.opas.org.br/sistema/arquivos/l_saber.pdf42. Palloni A, McEniry G. Aging and health status of elderly in Latin America and Caribbean: Preliminary findings. J Cross Cul Geron 2007; 22: 263-285.43. Eldemire D. Ageing the reality. Chapter 2. In Morgan, Owen, Health Issues in the Caribbean. UWI Press, Jamaica 2005; pp. 157-77.44. Alberts JF, Koopmans POC, Gerstenbluth I, Van der Heuvel WJ. The health profile of Curacao: results from the Curacoa health study. West Indian Medical Journal 1995; 44(Suppl. 2): 21-2.45. World Health Organization. Regional Core Health Data System: Country Profile – Jamaica; 2001. http://www.Documents and SettingsuserDesktopRegional Core Health Data System - Country Profile JAMAICA.mht.46. Planning Institute of Jamaica, Statistical Institute of Jamaica. Jamaica Survey of Living Conditions (JSLC), 1994. Kingston: Planning Institute of Jamaica, Statistical Institute of Jamaica; 1995. 139
    • 47. Desai M, Zhang P, Hennessy C. Surveillance for morbidity and mortality among older adults - United States 1995- 1996. MMWR. Morbidity and Mortality Weekly Report 1999; 48: 7- 25.48. Samos L, Roos B. Diabetes mellitus in older persons. Medical Clinics of North America 1998; 82: 791-803.49. Meneilly G, Tessier D. Diabetes in elderly adults. Journals of Gerontology Series A: Biological Sciences and Medical Sciences 2001; 56A ( 1 ): M5- M13 .50. Health Situation Trends. Situation Trends. Health in the Americas, 1988 Edition, Vol. 1. Washington, D.C.: PAHO; 1988 (Scientific Publication #569).51. Wilks R, Sargent LA, Guilliford MC, Reid M,Forrester T. Quality of care of hypertension in three clinical settings in Jamaica. West Indian Med J 2000; 49: 220-225.52. Wilks RJ, Sargent LA, Guilliford MC, Reid ME, Forrester TE. Management of diabetes mellitus in three settings in Jamaica. Rev Panam Salud Publica 2001; 9:65-72.53. Sargeant L, Boyne M, Bennett F, Forrester T, Cooper R, Wilks R. Impaired glucose regulation in adults in Jamaica: who should have the oral glucose tolerance test. Pan American Journal of Public Health 2004; 16: 35- 42.54. Wald H, Markowitz H, Zevin S, Popovtzer MM. Opposite effects of diabetes on nephrotoxic and ischemic acute tubular necrosis. Proc Soc Exp Biol Med 1990; 195: 51-56.55. Hypertension Study Group. Prevalence, awareness, treatment and control of hypertension among the elderly in Bangladesh and India: a multicentric study. Bull World Health Organ 2001; 79: 490-500.56. Kalavathy MC, Thankappan KR, Sharma PS, Vasan RS. Prevalence, awareness, treatment and control of hypertension in an elderly community-based sample in Kerala, India. Natl Med J India 2000; 13: 9-15.57. Planning Institute of Jamaica, Statistical Institute of Jamaica. Jamaica Survey of Living Conditions (JSLC), 2006. Kingston: Planning Institute of Jamaica, Statistical Institute of Jamaica; 2007.58. Lillard, L, Waite L. Til death do us part: Marital disruption and mortality. American Journal of Sociology 1995; 100: 1131-56.59. Diener E. Subjective wellbeing. Psychological Bulletin 1984; 95:542-575. 140
    • 60. Diener E, Emmons RA. The independence of positive and negative affect. Journal of Personality and Social Psychology 1984; 47:1105-1117.61. Lyubomirsky S. Why are some people happier than others? The role of cognitive and motivational process in wellbeing. American Psychologist 2001; 56:239-249.62. Diener E, Suh M, Lucas E. Smith H. Subjective well-being: Three decades of progress. Psychological Bulletin 1999; 125:276-302. 141
    • Table 5.1: Socio-demographic characteristic of the respondentsDetails n (%)Sex Men 1,807 (48.2) Women 1,941 (51.8)Marital Status Married 1,558 (42.4) Never married 1,148 (31.2) Divorced 63 (1.7) Separated 74 (2.0) Widowed 834 (22.7)Per capita population income quintile Poorest 687 (18.3) Poor 696 (18.6) Middle 743 (19.8) Wealthy 748 (20.0) Wealthiest 874 (23.3)Good health status No 1,468 (39.8) Yes 2,221 (60.2)Educational level Primary and below 2,122 (59.8) Secondary 1,292 (36.4) Tertiary 136 (3.8)Social support No 1,677 (44.7) Yes 2,071 (55.3)Living Arrangement With family or relative 3,035 (81.0) Without family (alone) 713 (19.0)Area of residence Rural 2,485 (66.3) Peri-Urban 805 (21.5) Urban 458 (12.2)Private Health Insurance Coverage Not insured 3,391 (92.4) Insured 277 (7.6)Age Mean (SD) 68.87 years (*.673)Consumption per person per household Median US$551.96 *Household Crowding Mean (SD) 1.25 person (0.96)Number of visits to made to health practitioners Mean (SD) 1.74 (1.47)* Rate in 2002 was US$ 1= Ja.$50.97 142
    • Table 5.2: Age-specific death rates by older ages and crude death rate, 1998-2007Ages 1998 1999 2000 2001 2002 2003 2004 2005 2006 200755-59 10.8 11.4 10.6 10.8 10.1 9.3 8.6 8.3 - -60-64 15.9 17.0 16.1 16.6 14.7 14.5 14.7 14.6 - -65-69 23.7 25.3 23.8 24.5 20.6 19.4 19.3 18.5 - -70-74 35.6 37.7 35.2 35.8 32.3 29.1 29.6 30.5 - -75+ 84.3 88.8 83.0 84.6 75.9 76.6 73.8 77.6 - -†CDR55+ 36.6 38.8 36.3 37.1 33.2 32.6 32.0 33.0 - -†† CDRpop 18.8 20.4 21.7 19.0 18.6 17.9 17.9 17.8 17.4 17.0†CDR55+ denotes crude death rate for the population ages 55 years and older†† CDRpop this is crude death rate for the population ages 0 years and olderNote: Computations of CDR55+ and the age-specific death rates (ASDRs) were done by Paul A. Bourne from Demographic Statistic, 2007 (Statistical Institute of Jamaica. Demographic Statistics, 2007. Kingston; STATIN; 2008:57) 143
    • Table 5.3: Life expectancy at birth of Jamaicans by sex: 1880-2004 Average expected years of life at birthPeriod: Male Female1880-1882 37.02 39.801890-1892 36.74 38.301910-1912 39.04 41.411920-1922 35.89 38.201945-1947 51.25 54.581950-1952 55.73 58.891959-1961 62.65 66.631969-1970 66.70 70.201979-1981 69.03 72.371989-1991 69.97 72.641999-2001 70.94 75.582002-2004 71.26 77.07Sources: Demographic Statistics (1972-2006) 144
    • Table 5.4: Mortality sex ratio by older ages and population, 1998-2006Ages 1998 1999 2000 2001 2002 2003 2004 200555-59 133.7 137.1 136.4 139.4 146.6 157.6 154.6 145.460-64 118.8 121.8 121.1 123.8 140.9 134.3 144.6 136.465-69 148.8 152.2 151.5 153.9 133.8 142.6 122.0 131.370-74 132.7 136.1 135.1 134.3 126.5 127.2 137.6 134.075+ 89.7 91.9 91.3 93.1 90.9 90.2 85.2 83.0Population 115.3 117.9 117.3 119.5 118.6 118.2 119.7 117.3 145
    • Table 5.5: Health status by Age group Age Cohort Total Health Status 55-59 60-64 65-69 70-74 75+ n (%) n (%) n (%) n (%) n (%) n (%) Poor 178 (24.5) 226 (33.2) 234 (36.1) 287 (49.4) 543 (51.7) 1468(39.8) Good 550 (75.5) 455 (66.8) 414 (63.9) 294 (50.6) 508 (48.3) 2221(60.2)Total 728 681 648 581 1051 3689Χ2 = 171.799, p = 0.001, cc = 0.211 146
    • Table 5.6: Diagnosed (chronic) illness by age cohort Age Cohort Total Pre Elderly Elderly Elderly (ages 55 Elderly (ages 65 (ages 70 Elderly CHRONIC to 59 (ages 60 to to 69 to 74 (ages 75+ ILLNESS years) 64 years) years) years) years) n (%) n (%) n (%) n (%) n (%) n (%) Cold 8(5.8) 14(7.4) 10(5.2) 10(4.3) 16(3.6) 58(4.9) Diarrhoea 1(.7) 2(1.1) 2(1.0) 5(2.1) 7(1.6) 17(1.4) Asthma 3(2.2) 5(2.7) 1(.5) 8(3.4) 15(3.4) 32(2.7) Diabetes 33(24.1) 42(22.3) 35(18.2) 55(23.5) 97(21.9) 262(22.0) Hypertension 55(40.1) 72(38.3) 77(40.1) 79(33.8) 165(37.3) 448(37.6) Arthritis 16(11.7) 23(12.2) 30(15.6) 40(17.1) 73(16.5) 182(15.3) Other 12(8.8) 22(11.7) 29(15.1) 30(12.8) 56(12.7) 149(12.5) No 9(6.6) 8(4.3) 8(4.2) 7(3.0) 13(2.9) 45(3.8) Total 137 188 192 234 442 1193χ2 = 24.46, p = 0.657 147
    • Table 5.7. Poor health status of elderly Jamaicans by some explanatory variables Std. Odds Coefficient Error Wald Ratio 95.0% C.I. Private Health insurance -0.159 0.193 0.685 0.853 0.584 - 1.244 Middle quintile 0.191 0.129 2.212 1.211 0.941 - 1.558 Two wealthiest quintile 0.118 0.138 0.725 1.125 0.858 - 1.476 †Poor Dummy Retirement income 0.379 0.193 3.868* 1.461 1.001 - 2.131 Household head -0.668 0.526 1.616 0.513 0.183 - 1.437 Medical expenditure 0.135 0.033 16.898*** 1.144 1.073 - 1.220 Average consumption 0.000 0.000 0.082 1.000 1.000 - 1.000 House tenure - rent -0.827 1.892 0.191 0.437 0.011 - 17.824 House tenure - owned -1.509 1.224 1.521 0.221 0.020 - 2.433 †House tenure – squatted Other towns -0.282 0.119 5.569* 0.754 0.597 - 0.953 Urban -0.181 0.177 1.046 0.834 0.589 - 1.181 †Rural area Physical environment -0.025 0.099 0.063 0.975 0.803 - 1.185 Separated, divorced, or widowed 0.643 0.128 25.094*** 1.901 1.479 - 2.445 Married 0.341 0.124 7.587** 1.406 1.103 - 1.792 †Single Secondary 0.187 0.095 3.899* 1.206 1.001 - 1.451 Tertiary -0.709 0.285 6.183* 0.492 0.281 - 0.861 †Primary Social support 0.155 0.092 2.839 1.167 0.975 - 1.398 Living arrangement -0.264 0.158 2.790 0.768 0.563 - 1.047 Sex -0.553 0.101 30.061** 0.575 0.472 - 0.701 Crowding -0.082 0.080 1.043 0.921 0.787 - 1.078 Crime Index 0.002 0.008 0.077 1.002 0.987 - 1.017 Land ownership 0.084 0.112 0.564 1.087 0.874 - 1.353 Negative affective 0.035 0.016 4.837* 1.035 1.004 - 1.068 Positive affective -0.056 0.020 8.016** 0.945 0.909 - 0.983 Number of men -0.109 0.054 3.982* 0.897 0.806 - 0.998 Number of women -0.053 0.058 0.853 0.948 0.847 - 1.062 Number of child -0.071 0.048 2.213 0.932 0.849 - 1.023 Durable goods Index -0.048 0.021 5.045* 0.953 0.914 - 0.994 Constant 1.113 1.365 0.665 3.043 -Nagelkerke R-square = 10.6%-2 Log likelihood = 2,901.81Hosmer and Lemeshow χ2 = 7.92; P = 0.441Model: Omnibus Test - χ2 =190.47, p=0.001Overall correct classification = 67.1% (n = 1,580)Correct classification of cases of poor health status =28.1% (n = 242)Correct classification of cases of good health status = 89.4% (n = 1,338);*p < 0.05, **p < 0.01, ***p < 0.001†Reference group 148
    • Chapter 6An Epidemiological Transition of Health Conditions, and HealthStatus of the Old-Old-To-Oldest-Old in Jamaica: A comparativeanalysis Paul Andrew BourneThere is a paucity of information on the old-old-to-oldest-old in Jamaica. In spite of studies onthis cohort, there has never been an examination of the epidemiological transition in healthcondition affect this age cohort. The aims of this paper are 1) provide an epidemiological profileof health conditions affecting Jamaicans 75+ years, 2) examine whether there is anepidemiological transition in health conditions affecting old-old-to-oldest-old Jamaicans, 3)evaluate particular demographic characteristics and health conditions of this cohort, 4) assesswhether current self-reported illness is strongly correlated with current health status, 5) mean ageof those with particular health conditions, 6) model health status and 7) provide valuableinformation upon which health practitioners and public health specialists can make moreinformed decisions. This paper utilized a sub-sample of approximately 4% from each nationalcross-sectional survey that was conducted in 2002 and 2007. The sub-sample was 282 peopleages 75+ years from the 6,783 respondents surveyed for 2007 and 1,069 people ages 75+ yearsfrom the 25,018 respondents surveyed for 2002. In 2007, 44% of old-to-oldest-old Jamaicanswere diagnosed with hypertension, which represents a 5% decline over 2002. The number ofcases of diabetes mellitus increased over 570% in the studied period. The poor indicated havingmore health conditions than the poorest 20% of the sample. The implications of the shift inhealth conditions will create a health disparity between 75+ year adults and the rest of thepopulation.IntroductionThe elderly population (ages 60+ years) constituted 10.9% of Jamaica‘s population, which meansthat this age cohort is vital in public health planning [1]. Eldemire [2] opined that ―The majorityof Jamaican older persons are physically and mentally well and living in family units‖. This viewwas substantiated in an early study; when Eldemire [3] found that approximately 81 percent of 149
    • the seniors reported that they were physically competent to care for themselves, without anyform of external intervention. Eldemire‘s work revealed that 88.5 percent being physiologicallyindependent. Many elderly persons are more than physically independent as Eldemire [3] found 65.5percent 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 socialsupport was directly related to self-reported health, which is collaborated by Okabayashi et al‘sstudy [5]. The aforementioned situation can explain why many elderly are offered socio-economic support. Eldemire [3] found that approximately 71 percent of children were willing toaccept responsibility for their parents, with seniors who were older than 75 years being likely toneed support. Seniors ages 75-84 years are referred to as old-old and those 85+ are referred asoldest-old. The 2001 Population Census of Jamaica found approximately 66 percent of the elderlylive 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 isnot atypical to Jamaica as DaVanzo and Chan [7], using data from the Second Malaysian FamilyLife Survey which includes 1,357 respondents of age 50 years and older living in privatehouseholds, noted that some benefits of co-residence range from emotional support,companionship, physical and financial assistance [8]. Embedded in DaVanzo and colleague‘swork is the issue of ‗Is it functional independence or stubbornness?‘ that accounts for the elderlypersons‘ report that they are physically and mentally well in order that family and onlookers will 150
    • not request that they live in home care facilities. This brings into focus the issues of health statusand health conditions of elderly Jamaicans. Physical disability and health problems increase with age [9]. Bogue [9] opined thatdemand 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 likewisetheir demand on the public services also increases. Statistics revealed that 15.5% of Jamaicansreported suffering from an illness/injury in 2007; this was 2.8 times more for individuals ages65+ and 2.4 times for those people ages 60+ years [10]. This further goes to concurs withBogue‘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 thatthis 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% comparedto the general population, 73.3%) and had more health insurance coverage (27.8%) compared tothe general population (21.1%) [10]. The aforementioned findings only concur with the work ofBogue, and still does not provide us with changing in health conditions of the elderly inparticular the old-old-to-oldest old. Using a sub-sample of 3,009 elderly Jamaicans, Bourne [11] found that the generalwellbeing was low; but, within the context of Bogue‘s work, raised the question of the old-old orthe 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 theoldest-old. There was no significant statistical difference between the poor health status of old-old and oldest-old Jamaicans. While poor health status comprised of health conditions, Bourne‘s 151
    • works do not provide us with an understanding of the health conditions over time and whetherthese 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 currenthealth status and adds value to discourse that health conditions provide some understanding ofhealth status. However, this finding does not clarify the epidemiological transition of healthconditions 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 studythat has examined an epidemiological transition of health conditions of people 75+ years. InJamaica, 4% of the population in 2007 were older than 75+ years, indicating that over 100,000Jamaicans have reached 75 years or older. This is a critical group that must be studied for publichealth planning as more elderly have chronic dysfunctions than any other age cohort in thepopulation. The aims of this paper are 1) provide an epidemiological profile of healthconditions affecting Jamaicans 75+ years, 2) examine whether there is an epidemiologicaltransition in health conditions affecting old-old-to-oldest-old Jamaicans, 3) evaluate particulardemographic characteristic and health conditions of this cohort, 4) assess whether current self-reported illness is strongly correlated with current health status, 5) mean age of those withparticular health conditions, 6) model health status and 7) provide valuable information uponwhich health practitioners and public health specialists can make more informed decisions.Materials and MethodsThis paper utilized a sub-sample of approximately 4% from each nationally cross-sectionalsurvey that was conducted in 2002 and 2007. The sub-sample was 282 people ages 75+ yearsfrom the 2007 cross-sectional survey (6,783 respondents) and 1,069 people ages 75+ years from 152
    • the 2002 survey (25,018 respondents). The survey is known as the Jamaica Survey of LivingConditions which began in 1989. 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 residences 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 (i.e. LFS) was selected for the JSLC [14, 15]. The sample wasweighted to reflect the population of the nation. The JSLC 2007 [14] 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 153
    • 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.MeasuresAge: The length of time that one has existed; a time in life that is based on the number of yearslived; 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 wasasked: ―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.Good health status is a dummy variable, where 1=good to very good health status, 0 = otherwiseIncome Quintile can be used to operationalize social class. Social class: 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). 154
    • 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 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) wasused 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%(i.e. 95% confidence interval).ResultSociodemographic characteristics of sampleOf the sample for 2002, 57.6% was female compared to 57.4% females in 2007. The mean age in2002 was 81.3 years (SD = 5.6 years), and this was 81.4 years (SD = 5.4 years) in 2007. Morethan two-thirds of the 2002 sample dwelled in rural areas, 20.8%. In 2007, the percent of samplewho resided in urban areas increased by 169.7%, and a reduction by 25.9% of those who dwelledin rural zones compared to a marginal reduction of 4.3% in semi-urban areas (Table 6.1).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%). 155
    • Illness (or health conditions)A number of shifts in diagnosed health conditions were observed in this paper. The number ofcases of hypertension and arthritis were observed between the two periods. The most significantincrease in health conditions was in diabetes mellitus cases (i.e. 576%) (Figure 1). A cross tabulation between self-reported illness and sex revealed that there was nosignificant statistical correlation between the two variables (Table 6.2). Although no statisticalassociated existed between the self-reported illness and sex, the percent of men who reported anillness in 2007 over 2002 increased by 30.5% compared to 16.4% for females. No significant statistical relationship existed between self-reported illness and maritalstatus (Tables 6.4 & 6.5). In spite of the aforementioned situation, the divorced samplereported the greatest percentage of increased in self-reported illness (16.7%) followed to marriedpeople (15.7%); separated individuals (11.6%), widowed (5.8%) and those who were nevermarried reported the least increase in self-reported illness (5.2%). No significant statistical correlation existed between self-reported illness and age cohortof respondents – P >0.05 – (Table 6.5). Although the aforementioned is true, the percent of old-old who reported illness in 2007 over 2002 increased by 23.6% compared to a 16.6% increasedin the oldest-old cohort over the same period. A cross tabulation between diagnosed self-reported health conditions and age ofrespondents revealed a significant association between the two variables (Table 6.6). Onexamination, in 2002, the lowest mean age was recorded by people who indicated that they hadarthritis. However, for 2007, the mean age was the lowest for old-old-to-oldest-old who hadreported the common cold. A shift which is evident from the finding is the mean age of those 156
    • with diabetes mellitus in 2002 (79.5 yrs. ± 2.5 yrs), which was the second lowest age of personwith illness in 2002 to the greatest mean age for people with the same dysfunction in 2007 (90.20yrs ± 3.54 yrs) (Table 6.6). Based on Table 6.7, no significant statistical association was found between diagnosedhealth conditions and age cohort of the sample – P >0.05. In spite of this reality, some interestingfindings are embedded in the data across the two years. The findings revealed an exponentialincrease in diabetes mellitus and the common cold. However, the most significant increaseoccurred in diabetic cases in the oldest-old. Reductions were recorded in hypertension, arthritisand unspecified categorization. A cross-tabulation between self-reported illness (in %) and Income Quintile revealed asignificant 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-reportedcases of illness compared to the other social groups. Although this was the case for 2002 and2007, the wealthy reported more illnesses than the wealthiest 20% of sample. Concurrently, thepoorest 20% reported the greatest increase in self-reported illness for 2007 over 2002 (19.4%)with the wealthy segment of the sample reported the least increase (2.7%). The first time that the Jamaica Survey of Living Conditions (JSLC) collected informationon self-reported illness and general health status (health status) of Jamaicans was in 2007. Basedon that fact, this paper will not be able to compare the health status of the sample for the twostudied years; however, this will be the basis upon which future studies can compare. The cross-tabulation between the two aforementioned variables was a significantly correlated one (χ2 (df =2) = 39.888, P < 0.001) (Table 6.8). 157
    • Health care-seeking behaviourA cross tabulation of health care seeking behaviour and aged cohort revealed no statisticalrelationship 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 6.9 revealed that there is a significant statistical relationship between health care-seeking 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 ashealth status decreases the percent of sample seeking medical care increases. Of those whoreported poor health, 86.7% of them have sought medical care in the 4-week period of thesurvey. When the aforementioned association was further investigated by aged cohort, thedifference was explained by old-old (χ2 (df = 2) = 11.296, P = 0.004, cc=0.305) and not oldest-old (χ2 (df = 2) = 0.390, P = 0.823) (Table 6.10). Controlling health care-seeking behaviour and health status by aged cohort revealed thatthe 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 beingless than 5 items, the non-statistical association possibly is a Type II Error. Type II Errorindicates that there is no statistical significant relationship between variables when there is aprobability that an association does exists.Multivariate analysis: Predictors of good health statusGood health status of old-old-to-oldest-old Jamaicans can be predicted by self-reported illness(Table 6.11). Based on Table 6.11, self-reported illness is a negative predictor of good healthstatus (OR = 0.176, 95% CI = 0.095 - 0.328). Twenty-four percent of the variability in good 158
    • health status can be explained by self-reported illness. Concurrently, no other variable exceptself-reported illness was significantly correlated with good health status. Furthermore, 75.9% ofthe data were correctly classified: 90.5% of good health status and 42.0% of those who has statedotherwise (poor to fair health status). In addition, an old-old-to-oldest-old Jamaican is 0.824times less likely to reported good health status.DiscussionAgeing is directly correlated with increased functional disability [18]. This can be concurredwith the disproportionate number of elderly who continue to outnumber other age cohorts invisits medical care facilities and number of cases in chronic dysfunctions. Statistics from thePlanning Institute of Jamaica and Statistical Institute of Jamaica revealed that elderly Jamaicansdisproportionately outnumber other ages in diabetes mellitus, hypertension, arthritis andmortality [10, 16, 17]. The Jamaican Ministry of Health data showed that the prevalence ofchronic diseases is greatest for those 65+ years. Is the aforementioned information sufficientenough for public health policy makers, health care practitioners and academics as a reference toa comprehensive understanding of the old-old-to-oldest-old in Jamaica? The answer is aresounding no as this paper will show. Bogue [9] showed that functional capacity, demand for medical care and health problemsincrease with ageing which concurs with Erber‘s work [18] and other research [19]. This paperfound that 10.3% more old-old-to-oldest-old Jamaicans reported at least one health condition in2007 over 2002 and this was associated with at 1.7% increase health care-seekers. In 2007, 73 159
    • 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 associationexisted between medical care and health status of sample. Interestingly in this paper though, isthe fact that as the old-old‘s health status fall to poor 89 out of every 100 of them sought carecompared to 53 out of every 100 old-old who had good health. A critical finding of this paper isthe fact that after an individual reaches 85 years and beyond, there is no difference in seekinghealth care. Intertwined in this finding is the psychological reluctance of prolonged life at theonset of illness compared to those in the old-old categorization as many of oldest-old believe thatthey 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 areassociated with different typologies of wellbeing [20]. Positive mood is not limited to activeresponses by individual, but a study showed that ―counting one‘s blessings,‖ ―committing acts ofkindness‖, 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 amood that does not change with time or situation; hence, happy people can experience negativemoods [23]. Within the context of the aforementioned, an individual who has lived or is livingfor 85+ years consider this as a blessing and so they are comfortable with that blessing, whichaccounts for the psychological reluctance to prolong life if this is accompanied by severity ofillness. The World Health Organization opined that the among the challenges of the 21st centurywill 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 160
    • 100 old-old-to-oldest old Jamaican reported an illness in 2002 and this increased to 52 out ofevery 100. The substantiate matter is not merely the increase in dysfunctions; but it is theepidemiological transition in typology of diseases. Health conditions were not only reported,they were substantially diagnosed by a medical practitioner. An alarming finding was theexponential 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 theaverage age for an old-old-to-oldest-old having diabetes mellitus increased from 79.5 years to90.0 years, and therefore this reinforces the point that psychological reluctance to live withcritical changes that diabetes mellitus may cause. The challenge for the old-old-to-oldest in Jamaica is not merely the lifestyle changes thatfollow diabetes mellitus; but the complication from having more than one illnesses and the issuessurrounding the diseases. These issues include blindness, renal failure and micro-vascularcomplications. Forty-four out of every 100 persons in the sample had hypertension in 2007, andthe fact that diabetes mellitus and hypertension are strongly related, the old-old-to-oldest-old willbe experiencing many health problems. A study by Callender [27] found that 50% of individualswith diabetes had a history of hypertension and given that Morrison [28] opined that these aretwin 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 paper is not able toprovide an explanation for this finding, factors such as sex, marital status, poverty and area ofresidence 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 161
    • afford food, health care and other necessities, may seem improbable as not being a predictor ofgood health of old-old-to-oldest old Jamaicans. However, it is associated with health conditionsfor this sample. This means that health status is wider than dysfunction, and how this cohort feelsabout life is even broader than the challenge of physical incapacity. In spite of this claim, healthconditions are a strong predictor of health status for the old-old-to-oldest-old in Jamaica. Thisconcurs with Hambleton and colleagues‘ work [13] which found that 33.6% of the totalexplanatory power (38.2%) of health status of elderly Barbadians was accounted for by currenthealth conditions. Embedded in Hambleton et al. [13] and this paper is the critical role thatcurrent health conditions play in determining health status.ConclusionThis paper provides information upon which public health and health practitioners can makemore informed decisions about this age group. A fundamental way for this impetus to proceed isthe immediate diabetes education in the elderly population in particular those 75+ years. On apanel 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] calledfor diabetes care treatment for elderly which indicates that the issue of diabetes education is notnew 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 increasein such cases, and cannot go unabated. The increase in diabetes mellitus could be accounted for 162
    • by the new persons who become 75 years each year or a higher percentage cases that wereformerly undetected become diagnosed. Which ever is the case, a public health promotion thrustis required to test all Jamaicans 75+ within the context of a disease prevention agenda andhealthy life expectancy. Hence, the implications of the shift in health conditions will create ahealth disparity between 75+ year adults and the rest of the population. This requires bettermanagement of older persons [38], which will also require that people 75+ with good health betested for diabetes mellitus.References1. Statistical Institute of Jamaica (STATIN). Demographic statistics, 2007. Kingston: STATIN;2008.2. Eldemire D. A situational analysis of the Jamaican elderly, 1992. Kingston: Planning Instituteof Jamaica; 1995.3. Eldemire D. The elderly and the family: The Jamaican experience. Bulletin of EasternCaribbean Affairs. 1994; 19:31-46.4. Franzini L, Fernandez-Esquer ME. Socioeconomic, cultural, and personal influences on healthoutcomes in low income Mexican-origin individuals in Texas. Soc Sci and Med. 2004; 59:1629-1646.5. Okabayashi H, Liang J, Krause N, Akiyama H, Sugisawa H. Mental health among older adultsin Japan: Do sources of social support and negative interaction make a difference? Soc Sci andMed. 2004; 59:2259-2270.6. Statistical Institute of Jamaica (STATIN). Population Census 2001, Jamaica. Volume1:Country Report. Kingston, Jamaica: STATIN; 2001.7. DaVanzo J, Chan A. Living arrangements of older Malaysians: Who coresideswith their adult children. Demography. 1994;31:9113.8. Pan American Health Organization, (PAHO), World Health Organization, (WHO). Health ofthe 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. 163
    • Chicago: Social Development Center; 1999.10. Planning Institute of Jamaica, (PIOJ), Statistical Institute of Jamaica, (STATIN). JamaicaSurvey of Living Conditions, 2007. Kingston: PIOJ, STATIN;2008.11. Bourne PA. Medical Sociology: Modelling Well-being for elderly People in Jamaica. WestIndian Med J. 2008; 57:596-04.12. Bourne PA. Good health status of older and oldest elderly in Jamaica: Are there differencesbetween 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 andcurrent predictors of self-reported health status among elderly persons in Barbados. Rev PanSalud 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:Planning Institute of Jamaica and Derek Gordon Databank, University of the West Indies[distributors]; 2008.15. Statistical Institute Of Jamaica. Jamaica Survey of Living Conditions, 2002 [Computer file].Kingston, Jamaica: Statistical Institute Of Jamaica [producer], 2002. Kingston, Jamaica:Planning Institute of Jamaica and Derek Gordon Databank, University of the West Indies[distributors]; 2003.16. Statistical Institute of Jamaica (STATIN). Demographic Statistics, 2005. Kingston:STATIN; 2006.17. World Health Organization, (WHO). Definition of an older or elderly person.Washington DC: 2009.18. Erber J. Aging and older adulthood. New York: Waldsworth; 2005.19. Planning Institute of Jamaica, (PIOJ), Statistical Institute of Jamaica, (STATIN). JamaicaSurvey of Living Conditions, 1989-2006. Kingston: PIOJ, STATIN;1989-2007.20. Lyubomirsky S. Why are some people happier than others? The role of cognitive andmotivational process in wellbeing. Am Psychologist. 2001;56:239-249.21. Sheldon K, Lyubomirsky S. How to increase and sustain positive emotion: The effects ofexpressing 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. Jof Happiness Studies. 2003;4:385-404.23. Diener E, Seligman MEP. 2002, Very happy people. Psychological Sci. 2002;13: 81–84. 164
    • 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 healthoutcomes – a population-based cross-sectional analysis. BMC Pediatrics. 2009, 9:5331. 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 SocialDeterminants of Health. Discussion paper for the Commission on Social Determinants ofHealth. Geneva: WHO; 2007.34. Graham H. Social Determinants and their Unequal Distribution Clarifying PolicyUnderstanding The MelBank Quarterly. 2004; 82:101-124.35. Marmot M. The influence of Income on Health: Views of an Epidemiologist. Does moneyreally 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: PanAmerican Health Organization, (PAHO). Equity and health. Washington DC: PAHO; 2001. p. 3-11.37. Herd P, Goesling B, House JS. Socioeconomic Position and Health: The Differential Effectsof Education versus Income on the Onset versus Progression of Health Problems. J of Health &Soci Behavior. 2007; 48:223-23838. Merrins C. Special considerations in providing medical nutrition therapy to the elderly withdiabetes. West Indian Med J. 2005; 54:39. 165
    • Table 6.1. Socio-demographic characteristics of sampleVariable 2002 2007 Frequency % Frequency %Sex Male 453 42.4 120 42.6 Female 616 57.6 162 57.4Marital status Married 304 29.2 88 32.4 Never married 255 24.5 66 24.3 Divorced 18 1.7 6 2.2 Separated 22 2.1 7 2.6 Widowed 442 42.5 105 38.6Income Quintile Poorest 20% 239 22.4 56 19.9 Poor 216 20.2 51 18.1 Middle 195 18.2 74 26.2 Wealthy 194 18.1 58 20.6 Wealthiest 20% 225 21.0 43 15.2Self-reported illness Yes 441 42.3 141 51.6 No 601 57.7 132 48.4Health care-seeking behaviour Yes 306 69.2 102 72.9 No 136 30.8 38 27.1Area of residence Rural 731 68.4 83 50.7 Semi-urban 222 20.8 56 19.9 Urban 116 10.9 143 29.4Educational level Primary or below 662 66.5 Secondary 309 31.1 Tertiary 24 2.4Health insurance coverage Yes 48 4.6 26.7 No 998 998 73.3Age Mean (SD) 81.29 yrs (±5.6yrs) 81.37 yrs (±5.38yrs)Public health care expenditure Ja $341.54 (±Ja.$1165.60) Ja $368.89.54Mean (SD) (±Ja.$1518.66)Private health care expenditure Ja. $1436.23 (±Ja.$2060.42) Ja. $1856.04 (±Ja.$4347.78)Mean (SD) 166
    • Table 6.2. Self-reported illness by sex of respondents, 2002 and 2007 20021 20072Self-reportedillness Male Female Male Female N (%) N (%) N (%) N (%)Yes 174 (39.3) 267 (44.6) 60 (51.3) 81 (51.9)No 269 (60.7) 332 (55.4) 57 (48.7) 75 (48.1)Total 443 599 117 156 1 χ2 (df = 1) = 2.927, P =0.087 2 χ2 (df = 1) = 0.011, P =0.916 167
    • Table 6.3. Self-reported illness by marital status, 2002 Marital status*Self-reported illness Married Never married Divorced Separated Widowed N (%) N (%) N (%) N (%) N (%)Yes 140 (46.8) 88 (34.8) 9 (50.0) 10 (45.5) 190 (43.2)No 159 (53.2) 165 (65.2) 9 (50.0) 12 (54.5) 250 (56.8)Total 299 253 18 22 440* χ2 (df = 4) = 9.027, P =0.060 168
    • Table 6.4. Self-reported illness by marital status, 2007 Marital status*Self-reported illness Married Never married Divorced Separated Widowed N (%) N (%) N (%) N (%) N (%)Yes 55 (62.5) 26 (40.0) 4 (66.7) 4 (57.1) 51 (49.0)No 33 (37.5) 39 (60.0) 2 (33.3) 3 (42.9) 53 (51.0)Total 88 65 6 7 104* χ2 (df = 4) = 8.589, P =0.072 169
    • Table 6.5. Self-reported illness by Age cohort, 2002 and 2007 20021 20072Self-reportedillness Old-Old Oldest-Old Old-Old Oldest-Old N (%) N (%) N (%) N (%)Yes 333 (42.8) 108 (40.9) 110 (52.9) 31 (47.7)No 445 (57.2) 156 (59.1) 98 (47.1) 34 (52.3)Total 778 264 208 65 1 χ2 (df = 1) = .289, P =0.591 2 χ2 (df = 1) = .535, P =0.465 170
    • Table 6.6. Mean age of oldest-old with particular health conditions 20021 20072Healthconditions Mean Age (±SD) Mean Age (±SD)Cold - 77.63 (±1.77) 80.00Diarrhoea - 85.00 (±9.66) 86.00Asthma - 81.00 (±5.20) 0.00Diabetes mellitus 90.92 (±4.84) 79.50 (±2.50)Hypertension 81.21 (±4.95) 80.13 (±0.84)Arthritis 79.13 (±3.54) 79.32 (±0.69)Other 83.90 (±6.82) 81.64 (±1.75)Total 80.14 (±4.73) 82.75 (±4.50)F statistic [7,134] = 2.085, P = 0.049 171
    • Table 6.7. Diagnosed Health Conditions by Aged cohort 20021 20072DiagnosedHealth Aged cohort Aged cohortconditions Oldest-Old Oldest-Old Old-Old Old-Old % % % %Cold 0.0 7.2 0.0 1.5Diarrhoea 8.3 2.7 3.2 0.0Asthma 0.0 1.8 3.2 0.0Diabetes mellitus 11.1 16.1 3.0 0.0Hypertension 44.1 45.2 47.8 58.3Arthritis 12.6 6.5 35.8 8.3Other 11.7 22.6 11.9 25.0 2.7 3.2 0.0 0.0No1 χ2 (df = 1) = 10.028, P =0.074 172
    • 2 χ2 (df = 1) = 5.382 P =0.613Table 6.8. Self-reported illness (in %) by health status. Health Status Good Fair PoorSelf-reported illness n (%) n (%) n (%)Yes 21 (25.3) 60 (55.0) 60 (74.1)No 62 (74.7) 49 (45.0) 21 (25.9)Total 83 109 81χ2 (df = 2) = 39.888, P < 0.001, cc=0.357 173
    • Table 6.9. Health care-seeking behaviour and health status, 2007 Health Status Good Fair PoorHealth care-seeking behaviour n (%) n (%) n (%)No 9 (42.9) 21(35.6) 8 (13.3)Yes 12 (57.1) 38 (64.4) 52 (86.7)Total 21 59 60χ2 (df = 2) = 10.539, P = 0.005, cc=0.265 174
    • Table 6.10. Health care-seeking behaviour by health status controlled for aged cohort Health statusAged cohort Good Fair Bad TotalOld-old1 Health Care- Seeking Behaviour No 7 (46.7) 18 (36.7) 5 (10.9) 30 (27.3) Yes 8 (53.3) 31 (63.3) 41 (89.1) 80 (72.7) Total 15 49 46 110Oldest-old2 Health Care- Seeking Behaviour No 2 (33.3) 3 (30.0) 3 (21.4) 8 (26.7) Yes 4 (66.7) 7 (70.0) 11 (78.6) 22 (73.3) Total 6 10 14 301 χ2 (df = 2) = 11.296, P =0.004, cc=0.3052 χ2 (df = 2) = 0.390, P =0.823 175
    • Table 6.11. Logistic regression on Good Health status by variables Wald Variable Coefficient Std. Error statistic Odds ratio 95.0% C.I. Self-reported illness -1.735 0.317 29.950 0.176 0.095 - 0.328*** Age -0.041 0.030 1.910 0.960 0.905 - 1.017 Middle Class -0.083 0.414 0.040 0.921 0.409 - 2.072 Upper class 0.391 0.759 0.264 1.478 0.334 - 6.546 †Poor Married 0.297 0.393 0.574 1.346 0.624 - 2.907 Divorced, separated or widowed -0.110 0.376 0.086 0.896 0.428 - 1.872 †Never married Urban area 0.347 0.350 0.981 1.414 0.712 - 2.808 Other town -0.398 0.414 0.922 0.672 0.298 - 1.513 †Rural area 2.979 2.456 1.471 19.667 - Constantχ2 =40.083, p < 0.001-2 Log likelihood = 283.783Nagelkerke R2 =0.222Overall 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 < 0.001 176
    • Figure 6.1. Diagnosed health conditions, 2002 and 2007Figure 6.1 expresses the percentage of people who reported being diagnosed with particularhealth 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. 177
    • Figure 6.2. Self-reported illness (in %) by Income Quintile, 2002 and 2007Figure 6.2 expresses the percentage of people who reported an illness by income quintiles for2002 and 2007. Q1 denotes the poorest 20% to the wealthiest 20% (ie Q5). 178
    • Chapter 7Health status of patients with self-reported chronic diseases inJamaica Paul A. Bourne & Donovan A. McGrowderDeveloping countries such as Jamaica are increasingly suffering from high levels of publichealth problems related to chronic diseases. To examine the physical health status and use amodel to determine the significant predictors of poor health status of Jamaicans who reportedbeing diagnosed with a chronic non-communicable disease. This paper extracted a sub-sample of714 people from a larger nationally representative cross-sectional survey of 6,783 Jamaicans. Aself-administered questionnaire was used to collect the data from the sample. Statistical analysiswas performed using chi-square which was used to investigate non-metric variables, and logisticregression to determine predictors of poor health status. Approximately one-quarter (25.3%) ofthe sample reported that they had poor health status. Thirty-three percent of the sample indicatedunspecified chronic diseases; 7.8% arthritis, 28.9% hypertension, 17.2% diabetes mellitus and13.3% asthma. Asthma affected 47.2% of children and 23.2% of young adults. Significantpredictors of poor health status of Jamaicans who reported being diagnosed with chronic diseaseswere age of respondents, area of residence and inability to work. Majority of the respondents inthe sample had good health, and adults with poor health status were more likely to report havinghypertension followed by diabetes mellitus and arthritis, while asthma was the most prevalentamong children. Improvement in chronic disease control and health status can be achieved withimproved patient education on the importance of compliance, access to more effectivemedication and development of support groups among chronic disease patients.IntroductionThe rapidly increasing burden of chronic diseases is a key determinant of global public health. In2001, chronic diseases contributed approximately 60% of the 56.5 million total reported deathsin the world and approximately 46% of the global burden of disease. The proportion of theburden of non-communicable diseases is expected to increase to 57% by 2020 [1]. 179
    • In five out of the six regions of the World Health Organization (WHO), deaths caused by chronicdiseases dominate the mortality statistics [2] and there is evidence that 79% of deaths attributableto chronic diseases are occurring in developing countries such as those in the Caribbeanpredominantly in middle-aged men [2]. Most Caribbean countries have experienced a healthtransition, with decreases in fertility and mortality rates and changing disease patterns. Leadingup to the mid 1990s, the mortality pattern changed from deaths being mainly due tocommunicable diseases to them being mainly due to non-communicable diseases [3, 4]. Morerecently, these countries have also been observing the re-emergence of ‗old‘ communicablediseases and the emergence of new communicable diseases, together with an increasingprominence of non-communicable diseases. Furthermore, with 15-20% and 20-25% of the adultpopulation in English and Dutch-speaking Caribbean countries having diabetes andhypertension, respectively, these non-communicable diseases accounting for the single largestexpenditure in national drug budgets [5].Jamaica has undergone a significant demographic transition in the last 5 decades [6, 7]. Somefeatures of this transition include the increase in the median age of the population from 17 yearsto 25 years between 1970 and 2000, the doubling of the proportion of persons older than 60 yearsold to over 10% and the increase in life expectancy at birth from less than 50 years in 1950 togreater than 70 years in 2000 [8]. As a result, the main causes of illness and death in Jamaica andmany other Caribbean islands and regions at a similar state of development are the chronic non-communicable diseases [9]. There is an increased prevalence of diet-related chronic non-communicable diseases, such as cardio-vascular diseases, diabetes and obesity. Wilks, et al. [10]reporting on a survey of body mass index in an urban population, found that 30.7% of the men 180
    • were overweight (7.2% were obese) and 64.7% of the women were overweight (31.5% obese). Inthis same study if was found that hypertension had a prevalence of 19.1% among the males and28.2% among the females; while the prevalence of diabetes was 8.9% and 15.3% among themales and females respectively [10].Chronic diseases such as heart disease, cancer and diabetes negatively affect the general healthstatus and quality of life of individuals [11] and there is the absence in the literature of studieslooking at the health status of persons in the Caribbean with chronic non-communicable diseases.It is against this background that this paper was undertaken. This paper was, therefore designedto explore any association between chronic non-communicable disease and health status. Theaim of the study was to examine the self-reported health status of Jamaicans in rural, peri-urbanand urban areas of residence. A model is used to predict the social determinants of poor healthstatus of Jamaicans who reported at least one chronic non-communicable disease.MethodThis paper extracted a subsample of 714 people who answered the question of having soughtmedical care in the last 4-weeks from a larger nationally representative cross-sectional survey of6,783 Jamaicans (Jamaica Survey of Living Conditions, 2007) [12]. The survey was drawn usingstratified random sampling. This design was a two-stage stratified random sampling designwhere there was a Primary Sampling Unit (PSU) and a selection of dwellings from the primaryunits. The PSU is an Enumeration District (ED), which constitutes a minimum of 100 residencein rural areas and 150 in urban areas. An ED is an independent geographic unit that shares acommon boundary. 181
    • This paper used JSLC 2007 [12] which was conducted by the Statistical Institute of Jamaica(STATIN) and the Planning Institute of Jamaica (PIOJ) between May and August 2007. Theresearchers chose this survey based on the fact that it is the latest survey on the nationalpopulation and that that it has data on self-reported health status of Jamaicans. A self-administered questionnaire was used to collect the data, which were stored and analyzed usingSPSS for Windows 16.0 (SPSS Inc; Chicago, IL, USA). The questionnaire was modelled fromthe World Bank‘s Living Standards Measurement Study (LSMS) household survey. Thequestionnaire 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 usedto analyze the socio-demographic characteristics of the sample. Chi-square was used to examinethe association between non-metric variables, and an Analysis of Variance (ANOVA) was usedto test the relationships between metric and non-dichotomous categorical variables. Logisticregression examined the relationship between the dependent variable and some predisposedindependent (explanatory) variables, because the dependent variable was a binary one (self-reported health status: 1 if reported poor health status and 0 if otherwise).The results were presented using unstandardized B-coefficients, Wald statistics, Odds ratio andconfidence interval (95% CI). The predictive power of the model was tested using the OmnibusTest of Model and Hosmer & Lemeshow [13] was used to examine goodness of fit of the model.The correlation matrix was examined in order to ascertain whether autocorrelation (ormulticollinearity) existed between variables. Based on Cohen & Holliday [14] correlation can below (weak) - from 0 to 0.39; moderate - 0.4-0.69, and strong - 0.7-1.0. This was used to exclude 182
    • (or allow) a variable in the model. Wald statistics were used to determine the magnitude (orcontribution) of each statistically significant variable in comparison with the others, and theOdds Ratio (OR) for the interpreting of each significant variable.Multivariate regression framework [15] was utilized to assess the relative importance of variousdemographic, socio-economic characteristics, physical environment and psychologicalcharacteristics, in determining the reported health status of Jamaicans; and this has also beenemployed outside of Jamaica [16, 17]. Having identified the determinants of health status fromprevious studies, using logistic regression techniques, final models were built for Jamaicans aswell as for each of the geographical sub-regions (rural, peri-urban and urban areas of residence)and sex of respondents using only those predictors that independently predict the outcome. A p-value of 0.05 was used to for all tests of significance.ModelThe use of multivariate analysis in the study of health and subjective wellbeing (i.e. self-reportedhealth or happiness) is well established [18] and this is equally the case in Jamaica and Barbados[19, 20]. The use of this approach is better than bivariate analyses as many variables can betested simultaneously for their impact (if any) on a dependent variable. This paper examined thesocial determinants of self-reported health status of Jamaicans (Equation 1). Equation 1 wasagain tested and decomposed by (i) sex of respondents and (ii) area of residents in order toascertain those social predictors of each sub-group.Ht=f(Ai, Gi,HHi, ARi, It, Ji, lnC, lnDi, EDi, MRi, Si, HIi, lnY, CRi, MCt, SAi, Ti , εi) [1]where Ht (ie self-rated current health status in time t) is a function of age of respondents, Ai ; sexof individual i, Gi; household head of individual i, HHi; area of residence, ARi; current self- 183
    • reported illness of individual i, It; injuries received in the last 4 weeks by individual i, Ji; loggedconsumption per person per household member, lnC; logged duration of time that individual iwas unable to carry out normal activities, lnDi; education level of individual i, EDi; marital statusof person i, MRi; social class of person i, Si; health insurance coverage of person i, HIi; loggedincome, lnY; crowding of individual i, CRi; medical expenditure of individual i in time period t,MCt; social assistance of individual i, SAi; length of time living in current household byindividual i, Ti; and an error term (ie. residual error).The final model that were derived from the general Equation [1] that can be used to predicthealth status of Jamaicans (Equation [2]).Ht = f(Ai, ARi, lnDUt, εi) [2]Variables that were investigated include age, self-reported illness (diabetes mellitus,hypertension) and social class. Age group is a non-binary measure: children (ages less than 15years); 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 andolder).ResultsDemographic characteristics of sampleThe sample constituted 714 respondents (36.7% men and 63.3% women), with a mean age of49.15 years. Majority of the sample was never married (44.7%), 13.4% widowed, 1.7%separated, 3.1% divorced and 37.1% married. Some 25.3% of the sample reported that they hadpoor health status, 31.9% indicated at least good and 42.8% indicated fair. Thirty-three percentof the sample indicated unspecified chronic illness; 7.8% arthritis, 28.9% hypertension, 17.2% 184
    • diabetes mellitus and 13.3% asthma. Marginally more of the sample was in the upper class(41.6%), 19.7% in the middle class and 38.7% in the lower class (i.e. poor). Majority of therespondents were elderly (ages 60 years and older - 41.6%) compared to 33.6% other-agedadults, 9.7% young adults and 15.1% children. Interestingly, the mean number of person perroom was 4.07 (S.D. 2.63 persons) and in rural areas it was 4.38 (S.D. 2.75 persons) compared to3.9 persons in other towns (S.D. 2.41) and 3.6 persons in urban areas (S.D. 2.42) - F statistic [2,711] = 6.642, p = 0.001.Table 7.1 revealed that there is a statistical correlation between social class, self-evaluated healthstatus, annual income and area of residence (p < 0.001). Just over 50% of the rural residents werein the lower class (i.e. poor) compared to 26.4% of other town residents and 18.0% of urbandwellers. With regards to self-evaluated health and area of residence, most of the residentsreported fair health status: urban residents (46.5%); other town residents (50.8%) and ruralresidents (38.4%). On the other hand, 28.6% of rural residents indicated that they had good self-evaluated health status compared to 31.7% of other town residents and 38.5% of urban dwellers.The mean annual income of rural residents was US$5,873.08 compared to US$8,218.05 for othertown residents and US$10,312.41 for urban residents. Most of the rural respondents were in thelower class (52.9%), while 26.4% of the other town residents in the lower class and 18% of theurban dwellers in the lower class.Table 7.2 revealed that there is a statistical correlation between diagnosed chronic diseases andage group [χ2 (df = 20) = 297.701, p < 0.001, n = 714]. Asthma was primarily an illness for theyounger ages and more so affecting children: 47.2% of children and 23.2% of young adults(Table 7.2). The findings revealed as an individual ages, he/she was more likely to report being 185
    • diagnosed with hypertension: 0% of children; 8.7% of young adults; 31.7% of other aged-adults;35.7% of young old; 50.5% of old-elderly and 48.3% of oldest-elderly. Arthritis was more likelyto affect older ages than young ages: 0% of children; 1.4% of young adults; 7.1% of other aged-adults; 12.9% of young-old; 14.4% of old-elderly and 6.9% of oldest-elderly. On the other hand,as an individual age, he/she is more to be aware of the typology of chronic illness that he/she hasthan at young ages (i.e. ages less than 31 years). Interestingly, 2.8% of children had diabetescompared to 4.3% of young adults; 18.3% of other aged-adults; 28.7% of young old; 19.6% ofold-elderly and 17.2% of oldest-elderly.Based on Table 7.3, no statistical correlation was found between diagnosed chronic disease andsocial class [χ2 (df = 8) = 13.882, p = 0.085, n = 714]. On the other hand, a statistical relationshipwas found between income, consumption, crowding and chronic disease (p < 0.5; Table 7.4).Furthermore, there is a similarity across the afore-mentioned variable as asthma was found to beassociated with the most income, consumption and persons per room; and unspecified chronicdisease was the second leading reported dysfunction. Diabetes mellitus was found to be the thirdleading reported chronic disease influencing people with more income and consumption. Whilehypertension was the third most reporting chronic disease associated with crowding, it was thefourth most reported dysfunction associated with income and consumption expenditure.Multivariate analysesUsing logistic regression analyses, of the 17 variables that were tested for this paper, only 3emerged as statistically significant predictors of poor health status of Jamaicans who reportedbeing diagnosed with chronic diseases (Table 7.5): age of respondents (OR = 1.029, 95% CI =1.018 - 1. 040), area of residence (urban areas - OR = 0.352, 95% CI = 0.191 - 0.652; other 186
    • towns - OR = 0.352, 95% CI = 0.173 - 0.744) and log duration unable to work (OR = 1.711, 95%CI = 1.280 - 2.271).The model (Equation 2) had statistically significant predictive power [χ2 (4) =59.76.149, p < 0.001;Hosmer and Lemeshow goodness of fit χ2 = 9.956, p = 0.268] and correctly classified 74.4% of thesample (correctly classified 92.6% of those who were in poor health and 31.6% of those who were not inpoor health). The logistic regression model can be written as: Log (probability of poor healthstatus/probability of not reporting poor health status) = -0.704 + 0.028 (age) -1.041(urban residents) -1.041 (other towns) + 0.537 (log duration unable to work). Furthermore, the predictors accountedfor 24% of the variability in poor health status (Table 7.5).DiscussionThere is an association between chronic disease and health status and the former has a significantnegative impact on the physical aspects of health [21]. Self-reported health status has beenwidely used in censuses, surveys, and observational studies and there is evidence suggesting thatself-reported health is an indicator of general health with good construct validity [22] and is arespectably powerful predictor of mortality risks [23], disability [24] and morbidity [25]. Theresults of this paper showed that the majority of those sampled reported to be experiencing atleast good or fair health, while approximately one-quarter indicated poor health. These resultsconcur with those by other researchers from Dominica [26] and Trinidad [27].This paper revealed that hypertension was the most common chronic disease among therespondents, followed by diabetes mellitus and arthritis. Hypertension was highest among theelderly, with just than one-half of the old-elderly and oldest-elderly being hypertensive. In astudy by Sargeant et al. [28], hypertension is more common among women and the elderly in 187
    • Jamaica. Studies from developed countries have reported prevalence of raised blood pressureamong elderly to vary from 60% to 80% [29]. Hypertension is one of the most importanttreatable causes of morbidity and mortality and accounts for a large proportion of cardiovasculardiseases in elderly in Jamaica [28]. The age and sex adjusted prevalence in Jamaica is 24% [30]with somewhat higher levels in women than in men. The Jamaican Healthy Lifestyle SurveyReport 2000 [31] noted a prevalence of hypertension of 19.9% among males and 21.7% amongfemales; prevalence increased with age in both rural and urban populations and in both sexes.Among persons known to be hypertensive, 42% were on treatment, and of this group, 37.7% hadbeen able to lower and maintain their blood pressure at 140/90 or less. In the Caribbean and theUSA, the higher prevalence of hypertension was associated with an increased prevalence ofobesity, especially in women, and with greater intake of dietary sodium [32, 33].Diabetes mellitus is an important cause of morbidity and mortality in Jamaica and represents asignificant burden on health services. Diabetes was the second leading cause of chronic diseasein this paper and was most prevalent among the young old with just under one-third reportingthat they have diabetes mellitus. The prevalence of diabetes mellitus is high in Jamaica and theCaribbean and many patients have poor metabolic control [34]. In Jamaica the prevalence ofdiabetes among persons 25-74 years old is estimated to be 12% to 16% [35-37], but of which athird is unrecognized [36, 37]. There is also evidence that the diabetes prevalence has increased[38]. In the Jamaican Healthy Lifestyle Survey Report 2000 [31], diabetes mellitus was found in6.3% of males and 8.2% of females and there was a sharp increase with age. Awareness ofdiabetes mellitus among those classified as diabetic by the survey was 76.3%. Almost one-thirdof those classified as diabetic were not being treated, and 60% of those who reported being on 188
    • medication did not have their condition controlled. The average length of stay was 8.3 days fordiabetes mellitus in 2002, compared to 6.3 days for all conditions [31]. Diabetes mellitusaccounts for about 10% of mortality in Jamaica [39] and is ranked fourth as the principal causeof death among Jamaicans during the period 1990 to 1994 [40]. But the impact of diabetesmellitus on mortality is under-reported since the disease may contribute to mortality from suchother conditions as cerebrovascular accidents and myocardial infarctions [41]. Furthermore, thereis evidence that the high prevalence of diabetes in Jamaica is due to the low rates of awareness,treatment and control among patients with diabetes mellitus [34].In the Caribbean, there has been growing concern at the apparent increase in asthma in childrenand young adults. In 2001, hospital morbidity patterns and primary care data indicated thatrespiratory illnesses dominated the list of childhood infirmities among children 0-14 years. Forchildren aged 0-4 years, asthma was the major condition for which patients were seen in healthfacilities, a condition mainly attributable to the high incidence of tobacco smoke to which thesechildren are exposed [42]. In this paper, asthma was the predominant chronic diseases affectingapproximately one-half of the children and almost one quarter of young adults. Asthma is animportant public health issue in Jamaica. Exercise-induced asthma has been reported to occur in20 per cent of school age children [43]. In government hospitals in Jamaica, five per cent ofclinic visits are asthma related and 25 per cent of respiratory admissions to hospital are due toasthma [44]. Barnes and colleagues [45] studied asthmatic children in Barbados where treatmentwas associated with use of inhalers, but no distinction between bronchodilators andcorticosteroids was made [46]. Asthma is a significant cause of mortality in Jamaica, resulting ina death rate of approximately 5 per 100,000 [47]. 189
    • Studies conducted over the last three decades in Third World countries have confirmed thatrheumatoid arthritis occurs throughout the world. Rheumatoid arthritis is a chronic systemicinflammatory disorder that may affect many tissues and organs but particularly the joints, oftenprogressing to destruction of the articular cartilage and ankylosis of the joints [48, 49]. Due to itsphysical, social and psychological burden, patients‘ experience many difficulties in variousaspects of their lives and can contribute in these patients experiencing poor health. Rheumatoidarthritis is the third chronic illness among the respondents in the study. In India, the prevalenceof rheumatoid arthritis (0.75%) is similar to that in the West [50]. The rarity of rheumatoidarthritis in rural Africa contrasts with the high prevalence of the disease in Jamaica, where over2% of the adult population is affected [51]. In a study in Latin America, rheumatoid arthritis wasthe reason for seeking medical advice in 22% of rheumatology clinic patients [52]. Quality of lifeis significantly low in patients with rheumatoid arthritis, knee osteoarthritis and fibromyalgiasyndrome, whose depression and/or anxiety scores are high [53]. Therefore, these patients shouldbe managed using a multidisciplinary approach including psychiatric support.In this paper just over one-third of the respondents indicated an unspecified chronic illness. Theunspecified chronic diseases could be other chronic non-communicable disease such as amalignant neoplasm or a chronic communicable disease. In Jamaica, cancers accounted for 15%of non-communicable diseases and 9% of total disease burden in 1990. Cancers of the breast andcervix are the most common neoplasms in women, with rates in 1991 of 22.6 and 19.2 per 1,000population, respectively. Prostate cancer was the number one form of cancer found in men [54].In 2002 there were 3,769 public hospital discharge diagnoses (4% of total discharge diagnoses)for malignant neoplasms with an equal gender distribution. The types of neoplasms involved for 190
    • males, in order of decreasing frequency, were: trachea, bronchus, and lungs; prostate; leukemia;and non-Hodgkin‘s lymphoma, representing 56% of all cancers. For females, the order was asfollows: breast; cervix uteri; other malignant neoplasms of female genital organs; trachea,bronchus, and lungs; leukemia; and non-Hodgkin‘s lymphoma, together representing 56% of allcancers [55]. The unspecified chronic illness may include HIV/AIDS, a communicable disease,has become a serious public health concern in Jamaica. The national incidence of AIDS in 2000was 352 per 1,000,000 population [56]. In addition, the unspecified chronic disease may includedepression and there is evidence to suggest that depressive disorders frequently accompany otherchronic medical diseases. The 2000 Lifestyle Survey found approximately 25 % depressivesymptoms in the general population [31]. Anderson et al. [57] concluded that the presence ofdiabetes mellitus increases the risk of depression and studies have shown that in personsdiagnosed with diabetes mellitus the prevalence of depression range from 6.1% - 60.7% [58].Majority of the respondents resided in rural areas and just over one-half of these were in thelower class. The study found that there was an income differential between respondents in ruralcompared with urban area of residence, with those in the rural having mean annual income ofapproximately two-thirds of their urban counterparts. Diabetes mellitus was found to be the thirdleading reported chronic disease influencing persons with greater income and consumption.While hypertension was the third most reported chronic disease associated with crowding, it wasthe fourth most reported dysfunction associated with income and consumption expenditure.According to Sobal and Stunkard [59], in developing societies there is a higher likelihood ofobesity among men in higher socio-economic strata. These men are at increased risk ofdeveloping type 2 diabetes mellitus [60] which is increasing in the adult population. Most of the 191
    • respondents in this paper were female and single women constitute 45% of Jamaican head ofhouseholds [61]. In Jamaica, female-headed households are poorer than those headed by malesand twice as likely to be unemployed. Male-headed households are smaller and have a per capitaexpenditure 10 times higher than female-headed households [62, 63]. The 1999 data fromSTATIN show that individuals who live in rural areas, who are in the poorest quintile, and whoare males are less likely to seek health care [64].ConclusionThe general epidemiological shift from infectious to chronic non-communicable diseases inJamaica puts the residents at risk. Majority of the respondents in the sample had good health.Adults with poor health status were more likely to report having hypertension followed bydiabetes mellitus and arthritis, while asthma was the most prevalent among children. Poor healthstatus was more prevalent among those of lower economic status in rural areas who reported theleast annual income. Predictors of poor health status of Jamaicans who reported being diagnosedwith a chronic disease were age, area of residence and inability to work, therefore beingunemployed. Given the high prevalence and poor levels of control, hypertension and diabetesmellitus remain formidable issues for public health care in Jamaica and the Caribbean. Poverty,low education and poor access to health care in rural communities intensify the inertia to thelifestyle modifications that are necessary to bring about greater levels of control. We suggest thatfurther improvement in chronic disease control can be achieved with improved patient educationon the importance of compliance, access to more effective medication and development ofsupport groups among patients with chronic disease(s). 192
    • References1. World Health Organization (WHO). The world health report 2002: reducing risks, promoting healthy life. Geneva, World Health Organization; 2002.2. World Health Organization. Diet, physical activity and health. Geneva: World Health Organization; 2002.3. Figueroa JP. Health trends in Jamaica. Significant progress and a vision for the 21st century. West Indian Med J 2001; 50 (Suppl 4): 15-22.4. Guilliford MC. Epidemiological transition in Trinidad and Tobago, West Indies 1953-1992. Int J Epidemiol 1996; 25: 357-365.5. Caribbean Commission on Health and Development Report; 2004.6. Forrester TE. Research into policy. Hypertension and diabetes mellitus in the Caribbean. West Indian Med J 2003; 52: 164-169.7. Wilks R, Bennett F, Forrester T, McFarlane-Anderson N. Chronic diseases: the new epidemic. West Indian Med J 1998; 47(Suppl 4): 40-44.8. Statistical Institute of Jamaica (STATIN). Demographic Statistics 2001. Kingston: STATIN; 2002.9. Sargeant LA, Wilks RJ, Forrester TE. Chronic diseases-facing a public health challenge. West Indian Med J 2001; 50(Suppl 4): 27-31.10. Wilks R, Bennett F, Forrester T, McFarlane-Anderson N, Anderson SG, Kaufman JS, Rotimi C, Cooper RS, Cruickshank JK. Chronic disease: the new epidemic. West Indian Medical Journal 1998; 47(suppl 4): 40.11. Measuring Healthy Days: Population assessment of health-Related quality of life. Atlanta, Ga: Centers for Disease Control and Prevention; 2000. 193
    • 12. Planning Institute of Jamaica and Statistical Institute of Jamaica (PIOJ & STATIN). Jamaica Survey of Living Conditions 2007. Kingston: PIOJ, STATIN; 2008.13. Homer D, Lemeshow S. Applied logistic regression, 2nd edn. John Wiley & Sons Inc., New York; 2000.14. Cohen L, Holliday M. Statistics for social sciences. London, England: Harper and Row; 1982.15. Asnani MR, Reid ME, Ali SB, Lipps G, Williams-Green P. Quality of life in patients with sickle cell disease in Jamaica: rural-urban differences. Rural and Remote Health 2008; 8(890): 1-9.16. Grossman M. The demand for health - a theoretical and empirical investigation. New York: National Bureau of Economic Research; 1972.17. 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(5-6): 342-352.18. Smith JP, Kington R. Demographic and economic correlates of health in old age. Demography 1997; 34: 159-170.19. Hutchinson G, Simeon DT, Bain BC, Wyatt GE, Tucker MB, LeFranc E. Social and health determinants of wellbeing and life satisfaction in Jamaica. International Journal of Social Psychiatry 2004; 50: 43-53.20. Bourne P. Using the biopsychosocial model to evaluate the wellbeing of the Jamaican elderly. West Indian Medical J 2007; 56(suppl 3): 39-40. 194
    • 21. Groothoff JW, Grootenhuis MA, Offringa M, Gruppen MP, Korevaar JC, Heymans HS. Quality of life in adults with end-stage renal disease since childhood is only partially impaired. Nephrol Dial Transplant 2003; 18: 310-317.22. Smith J. Measuring health and economic status of older adults in developing countries. Gerontologist 1994; 34: 491-496.23. Idler EL, Benjamin Y. Self-rated health and mortality: A Review of twenty-seven community studies. Journal of Health and Social Behavior 1997; 38: 21-37.24. Idler EL, Kasl S. Self-ratings of health: Do they also predict change in functional ability? Journal of Gerontology 1995; 50B(6): S344-S353.25. Schechter S, Beatty P, Willis GB. Asking survey respondents about health status: Judgment and response issues, in N. Schwarz, D. Park, B. Knauper and S. Sudman [ed.]: Cognition, Aging, and Self-Reports. Ann Arbor, Michigan: Taylor and Francis; 1998.26. Luteijn B. Health status of the elderly in the Marigot Health District, Dominica. West Indian Medical Journal 1996; 45(Suppl.2): 31.27. Rawlins JM, Simeon DT, Ramdath DD, Chadee DD. The elderly in Trinidad: Health, social and economic status and issues of loneliness. West Indian Medical Journal 2008; 57: 589- 595.28. Sargeant L, Boyne M, Bennett F, Forrester T, Cooper R, Wilks R. Impaired glucose regulation in adults in Jamaica: who should have the oral glucose tolerance test. Pan American Journal of Public Health 2004; 16: 35-42.29. Kalavathy MC, Thankappan KR, Sharma PS, Vasan RS. Prevalence, awareness, treatment and control of hypertension in an elderly community-based sample in Kerala, India. Natl Med J India 2000; 13: 9-15. 195
    • 30. Cooper R, Rotimi C, Ataman S, McGee D, Osotimehin B, Kadir S, Muna W, Kingue H, Fraser H, Forrester T, Bennett F, Wilks R. The prevalence of hypertension in seven populations of West African origin. Am J Public Health 1997; 7: 160-168.31. Figueroa JP, Ward E, Walters C, Ashley DE, Wilks RJ. Jamaica Healthy Lifestyle Survey Report; 2000.32. Ravallion M. Poverty comparisons. Chur, Switzerland: Harwood Academic Publishers; 1994.33. Sadana R, Mathers CD, Lopez AD, Murray CJL, Iburg K. Comparative analyses of more than 50 household surveys on health status. Geneva: World Health Organization; 2000.34. Wilks R, Sargeant L, Gulliford M, Reid M, Forrester T. Management of diabetes mellitus in three settings in Jamaica. Pan Am J Public Health 2001; 9: 65-71.35. Wilks R, Bennett F, Forrester T, McFarlane-Anderson N, Anderson SG, Kaufman JS, Rotimi C, Cooper RS, Cruickshank JK. Diabetes in the Caribbean: results of a population survey from Spanish Town, Jamaica. British Diabetic Association. Diabetic Medicine 1999; 16: 875-883.36. Ragoobirsingh D, Lewis-Fuller E, Morrison EY. The Jamaican Diabetes Survey. Diabetes Care 1995; 18(9): 1277-1279.37. Cooper RS, Rotimi CN, Kaufman JS, Owoaje EE, Fraser H, Forrester T, Wilks R, Riste LK, Cruickshank JK. Prevalence of NIDDM among populations of the African diaspora. Diabetes Care 1997; 20(3): 343-348.38. Florey Cdu V, McDonald H, McDonald J, Miall WE. The prevalence of diabetes in a rural population of Jamaican adults. Int J Epidemiol 1972; 1(2): 157-166.39. Statistical Institute of Jamaica. Demographic statistics 1995. Kingston, Jamaica: Statistical Institute; 1996. 196
    • 40. Pan American Health Organization. Caribbean Regional Health Study. Washington, DC: Pan American Health Organization, 1996: 21-22.41. Alleyne SI, Cruickshank JK, Golding AL, Morrison EY. Mortality from diabetes mellitus in Jamaica. Bull Pan Am Health Organ 1989; 23(3): 306-314.42. Prendergast K, Ashley D. Report on the Results of the Global Youth Tobacco Survey in Jamaica - 2001; 2001. http:/w/wwww.cdc.gov/tobacco/global/gyts/reports/paho/2001/ Jamaica.2001Paho01.htm43. Nichols DJ, Longsworth, FG. Prevalence of exercise-induced asthma in schoolchildren in Kingston, St Andrew and St Catherine, Jamaica. West Indian Med J 1995; 44: 16-19.44. Ward E, Grant A. Epidemiological Profile of Selected Health Conditions and Selected Services in Jamaica. A Ten Year Review; 2002.45. Barnes K C, Brenner R J, Helm R M, Howitt M E, Naidu R P, Roach T. The role of the house dust mite and other household pests in the incidence of allergy among Barbadian asthmatics. West Indian Med J 1992; 41 (suppl 1): 38.46. Barnes K C, Naidu R P. Plenty children got wheeze these days: lay knowledge, beliefs and stated behaviours related to asthma in Barbados. West Indian Med J 1993; 42(suppl 1): 37.47. Scott PW, Mullings RL. Bronchial asthma deaths in Jamaica. West Indian Med J 1998; 47: 129-132.48. Katz WA. Rheumatoid arthritis. In: Katz WA, ed. Diagnosis and Management of Rheumatic Diseases. Philadelphia: Lippincott; 1998; 380-396.49. Ravinder N, Feldmann MM. Rheumatoid arthritis. In: Maddison PJ, Isenberg DA, Woo P, Glass DN, ed. Oxford textbook of Rheumatology. Second Edition, New York: Second Edition. New York: Oxford University Press. 1998; 1004-1027. 197
    • 50. Malaviya AW; Kapoor SK, Singh RR, Kumar A, Pande I. Prevalence of Rheumatoid arthritis in the adult Indian population. Rheumatology International 1993; 13(4): 131-134.51. Mijiyawa M. Epidemiology and Semiology of rheumatoid arthritis in third world countries. Rev Rhum Engl Ed 1995; 62(2): 121-126.52. Kerr G, Richards J, Harris E. Rheumatic disease in minority population. Medical Clinics of North America 2005; 89(4): 829-868.53. Ozcetin A, Ataoglus S, Kocer E, Yazici S, Yildiz O, Ataoglul A, Icmeli C. Effects of depression and anxiety on quality of life in patients with rheumatoid arthritis, knee osteoarthritis and fibromyalgia syndrome. West Indian Medical Journal 2007; 56(2): 122- 129.54. Pan American Health Organization. Health in the Americas, 1998 Edition, Volume II – Jamaica. Washington D.C.; 1998.55. Jamaica, Ministry of Health. Ministry of Health Annual Report, 2002. Kingston: Ministry of Health; 200356. Pan American Health Organization. Jamaica - Health situation analysis and trends summary. www.paho.org/English/DD/AIS/cp_388.htm57. Anderson R, Freedland KE, Clouse RE, Lustman PJ. The prevalence of co-morbid depression in adults with diabetes. Diabetes Care 2001; 24: 1069-1078.58. Friis R, Nanjundappa G. Diabetes, depression and employment status. Soc Sci Med 1986; 23: 471-475.59. Sobal J, Stunkard AJ. Socioeconomic status and obesity: a review of the literature. Psychol Bull 1989; 105: 260-275. 198
    • 60. Astrup A, Finer N. Redefining Type 2 diabetes: Diabetes or obesity dependent diabetes. Obesity Reviews 2001; 1(2): 57-59.61. Dunn LL. Jamaica: Situation of children in prostitution: A rapid assessment. International Labor Organization: International Program on the Elimination of Child Labor, Geneva, Switzerland; 2001.62. United Nation‘s Nation Children Fund (UNICEF). Situation analysis on excluded children in Jamaica, 2006. Kingston: UNICEF; 2006.63. World Bank. A review of gender issues in the Dominican Republic, Haiti and Jamaica, 2002. Report No. 21866-LAC. Washington, DC: The World Bank; 2002.64. The Statistical Institute of Jamaica. Jamaica Survey of Living Conditions: report. The Statistical Institute of Jamaica, Kingston, Jamaica, 1999: 45-47. 199
    • Table 7.1: Socio-demographic characteristics of sample Area of residence Variable Urban Other towns Rural P n (%) n (%) n (%)Sex 0.702 Male 70 (35.0) 48 (39.7) 144 (36.6) Female 130 (65.0) 73 (60.3) 249 (63.4)Injury 0.347 Yes 4 (2.0) 6 (5.0) 13 (3.3) No 195 (98.0) 115 (95.0) 380 (96.7)Self-reported chronic illness 0.214 Asthma 33 (16.5) 11 (9.1) 51 (13.0) Diabetes 32 (16.0) 27 (22.3) 64 (16.3) Hypertension 47 (23.5) 41 (33.9) 118 (30.0) Arthritis 16 (8.0) 10 (8.3) 30 (7.6) Unspecified 72 (36.0) 32 (26.4) 130 (33.1)Social class < 0.001 Poor 36 (18.0) 32 (26.4) 208 (52.9) Middle 30 (15.0) 27 (22.3) 84 (21.4) Upper 134 (67.0) 62 (51.3) 101 (25.7)Self-evaluated health status < 0.001 Good 77 (38.5) 38 (31.7) 112 (28.6) Fair 93 (46.5) 61 (50.8) 150 (38.4) Poor 30 (15.0) 21 (17.5) 129 (33.0)Household head 0.082 Yes 105 (52.5) 72 (59.5) 189 (48.1) No 95 (47.5) 49 (40.5) 204 (51.8)Marital status Married 60 (35.3) 34 (31.8) 130 (39.8) 0.166 Never married 78 (45.9) 48 (44.9) 144 (44.0) Divorced 7 (4.1) 6 (5.6) 6 (1.8) Separated 4 (2.4) 4 (3.7) 2 (0.6) Widowed 21 (12.4) 15 (14.0) 45 (13.8)Educational level 0.466 No formal 160 (80.0) 106 (87.6) 319 (81.2) Basic 14 (7.0) 5 (4.1) 33 (8.4) Primary/Preparatory 12 (6.0) 5 (4.1) 25 (6.4) Secondary/High 9 (4.5) 4 (3.3) 13 (3.3) Tertiary 5 (2.5) 1 (0.8) 3 (0.8)Age Mean (SD) 47.5 yrs (25.07 yrs) 53.36 yrs. (23.61) 48.7 (25.79 yr) 0.114†Annual Income Mean (SD) US $10,312.41 (US US $8,218.05 US $5,873.08 < 0.001 $9,059.70) (US $7,653.84) (US 4,473.51)Number of visits to health care 1.4 (1.1) 1.5 (1.5) 1.4 (1.1) 0.842practitioner Mean (SD)†Annual Income is quoted in US $ (US$ 1.00 = Ja. $ 80.47 at the time of the survey) 200
    • Table 7.2: Diagnosed chronic recurring illness by age group Age group Young Other aged- Oldest Children adults adults Young old Old elderly elderly Total Diagnosed chronic illness n (%) n (%) n (%) n (%) n (%) n (%) n (%)Asthma 51 (47.2) 16 (23.2) 18 (7.5) 7(4.1) 2 (2.1) 1 (3.4) 95 (13.3) 3 (2.8) 3 (4.3) 44 (18.3) 49 (28.7) 19 (19.6) 5 (17.2) 123 (17.2)Diabetes mellitus 0 (0.0) 6 (8.7) 76 (31.7) 61 (35.7) 49 (50.5) 14 (48.3) 206 (28.9)Hypertension 0 (0.0) 1 (1.4) 17 (7.1) 22 (12.9) 14 (14.4) 2 (6.9) 56 (7.8)Arthritis 54 (50.0) 43 (62.3) 85 (35.4) 32 (18.7) 13 (13.4) 7 (24.1) 234 (32.8)Other (unspecified) 108 69 240 171 97 29 714 Totalχ2 (df = 20) = 297.701, P < 0.001 201
    • Table 7.3: Diagnosed chronic illness by social class Social class Poor Middle class Upper class Total Diagnosed chronic illness n (%) n (%) n (%) n (%)Asthma 42 (15.2) 19 (13.5) 34 (11.4) 95 (13.3) Diabetes mellitus 41 (14.9) 16 (11.3) 66 (22.2) 123 (17.2) Hypertension 82 (29.7) 48 (34.0) 76 (25.6) 206 (28.9) 25 (9.1) 12 (8.5) 19 (6.4) 56 (7.8) ArthritisOther (unspecified) 86 (31.2) 46 (32.6) 102 (34.3) 234 (32.8)Total 276 141 297 714χ2 (df = 8) = 13.882, P = 0.085 202
    • Table 7.4: Crowding, income and annual consumption expenditure by diagnosed chronic disease 95% CI Std. N Mean Deviation Std. Error Lower Upper †Crowding Asthma 95 5.14 2.88 0.30 4.55 5.72 Diabetes mellitus 123 3.55 2.33 0.21 3.14 3.97 Hypertension 206 3.86 2.59 0.18 3.51 4.22 Arthritis 56 3.18 1.93 0.26 2.66 3.69 Other (unspecified) 234 4.30 2.69 0.18 3.95 4.65 Total 714 4.07 2.63 0.10 3.88 4.26 †† Annual income* Asthma 95 735796.96 636673.50 65321.32 606099.94 865493.98 Diabetes mellitus 123 568805.41 441764.01 39832.52 489952.96 647657.86 Hypertension 206 554090.28 536998.15 37414.43 480323.85 627856.71 Arthritis 56 460341.89 484472.24 64740.33 330599.37 590084.40 Other (unspecified) 234 649294.58 591718.97 38681.88 573083.63 725505.52 Total 714 604650.49 554806.11 20763.10 563886.37 645414.61 †††Annual Asthma consumption 95 655299.59 461384.09 47337.01 561310.85 749288.33 expenditure* Diabetes mellitus 123 509264.21 363216.62 32750.14 444432.04 574096.38 Hypertension 206 500635.23 450169.33 31364.78 438796.32 562474.15 Arthritis 56 404152.14 352416.40 47093.62 309774.41 498529.87 Other (unspecified) 234 586512.66 432316.66 28261.42 530832.07 642193.25 Total 714 543277.73 429059.15 16057.14 511752.81 574802.65†Crowding - F statistic [4, 709] = 7.778, p < 0.001††Income - F statistic [4, 709] = 3.250, p = 0.012,†††Annual consumption Expenditure - F statistic [4, 709] = 4.472, p = 0.001*Income and Annual Consumption Expenditure were quoted in Jamaican dollars (Ja. $80.47 = US $1.00 at the time of the survey) 203
    • Table 7.5: Logistic regression: Predictor of poor health status of patients who reported chronicdisease Wald Std. statistic OddsPredictors error ratio 95.0% C.I.Age 0.006 26.131*** 1.029 1.018 - 1.040 0.313 11.061** 0.353 0.191 - 0.652Urban areas 0.372 7.582** 0.359 0.173 - 0.744Other townsLog duration unable 0.145 13.803*** 1.711 1.289 - 2.271to workχ2 (df = 4) =59.76.149, p < 0.001; n = 714)-2 Log likelihood = 332.325Nagelkerke R2 =0.240Hosmer and Lemeshow goodness of fit χ2=9.956, P = 0.268†Reference group – rural areas*P < 0.05, **P < 0.01, ***P < 0.001 204
    • Chapter 8The changing faces of diabetes, hypertension and arthritis in aCaribbean population Paul A. Bourne, Samuel McDaniel, Maxwell S. Williams, Cynthia Francis, Maureen D. Kerr-Campbell & Orville W. BeckfordGlobally, chronic illnesses are the leading cause of mortality, and this is no different indeveloping countries, particularly in the Caribbean. Little information emerged in the literatureon the changing faces of particular self-reported chronic diseases. This paper examines thetransitions in the demographic characteristics of those with diabetes, hypertension and arthritis,as we hypothesized that there are changing faces of those with these illnesses. A sample of 592respondents from the 2002 and 2007 Jamaica Survey of Living Conditions. Only respondentswho indicated that they were diagnosed with these particular chronic conditions were used forthe analysis. The prevalence of particular chronic diseases increased from 8 per 1,000 in 2002 to56 per 1,000 in 2007. The average annual increase in particular chronic diseases was 17.2%.Diabetes mellitus showed an exponential average annual increase of 185% compared tohypertension (+ 12.7%) and arthritis (- 3.8%). Almost 5 percent of diabetics were less than 30years of age (2.4% less than 15 years), and 41% less than 59 years. Three percent of hypertensiverespondents were 30 years and under as well as 2% of arthritics. The demographic transition inparticular chronic conditions now demands that data collection on those illnesses be lowered to <15 years. This research highlights the urgent need for a diabetes campaign that extends beyondparents to include vendors, confectionary manufacturers and government, in order to address thetsunami of chronic diseases facing the nation.IntroductionGlobally, chronic illnesses are the leading cause of mortality (60%) [1, 2], and this is no differentin developing countries, particularly in the Caribbean [2-6]. Statistics indicate that 79% of allmortalities are attributable to chronic diseases, and that they are occurring in developing 205
    • countries such as those in the Caribbean [3]. Using data for 1989 and 1990, Holder & Lewis [7]showed that hypertension and diabetes mellitus were among the 5 leading causes of mortality inthe English-speaking Caribbean and Suriname. The findings from Holder and Lewis indicatedthat mortality resulting from hypertension was highest in Dominica (over 90 per 100,000 of thepopulation) and diabetes crude death rates per 100,000 of the population were the greatest inTrinidad and Tobago (over 85 per 100,000). The 20th century has brought with it massive changes in the typology of diseases, wheredeaths have shifted from infectious diseases such as tuberculosis, pneumonia, yellow fever,Black Death (i.e. Bubonic Plague), smallpox and ‗diphtheria‘ to diseases such as cancer, heartcomplaints and diabetes. Although diseases have moved from infectious to degenerate, chronicnon-communicable illnesses have arisen and are still lingering in spite of all the advances inscience, medicine and technology. Morrison [8] titled an article ‗Diabetes and Hypertension:Twin Trouble‘ in which he established that diabetes mellitus and hypertension have now becometwo problems for Jamaicans and people in the wider Caribbean. This situation was corroboratedby Callender [9] and Steingo at the 6th International Diabetes and Hypertension Conference,which was held in Jamaica in March 2000. They found that there is a positive associationbetween diabetic and hypertensive patients - 50% of individuals with diabetes had a history ofhypertension [9, 10]. Prior to those scholars‘ work, Eldemire [11] found that 34.8% of new casesof diabetes and 39.6% of hypertension were associated with senior citizens (i.e. ages 60 andover). In an article published by Caribbean Food and Nutrition Institute, the prevalence rate ofdiabetes mellitus affecting Jamaicans is noted to be higher than in North American and ―manyEuropean countries‖ [9]. 206
    • Chronic illnesses have been on the rise in the Caribbean. In a 1996 study conducted byMorrison and colleagues in Trinidad and Tobago [12], they noted that there is an alarming rise inthe prevalence rate of diabetes mellitus (15-18%). A study in Barbados found that between 1988and 1992 the prevalence rate of diabetes mellitus for the population was 17.5%; 12.5% in mixedpopulation (black/white), 6.0% in white/other and 0.3% in the younger population [13]. Anotherresearch, in Europe, found that the prevalence among newly diagnosed diabetics in Europeanswas 20%; African-Caribbeans, 22%; and in Pakistanis, 33% [14]. They also postulated that thereis an association between poverty and diabetes. Van Agt et al. [15] went further when they foundthat poverty was greater among the chronically ill, with which a later study by the World HealthOrganization [16] concurred. The WHO [16] stated that 80% of chronic illnesses were in lowand middle income countries, emphasizing the association between not only diabetes andpoverty, but chronic conditions and poverty. The relationship between poverty and chronicconditions extends to premature mortality [17]. Findings from the WHO [4] showed that 60% ofglobal mortality is caused by chronic illness, which offers an explanation of the face for thosewith these particular conditions. Within the context of a strong association between poverty andchronic illness, the high prevalence of diabetes mellitus, hypertension and other chronicconditions in developing countries should not be surprising [16, 18]. Yach et al. [18] further opined that the global figure for diabetes is projected to movefrom 171 million (2.8%) in 2000 to 366 million (6.5%) in 2030. Of this figure 298 million ofthese persons will be in developing countries, which reinforces the poverty-illness relationship.Chronic diseases can be likened to a tsunami [19] in developing nations [20-22], and it seems tobe spiralling because of the unhealthy lifestyle of people. The tsunami of chronic illnesses in thedeveloping countries is equally reflected in the Americas [20, 21], and particularly Jamaica. The 207
    • face of chronic illness in developing nations is therefore for (1) lower socioeconomic strata, (2)rural residents, (3) adults, (4) gender differences, (5) lower educational level, and (6) marriedpeople. A great deal of research exists on the management of chronic illnesses, and rightfully so,as these go to the health status and mortality of a population [23, 24]. The profiles of those withchronic diseases have never been examined in Latin America and the Caribbean, and studiesoutside of this region have used a piecemeal approach to the investigation of chronic conditions.Hence information is available on one or a few of the aforementioned faces of chronic illness,and some research has examined diabetes mellitus and hypertension but not arthritis. The presentgap in the literature will be lowered by this paper examining the faces of chronic illness fromhalf a decade of data. Using data for 2002 and 2007, the current paper will investigate thechanging faces of chronic diseases in Jamaica. The study will utilize three chronic diseases (i.e.diabetes mellitus, hypertension, and arthritis), and analyze health status, health insurance status,health care utilization, chronic illness and other sociodemographic characteristics in order toascertain the transition occurring in the population. We hypothesized that there are changingfaces of those with diabetes, hypertension and arthritis over the last half a decade (2000-2007).Materials and methodsDataThis paper extracted a sample of 592 respondents from the 2002 and 2007 Jamaica Survey ofLiving Conditions (JSLC). Only respondents who indicated that they were diagnosed withparticular chronic conditions were used for this analysis (i.e. diabetes mellitus, hypertension, andarthritis). The present subsample represents 0.8% of the 2002 national sample (25,018) and 5.7% 208
    • of the 2007 sample (6,783). The JSLC is an annual and nationally representative cross-sectionalsurvey that collects information on consumption, education, health status, health conditions,health care utilization, health insurance coverage, non-food consumption expenditure, housingconditions, inventory of durable goods, social assistance, demographic characteristics and otherissues [25]. 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 [26]. A self-administered questionnaire was used to collect the data. Overall, the response rate for the 2007 JSLC was 73.8% and 72.3% for 2002. Over 1,994households of individuals nationwide are included in the entire database of all ages [27]. Theresidents of a total of 620 households were interviewed from urban areas, 439 from other townsand 935 from rural areas. This sample represents 6,783 non-institutionalized civilians living inJamaica at the time of the survey. The JSLC used complex sampling design, and it is alsoweighted to reflect the population of Jamaica.Statistical analysisStatistical analyses were performed using the Statistical Packages for the Social Sciences forWindows 16.0 (SPSS Inc; Chicago, IL, USA). Descriptive statistics such as mean, standarddeviation, frequency and percentage were used to analyze the socio-demographic characteristicsof the sample. Chi-square was used to examine the association between non-metric variables,and an Analysis of Variance was used to test the equality of means among non-dichotomouscategorical variables. Means and frequency distribution were considered significant at P < 0.05using chi-square, independent sample t-test, and analysis of variance f test. 209
    • MeasuresTable 8.1 presents the operational definitions of some of the variables used in this paper.ResultsHealth care utilization, health insurance status, particular chronic illness (i.e. diabetes mellitus,hypertension and arthritis), and sociodemographic characteristics are presented in Table 8.2. Thefindings in Table 8.2 showed that the average annual increase in the particular chronic illnesswas 17.2% between 2002 and 2007. Arthritis showed an average annual reduction of 3.8%,hypertension, + 12.7% and diabetes mellitus, + 185.0%. Furthermore, the average annualincrease in health care utilization (visits to health care institutions) was 11.9% (public hospital, +8.2%; private hospital, + 10.7%; public health care centre, + 8.4%; private health care centre, +17.1%). On average the annual increase in health insurance coverage was + 148%; while thehealth care utilization (health seekers) increased by 11.7%. The particular chronic illnesses haveshifted mostly from urban (67.6%) to rural residents (55.1%). This shift could be attributed tocultural factors affecting how and what individuals eat in rural versus urban areas. The sedentarylifestyles of urban areas also added to the overall dramatic increase in chronic illnesses. Table 8.3 presents information on self-reported diagnosed particular chronic illness bysex of respondents for 2002 and 2007. On average, the annual increase in particular chronicillness in males was 19.0% compared to 16.5% in females. Diabetes mellitus showed the highestannual percentage increase (males 186.7% and females 184.4%), while arthritis fell in females(average annual 7.9%) compared to an increase in males (average annual 10.0%). Hypertensionincreased more in females (average annual 14.0%) compared to 9.7% in males. This could be 210
    • attributed to the increasing absorption of females into the upper echelons of management instressful occupations such as banking and finance, law, and the police force. Table 8.4 examines information on health coverage, health status, health care utilizationand some sociodemographic characteristics by self-reported diagnosed particular chronicillnesses for 2002 and 2007. Based on Table 8.4, although particular chronic illnesses havedecreased in rural respondents, rural dwellers continue to be the face of chronic conditions aswell as married, primary, uninsured, private health centres and those in the lower class. Theaverage annual increase in particular chronic illnesses increased by 22.9% for those in the lowerstrata compared to 11.0% for those in the middle class and 16.0% for those in the wealthysocioeconomic strata. However, the greatest increase occurred in diabetics belonging to theupper class (average annual + 200%) compared to those lower class (116.7%). On the otherhand, the highest average annual increase in hypertension occurred in the lower socioeconomicgroup (26.9%) as compared to those in the middle class (7.4%) and upper socioeconomic strata(7.1%). The massive increase in cases of diabetes within the upper class is clearly not due to thelack of resources for seeking health care. A more detailed analysis of their diet and lifestyle isneeded to ascertain the real causes for the drastic increase relative to other socioeconomicgroups. Table 8.5 presents information on the age of respondents and particular self-reportedchronic conditions for 2002 and 2007. Based on this information, there is a change in the face ofparticular chronic ailments in Jamaica. The face is changing to reflect the inclusion of those lessthan 30 years of age (including children) as distinct from the elderly population. 211
    • DiscussionThe present study revealed that the prevalence of particular chronic diseases (i.e. diabetesmellitus, hypertension and arthritis) increased from 8 per 1,000 in 2002 to 56 per 1,000 in 2007.The average annual increase of particular chronic illnesses was 17.2%. Diabetes mellitusshowed an exponential average annual increase of 185% compared to hypertension (+ 12.7%)and arthritis (- 3.8%). While hypertension remained the most prevalent of the particular chronicdiseases in this paper, diabetes mellitus showed the greatest annual increase. The transitions ofparticular chronic conditions are accounted for by (1) urban-to-rural shift, (2) female-to-male, (3)aged-to-young people, and (4) lower socioeconomic strata to upper class. The average annualincrease in particular chronic diseases was greatest among those in the lower socioeconomicgroups. However when the particular chronic ailments were disaggregated, the findings indicatedthat those in the wealthy socioeconomic group had the largest prevalence increase in diabetesmellitus, hypertension was greatest among those in the lower class and those in the upper classhad the greatest reduction in arthritic cases. Particularly of note is the switching from publichealth care utilization by particular chronically ill respondents to private health care utilization.Similarly, the prevalence of health insurance coverage on average saw an exponential annualincrease of 148%, while health care seeking behaviour over the same period showed a marginalincrease of 12%. There is an emerging body of literature to support the changing face of people withparticular chronic diseases from old ages (30+ years) to younger people including children [28-32]. Traditionally chronic conditions such as diabetes mellitus were mostly prevalent among theelderly. This reality supports the large reservoir of literature on elderly diabetic, hypertensive 212
    • and arthritic patients. With the emergence of epidemiological and population transition, muchattention was placed on diseases in middle and later ages as well as those conditions thataccounted for most of the mortality and morbidity in a population. Because lifestyle practiceswere mostly responsible for chronic illness, many researchers limited their investigation topeople 30+ years old [8-11, 23, 33 and 34]. The present paper supports the literature that particular self-reported chronic diseases(such as diabetes, hypertension and arthritis) are found mostly among the elderly (60+ years).The findings revealed that the mean ages of those with the specific self-reported chronic ailmentshave fallen marginally in Jamaica over the period (2002-2007). This is somewhat deceptive as41% of those with diabetes were less than 60 years of age, compared to 40% of those withhypertension and 31% of arthritic respondents. Two percent of diabetic respondents were lessthan 15 years of age, but no children had hypertension or arthritis. Similarly, increases wereobserved in diabetes and arthritis for the young adult (diabetics aged 15 – 30 years) for theperiod. This is evidence that self-reported particular chronic diseases are changing face asalmost 5% of diabetics were less than 31 years old in 2007 compared to 0% in 2002. Anotheremerging face of particular self-reported chronic illness is that of those with arthritis, as almost2% of cases were among people ages 15-30 years of age. The young face of those with diabetes and other chronic diseases can be accounted for by(1) maternal nutrition during pregnancy [31], (2) diet [35] and the environment [30]. Thesedentary lifestyles of the youth in the population are further entrenched by the modernelectronic games which have removed the young person from the playing field and see himspending longer periods on the couch in front of the television. This hooked-on-egame syndrome 213
    • has also resulted in the increased consumption of sweet snacks and other so-called junk food.The new face of those with particular chronic diseases is changing, and this reality is therefore acause for public health concern. This means that policy makers, health care practitioners,educators and the wider community need to recognize that chronic conditions such as diabetes,hypertension and arthritis have begun manifesting in young people as well as children. There isan urgent rationale for an intervention campaign that will sensitize educators, medicalpractitioners, parents, and children about the current reality of children and young adults beingdiagnosed with particular chronic illnesses. The intervention programme that should beformulated must include signs of ailments, place of reference, chronic disease management,nutrition, and medical practitioners understanding that testing for diabetes, hypertension andarthritis must be a rudimentary part of medical examinations, even of children, and further, evenif their parents are not experiencing those conditions. The emerging young face of diabetics, and hypertensive and arthritis patients requires anew thrust in the study of mortality and morbidity data for health planning. Although diabetes,hypertension and arthritis may not be among the 10 leading causes of mortality in Jamaica [36]or the developing society, the emergence of those conditions requires researchers, demographers,epidemiologists and policy makers to embark on the inclusion of data on those conditions inpublications in order that they can be examined. In a recently conducted study by Wilks et al.[37], they used teens of 15+ years to present information on those with particular diseases, butneglected to mention the new reality of children of younger ages with particular chronicillnesses. The new reality means that researchers, policy makers and the general society need tobe cognizant of these facts. This will be accommodated by researchers, and in particular thestatistical agency, publishing findings on the new reality in order to commence the discourse and 214
    • intervention campaign. With the absence of information on the matter, this can be construed as aminiscule problem. However, the new findings are reflecting the early onset of diabetes (< 15years) and the provision of data beginning at 15 years omits 0.8% of infected children or 2.4% ofdiabetics. The present paper unearths more information on the new faces of those with particularchronic conditions at younger ages. Fifty-four out of every 100 persons with particular chronicdiseases (i.e. diabetes, hypertension and arthritis) had hypertension, 32 out of every 100 haddiabetes and 15 out of every 100 had arthritis. Despite the majority of those with particularchronic illnesses having hypertension, the prevalence rate for those with diabetes increasedexponentially more than the other conditions. Many studies have established a relationshipbetween poverty and illness [1, 2, 16 and 22], and particularly poverty and chronic illness [15].Van et al.‘s work [15] revealed that chronic diseases were greater among those in the lowersocioeconomic strata than the other social classes, but this paper found that more people in thewealthy class had diabetes, while more hypertensive and arthritic respondents were in the lowersocioeconomic group. The current findings are providing some clarification for Van et al.‘sresearch. Although the prevalence rate of particular chronic illnesses was greater among thewealthy strata for 2002 and 2007, those in the lower socioeconomic group recorded the greatestaverage annual percentage change. On disaggregating the particular chronic diseases, the presentpaper showed that the prevalence of diabetes was greater among the upper than the lower class,and the opposite was noted for hypertension and arthritis. This finding does not only clarify Vanet al.‘s research, but provides pertinent information on the unhealthy lifestyle practices among 215
    • the wealthy, and reinforces the role of material deprivation on health, health conditions andmortality. Two scholars opined that money can buy health [38], implying that health is atransferable commodity, and that unhealthy lifestyle practices by the wealthy can be reversedwith money. Clearly Smith and Kington‘s claim [38] can be refuted as 42 out of every 100chronically ill respondents were in the upper class, and more than half of those with diabeteswere part of the wealthy income group. For any postulation to hold true about money purchasinghealth, one of the key axioms that needs to be looked at is the health conditions being loweramong the wealthy than those in the lower class. The wealthy will continue to live by theirdesires, and at the onset of chronic ailments, may be able to reverse this by medical expenditure.It is well established that income is positively correlated with health, as money affords aparticular diet, nutrition, medical facilities, safe drinking water, proper sanitation, leisure andgood physical milieu, but the reality is that whenever unhealthy lifestyle practices become thechoice of an individual, his/her money will not be able to eradicate the onset of diabetes,hypertension, heart disease, or other chronic diseases. Therefore, money enhances the scope ofbetter health, but it cannot buy good health as this is not transferable from one person to the next. The very reason that health is non-transferable is the rationale behind the mortality of thewealthy elderly, and morbidity among the upper class. Socioeconomic status was found to bethe strongest determinant of variations in health [39, 40], as wealth allows for particular choices,opportunities, access, resources and privileges that are not available to the poor. While thosematters provide a virtual door leading to better health, money or wealth does not reduce the riskof ill-health arising from poor choices. A study by Wilks et al. [37] found that most (71%) of 216
    • those in the upper socioeconomic strata currently use alcohol which is more than those in thelower class (59%) and the middle class (64%). Twice as many people in the upper class (14%)had heart attacks compared to those in the middle class (7%) and 6% in the lower class [37]. Theevidence is in that concretizes and refutes the proposition that ‗money can buy health‘, andalthough the association between income and health is well established, unhealthy lifestylechoices cannot be reversed with money. The carbonated soft drink industry is experiencing a boom in the USA and the Caribbean[41, 42]. Recently, research conducted by Ha et al. [41] found that carbonated soft drinks andmilk were the two most popular non-alcoholic beverages in the USA. They accounted for 39.1%of total beverage consumption. This explosion in carbonated soft drinks means that added sugaris infesting the dietary intake of young people and children more than in previous decades.Another study showed that among children aged 6 to 19 years there was a positive significantstatistical association with soft drink consumption and a negative one with milk intake [43]. Asedentary lifestyle along with the consumption of sugar, salted food and fast food are accountingfor the overweight and obesity in the world. According to Bostrom and Eliasson [44], over 50%of men and 33.3% of women between the ages of 16 and 74 years in Sweden are overweight andobese. Wilks et al. [37] found that 73% of Jamaicans aged 15 to 74 years practice a sedentarylifestyle, and obesity was the third most popular disease (5.6% of the population, 8.5% offemales and 2.7% of males) behind hypertension (20.2%) and diabetes mellitus (7.6%). The growing global tsunami of chronic diseases in developing countries, and in particularJamaica, requires urgent policy and public health intervention. The carbonated soft drinkindustry has infiltrated the consumption intake of young adults and children. Sugar in the form of 217
    • sweets (lollipops, candies, et cetera) is sold in every shop and supermarket, and at school gates inJamaica. Children and young adults are fed a diet of more sugar than vegetables, beans, legumes,nuts, protein, diary products, fruits and fibre. Embedded in the increase in diabetes in childrenand young adults in Jamaica are parents‘ and children‘s nutritional intake (or lack thereof), as thedietary habits of Jamaicans have changed to include more fast foods and less nutrient dense diets.This extends beyond Jamaica to Barbados [44] and the USA [41]. With the exponential increase in diabetes over the last 5 years in Jamaica, and theincrease in unhealthy lifestyle practices of the people, coupled with the sales explosion of thecarbonated soft drink industry and the increase in fast food outlets, Jamaica is experiencing adiabetes epidemic which cannot be resolved without government and policy interventions. As isclearfrom the literature, with the increase in carbonated soft drinks, reduction in milk intake andinflux of fast food entities in the Americas, the diabetes epidemic of Jamaica may become areality across the Americas. This is not just affecting countries in the Americas, as studies haveshown that Type 2 diabetes has become a global public health problem [46, 47]. The WHOcontextualized the global public health Type 2 Diabetes epidemic when it stated that during1999-2025 the prevalence of this ailment will be 40% in the developed nations and 170% in thedeveloping countries. Clearly this paper is showing that diabetes has now reached an epidemicstate in Jamaica, and may no longer be an epidemic but a pandemic disease. Type 2 diabetes isno longer an ―adult‖ or ―later life‖ disease, as was the case a generation ago, as it is now beingdiagnosed in children in Jamaica and other countries [48, 49]. This paper highlights the changing image of those with particular chronic diseases (i.e.diabetes, hypertension and arthritis) in Jamaica. With 2 out of every 100 diabetics being children 218
    • (< 15 years) and the new image of hypertensive and arthritic patients being 15 – 30 years, plusthe exponential increase in diabetes in the wealthy class, the present research highlightssignificant public health problems. In the last half a decade (2002-2007), the average annualincrease in diabetes mellitus has risen by 185% indicating the unhealthy lifestyle practices ofpregnant women, children and other young adults. The image of particular chronic illness in Jamaica continues to be lower class female andrural residents, but the average annual increase in diabetes mellitus was 200% for those in thewealthy class, compared to 117% of those in the lower socioeconomic class. Forty-seven out ofevery 100 chronically ill people in Jamaica utilize public health care facilities, which denotesthat the matter is a public one and not solely individual. The cost of public health care in the next5-10 years will increase phenomenally, as greater proportions of the population who rely on thepublic health care system will be afflicted with these chronic diseases. This has seriousimplications for the sustainable development of developing countries as well as their futureachievements regarding the United Nations Millennium developments goals. To act now will notonly save lives but will also save the various developing countries billions of dollars that can bespent on other development programmes. The demographic transition, in particular chronic conditions, now demands that datacollection on those illnesses be lowered to < 15 years. Apart from the lowering of the ages in thedata collection process, public health specialists need to address the massive changes in newdiabetic cases. This is an obvious problem, which requires public health intervention as well aslifestyle management of diabetes. This sensitization and lifestyle management campaign must 219
    • extend to include educators, parents, children, vendors (especially those at schools), and thegovernment. Governments need to regulate the sugar content of products in Jamaica (carbonated softdrinks, confectionary and fast food) as this is contributing to a public health problem which willcost the government and people in the medium to long-term. Diabetes can be likened to atsunami in Jamaica and one that demands government intervention. Currently, there is a lifestylecampaign dealing with sexual behaviour, condom usage, and cancer in Jamaica; this researchhighlights the urgent need for a diabetes campaign that extends beyond parents to includevendors, confectionaries, soft drink manufacturers and government, in order to sensitize thepublic about this new public health problem. The gravity of the situation is that such aprogramme cannot be delayed for some time in the future as the opportunity costs of delay are(1) higher public expenditure, (2) increasing cost of diabetic care and management, (3) lowerproduction cost, (4) increased unemployment benefits, (5) the imputed cost of ignorance, and (6)an increased mortality rate.Conclusion In summary, the theoretical position that underlines testing for diabetes among otherchronic diseases should be abandoned, as the findings show the need to begin rudimentary healthexaminations of all ages. The new thrust of governments, public health specialists andresearchers is to commence a mandate that addresses confectionary products‘ ingredients, andinstitution guidelines about the sugar and salt components of manufactured commodities. Thewider confectionary and food industry cannot be left unregulated as the chronic diseases tsunamiis upon us, and it will require a concerted effort from everyone to combat this public health 220
    • problem as the nation addresses the diabetes epidemic. Diabetes has risen to such epidemicproportions that it now requires a policy initiative aimed at reducing the level of increases in amanaged way.Conflict of interestThe authors have no conflict of interest to report.DisclaimerThe researchers would like to note that while this paper used secondary data from the JamaicaSurvey of Living Conditions, none of the errors in this paper should be ascribed to the PlanningInstitute of Jamaica or the Statistical Institute of Jamaica, but to the researchers.References65. World Health Organization. The World Health report 2002: reducing risks, promoting healthy life. Geneva: World Health Organization; 2002.66. Bourne PA, McGrowder DA. Health status of patients with self-reported chronic diseases in Jamaica. North Am J Med Sci. 2009; 1: 356-364.67. World Health Organization. Diet, physical activity and health. Geneva: World Health Organization; 2002.68. Figueroa JP. Health trends in Jamaica. Significant progress and a vision for the 21st century. West Indian Med. J 2001; 50 (Suppl 4):15-22.69. Guilliford MC. Epidemiological transition in Trinidad and Tobago, West Indies 1953-1992. Int J Epidemiol. 1996; 25:357-65.70. McGlashen ND. Causes of death in ten English-speaking Caribbean countries and territories. Bull Pan Am Health Organ. 1982; 16: 212-22.71. Holder Y, Lewis, MJ. Epidemiological overview of morbidity and mortality. In: Pan- American Health Organization, editor. Health conditions in the Caribbean. Washington: PAHO; 1997. p. 22-45.72. Morrison E. Diabetes and hypertension: twin trouble. Cajanus 2000; 33: 61-63.73. Callender J. Lifestyle management in the hypertensive diabetic. Cajanus 2000; 33: 67-70. 221
    • 74. Steingo B. Neurological consequences of diabetes and hypertension. Cajanus 2000; 33: 70- 7675. Eldemire S. A situational analysis of the Jamaican elderly, 1992. Kingston: Planning Institute of Jamaica; 1995.76. Morrison EY, Ragoobirsingh D, Thompson H, Fletcher C, Smith-Richardson S, McFarlane S, et al. Phasic insulin dependent diabetes mellitus: manifestations and cellular mechanisms. J Clin Endo & Metabl. 1995; 80: 1996-2001.77. Hennis A, Wu Suh-Yuh, Nemesure B, Li Xiaowei, Leske MC. Diabetes in a Caribbean population: epidemiological profile and implications. Int J of Epidemiol. 2002; 31: 234-239.78. Riste L, Khan F, Cruickshank K. High prevalence of Type 2 diabetes in all ethnic groups, including Europeans, in a British Inner City. Diabetes Care 2001; 24: 1377-1383.79. Van Agt HME, Stronks K, Mackenbach JP. Chronic illness and poverty in the Netherlands. Eur J of Public Health 2000; 10: 197-200.80. World Health Organization. Preventing chronic diseases a vital investment. Geneva: WHO; 2005.81. Barcelo A. Diabetes and hypertension in the Americas. West Indian Med J. 2000; 49: 262- 265.82. Yach D, Hawkes C, Gould CL, Hofman, KJ. The global burden of chronic diseases: overcoming impediments to prevention and control. JAMA 2004; 291: 2616-2622.83. Catford J. Chronic disease: preventing the world‘s next tidal wave – the challenge for Canada 2007? Health Promotion International 2007: 22:1-3.84. Huicho L, Trelles M, Gonzales F, Mendoza W, Miranda J. Mortality profile in a country facing epidemiological transition: an analysis of registered data. BMC Public Health 2009; 9: 47.85. Choi BC, Corber SJ, McQueen DV, Bonita R, Zevallos JC, Douglas KA. Enhancing regional capacity in chronic disease surveillance in the Americas. Rev Panam Salud Publica. 2005; 17: 130-141.86. Foster AD. Poverty and illness in low-income rural areas. the Am Economic Review 1994; 84 (2): pp. 216-220.87. Swaby P, Wilson E, Swaby S, Sue-Ho R, Pierre R. Chronic diseases management in Jamaican setting: HOPE worldwide Jamaica‘s experience. PNG Med J. 2001; 44: 171-175. 222
    • 88. Eliasson M, Bostrom G. Major public health problems – diabetes. Scandinavian J of Public Health 2006; 34(Suppl 67): 59-68.89. Planning Institute of Jamaica, Statistical Institute of Jamaica. Jamaica survey of living conditions, 1989-2007. Kingston: PIOJ, STATIN; 2008.90. World Bank. Jamaica Survey of living conditions, 1988-2000: basic information [Internet]. Washington: The World Bank; 2002. [cited 2009 Sept 2]. Available from: http://siteresources.worldbank.org/INTLSMS/Resources/3358986-1181743055198/3877319- 1190214215722/binfo2000.pdf).91. Statistical Institute Of Jamaica. Jamaica survey of living conditions, 2007. Kingston, Jamaica: Statistical Institute of Jamaica. [Unpublished manuscript].92. Hagley KE. Diabetes mellitus – the deluge. In: Morgan O, editor. Health issues in the Caribbean. Kingston: Ian Randle; 2005. p. 115-121.93. Murphy MJ, Metcalf BS, Voss LD, Jeffery AN, Kirby J, Mallam KM et al. Girls at five are intrinsically more insulin resistant than boys: the programming hypotheses revisited – the early bird study (Early Bird 6). Pediatrics 2004; 113: 82-86.94. Fogel RW. Changes in the disparities in chronic diseases during the course of the 20th century. Perspectives in Biology and Medicine 2005; 48: S150-S165.95. Martin-Gronert MS, Ozanne SE. Maternal nutrition during pregnancy and health of the offspring. Biochemical Society Transactions 2006; 34: 779-782.96. Marvicsin D. School-age children with diabetes: role of maternal self-efficacy, environment, and management behaviors. The Diabetes Educator 2008; 34: 477-483.97. Middelkoop B JC, Kesarlal-Sadhoeram SM, Ramsaransing GN, Struben HWA. Diabetes mellitus among South Asian inhabitants of The Hague: high prevalence and age-specific socioeconomic gradient. Int J of Epidemiol. 1999; 28: 1119-1123.98. Barreto SM, Figueirredo RC. Chronic diseases, self-perceived health status and health risk behaviors: gender differences. Rev Saude Publica. 2009; 43: 1-9.99. Merchant AT, Dehghan M, Behnke-Cook D, Anand SS. Diet, physical activity, and adiposity in children in poor and rich neighbourhoods: a cross-sectional comparison. Nutrition Journal 2007; 6: 1.100. Statistical Institute of Jamaica. Demographic statistics, 2007. Kingston: STATIN; 2008. 223
    • 101. Wilks R, Younger N, Tulloch-Reid M, McFarlane S, Francis D: Jamaica health and lifestyle survey 2007-8. Kingston: Tropical Medicine Research Institute, University of the West Indies, Mona; 2008.102. Smith JP, Kington R. Demographic and economic correlates of health in old age. Demography 1997; 34: 159-170.103. Adler NE, Boyce T, Chesney MA, Folkman S, Syme SL. Socioeconomic inequalities in health: no easy solution. JAMA 1993; 269: 3140-3145.104. Williams DR, Collins C. US socioeconomic and racial differences in health. Annu Rev Sociol. 1995; 21: 349-386.105. Ha E-J, Caine-Bish N, Holloman C, Lowry-Gordon K. Evaluation of effectiveness of class-based nutrition intervention on changes in soft drink and milk consumption among young adults. Nutrition J. 2009; 8: 50.106. Jacoby E. The obesity epidemic in the Americas: making healthy choices the easiest choices. PAHO Journal 2004; 15: 278-84.107. Forshee RA, Storey ML. Total beverage consumption and beverage choices among children and adolescents. Int J Food Sci Nutr. 2003; 54: 297-307.108. Bostrom G, Eliasson M. Major public health problems – overweight and obesity. Scandinavian J of Public Health 2006; 34 (Suppl 67): 69-77.109. Sharma S, Cao X, Harris R, Hennis AJM, Wu S, Leske MC. Assessing dietary patterns in Barbados highlights the need for nutritional intervention to reduce risk of chronic disease. J Hum Nutr Diet 2008; 21: 150-158.110. Zimmet P. Globalization, coca-colonization and the chronic disease epidemic: can the doomsday scenario be averted. J Intern Med. 2000; 247: 301-310.111. World Health Organization. Obesity: preventing and managing the global epidemic. Geneva: WHO; 1998.112. American Diabetes Association. Type 2 diabetes in children and adolescents. Diabetes Care 2000; 23: 381-389.113. Fagot-Campagna A, Pettitt DJ, Engelgau, MM, et al. Type 2 diabetes among North American children and adolescents: an epidemiological review and a public health perspective. J Pediatr. 2000; 136: 11-16. 224
    • Table 8.1: Operational definitions of particular variablesVariable Operational definition CodingSelf-evaluated This is taken from the question ―In general, would you say your health ishealth status (or excellent, good, moderate, poor or very poor?‖health status)Sex Being male or femaleAge group Age group is classified into 4 Children - ages < 15 years old categories. Young adults - 15 to 30 years old Other age adults – 31- 59 years old Young old – 60 – 74 years old Old old – 75 – 84 years old Oldest old – 85+ years oldSocial hierarchy Income quintiles were used to Low = poorest 20% to poor; middle = measure social class, and these middle quintile and upper = wealthy to range from quintile 1 (poorest wealthiest 20% 20%) to 5 (wealthiest 20%)Health care- Visits to pharmacies, medical 1 = visits to health care professionals,seeking practitioners, nurses in the last 0=otherwisebehaviour 4-weeks(health seekingbehaviour)Self-reported Have you had any illness or injury during the past four weeks? For example,illness have you had a cold, diarrhoea, asthma, diabetes, hypertension, arthritis or other?Chronic illness These can be broadly defined as conditions which prolonged, do not resolved spontaneously, and are infrequently curable. This is taken from the question ‗What are the illnesses that you have been diagnosed with – Cold, diarrhoea, asthma, diabetes mellitus, hypertension, arthritis, other chronic conditions (unspecified)? The chronic conditions were diabetes mellitus, hypertension and arthritis. 225
    • Table 8.2. Demographic characteristic of sample, 2002 and 2007 2002 2007Characteristic n % n %Chronic illness Diabetes mellitus 12 5.8 123 31.9 Hypertension 126 60.9 206 53.5 Arthritis 69 33.3 56 14.5Sex Male 58 28.0 113 29.4 Female 149 72.0 272 70.6Marital status Married 95 46.1 163 42.8 Never married 50 24.3 130 34.1 Divorced 1 0.5 14 3.7 Separated 3 1.5 10 2.6 Widowed 57 27.7 64 16.8Income quintile Poorest 20% 29 14.0 83 21.6 Poor 40 19.3 65 16.9 Middle 49 23.7 76 19.7 Wealthy 39 18.8 79 20.5 Wealthiest 20% 50 24.2 82 21.3Health care utilization Public hospital 51 28.8 72 25.5 Private hospital 15 8.5 23 8.2 Public health centre 43 24.3 61 21.6 Private health centre 68 38.4 126 44.7Health care utilization Sought medical care 163 79.1 258 67.4 Did not seek care 43 20.9 125 32.6Health insurance status Insured 15 7.2 126 32.8 Uninsured 192 92.8 258 67.2Age cohort Children 0 0.0 3 0.8 Young adults 2 1.0 10 2.6 Other age adults 49 23.7 137 35.6 Young-old 90 43.5 132 34.3 Old-old 58 28.0 82 21.3 Oldest-old 8 3.9 21 5.5Area of residence Urban 24 11.6 95 24.7 Semi-urban 43 20.8 78 20.3 Rural 140 67.6 212 55.1 226
    • Table 8.3. Self-reported diagnosed chronic illness by sex of respondents, 2002 and 2007 20021 20072Characteristic Sex of respondents Sex of respondents Male Female Male Female n (%) n (%) n (%) n (%)Chronic illness Diabetes mellitus 3 (5.2) 9 (6.0) 31 (24.7) 92 (33.8) Hypertension 39 (67.2) 87 (58.4) 58 (51.3) 148(54.4) Arthritis 16 (27.6) 53 (35.6) 24 (21.2) 32 (11.8) 58 149 113 2721 2 χ = 1.39, P = 0.4992 2 χ = 6.09, P = 0.048 227
    • Table 8.4: Particular demographic and health variable by diagnosed chronic illness, 2002 and2007 2002 2007 Chronic illness Chronic illnessCharacteristic Diabetes Hypertension Arthritis Diabetes Hypertension Arthritis mellitus mellitus n (%) n (%) n (%) n (%) n (%) n (%)Area of residence Urban 1 (8.3) 15 (11.9) 8 (11.6) 32 (26.0) 47 (22.8) 16 (28.6) Semi-urban 1 (8.3) 29 (23.0) 13 (18.8) 27 (22.0) 41 (19.9) 10(17.9) Rural 10 (83.3) 82 (65.1) 48 (69.6) 64 (52.0) 118 (57.3) 30 (53.6)Marital status Married 4 (33.3) 61 (48.4) 30 (44.1) 48 (40.0) 91 (44.4) 24 (42.9) Never married 4 (33.3) 30 (23.8) 16 (23.5) 39 (32.5) 69 (33.7) 22 (39.3) Divorced 0 (0.0) 0 (0.0) 1 (1.5) 10 (8.3) 3 (1.5) 1 (1.8) Separated 0 (0.0) 2 (1.6) 1 (1.5) 4 (3.3) 5 (2.4) 1 (1.8) Widowed 4 (33.4) 33 (26.2) 20 (29.4) 19 (15.8) 37 (18.0) 8 (14.3)Health utilization Public hospital 3 (30.0) 31 (29.5) 17 (23.0) 27 (32.9) 35 (25.5) 10 (32.3) Private hospital 1 (10.0) 9 (8.6) 5 (6.8) 11 (13.4) 7 (5.2) 5 (16.1) Public centre 2 (20.0) 21 (20.0) 20 (27.0) 23 (28.1) 34 (24.8) 4 (12.9) Private centre 4 (40.0) 44 (41.9) 32 (43.2) 21 (25.6) 61 (44.5) 12 (38.7)Health seekers Did not 1 (9.1) 26 (20.6) 16 (23.2) 34 (27.6)† 66 (32.0)† 27 (48.2)† Sought 10 (90.9) 100 (79.4) 53 (76.8) 89 (72.4)† 140 (68.0)† 29 (51.8)†Education Primary 8 (66.7) 73 (59.8) 43 (63.2) 121 (98.4) 205 (99.5) 56 (100.0) Secondary 4 (33.3) 47 (38.5) 24 (35.3) 2 (1.6) 0 (0.0) 0 (0.0) Tertiary 0 (0.0) 2 (1.6) 1 (1.5) 0 (0.0) 1 (0.5) 0 (0.0)Health coverage Uninsured 11 (91.7) 114 (90.5) 67 (97.1) 69 (56.1)† 148 (71.8)† 41 (74.5)† Insured 1 (8.3) 12 (9.5) 2 (2.9) 54 (43.9)† 58 (28.2)† 14 (25.5)†Social class Lower 6 (50.0) 35 (27.8) 28 (40.6) 41 (33.3)† 82 (39.8)† 25 (44.6)† Middle 0 (0.0) 35 (27.8) 14 (20.3) 16 (13.0)† 48 (23.3)† 12 (21.4)† Upper 6 (50.0) 56 (44.4) 27 (39.1) 66 (53.7)† 76 (36.9)† 19 (33.9)†Health status Very good NI NI NI 5 (4.1) 10 (4.9) 1 (1.8) Good NI NI NI 21 (17.1) 45 (21.8) 12 (21.4) Fair NI NI NI 67 (54.5) 91 (44.2) 25 (44.6) Poor NI NI NI 26 (21.1) 52 (25.2) 18 (32.1) Very poor NI NI NI 4 (3.3) 8 (3.9) 0 (0.0)NI – No information† Significant (P < 0.05) 228
    • Table 8.5. Age of respondent by particular chronic illness, 2002 and 2007 2002 2007 Chronic illness Chronic illnessCharacteristic Diabetes Hypertension Arthritis Diabetes Hypertension Arthritis mellitus mellitus n (%) n (%) n (%) n (%) n (%) n (%)Age cohort Children 0 (0.0) 0 (0.0) 0 (0.0) 3 (2.4) 0 (0.0) 0 (0.0) Young adult 0 (0.0) 2 (1.6) 0 (0.0) 3 (2.4) 6 (2.9) 1 (1.8) Other age adult 5 (41.7) 31 (24.6) 13 (18.8) 44 (35.8) 76 (36.9) 17 (30.4) Young-old 5 (41.7) 54 (42.9) 31 (44.9) 49 (39.8) 61 (29.6) 22 (39.3) Old-old 2 (16.7) 32 (25.4) 24 (34.8) 19 (15.4) 49 (23.8) 14 (25.0) Oldest-old 0 (0.0) 7 (5.6) 1 (1.4) 5 (4.1) 14 (6.8) 2 (3.6)Age Mean (SD) 62.1 (12.6) 67.2 (12.8) 68.4 (11.5) 60.9 (16.0) 62.5 (16.8) 64.3 (14.5)† Significant (P < 0.05) 229
    • Chapter 9Comparative Analysis of Health Status of men 60+ years and men73+ years in Jamaica: Are there differences acrossmunicipalities? Paul Andrew BourneIntroductionFrom 1880–1882, life expectancy at birth for females in Jamaica was 39.8 years compared to37.02 years for males (Table 9.1). One century later (2004), females were outliving males by 6years (Table 9.1). In Jamaica, population ageing is a feminized phenomenon. This is typically thesame around the world. From 1950-1955, world statistics showed that life expectancy at birth forfemales was 47.9 years compared to 45.2 years for males, indicating that former sex wasoutliving the latter by 2.7 years.1,2 The disparity in life expectancy at birth between the sexcohorts increased to 4.2 years between 2000-2005.1 According to the Demographic Statistics for 3Jamaica, 10.9% of females were 60+ years compared to 10.3% of males. For the world, in2000, 11.1% of the female population was older than 60 years compared to 8.9% of males.Concomitantly, world statistics indicated that a female who is 60 years old is likely to live for anadditional 20.4 years compared to 17.0 years for males.1 Life expectancy is one of the indicatorsof the health status of an individual or population, which implies that females are enjoying abetter health status than males.Insert Table 9.1 : Life Expectancy at Birth of Jamaicans by Sex: 1880−2004Courtenay4 noted, from research conducted by the Department of Health and Human Servicesand Centers for Disease Control, that from the 15 leading causes of death (except Alzheimer‘sdisease), the death rates were higher for men and boys in all age cohorts compared to women andgirls. Embedded within this theorizing, are the differences in fatal diseases explained by gender 230
    • constitution,5 which Courtenay5 contributed to behavioural practices of the sexes causing men todie approximately 6 years earlier than females.6Studies have shown, however, that females have a higher propensity to contract particularconditions, such as depression, osteoporosis and osteoarthritis.7,8 Herzog8 noted that ‘…itappears that older women are more likely to be impaired by their health problems, while oldermen (60 years) are more likely to die from them.‘ A study that was conducted by Schoen et al.9on a group of adolescents, revealed a different finding from what was reported by the WHO.They found that males were more likely than females to feel stressed, ‗overwhelmed‘, or‗depressed‘; they attributed this to the limited nature of men‘s social networks.Schoen et al9 found that men in general tend to be more stressed and less healthy than females,and further argued that men are more likely to use denial, distraction, alcoholism, and othersocial strategies to conceal their illness or disabilities.10-13 On the other hand, Herzog8 in Physicaland Mental Health in Older Women – referring to studies from a number of experts - wrote thatfemales had higher rates of depression than their male counterparts. Could suicide among theaged be the result of depression? This is likely to be underreported, because other illnesses areoften present and given as cause of death? He noted that data on suicide and depression yieldeddifferent results, and therefore, suicide is not necessarily an indicator of depression.Along with the longer life spans, particularly of females, unhealthy years are on the rise inkeeping with the longer life expectancy.14 The WHO14 developed DALE (Disability AdjustedLife Expectancy) in order to account for unhealthy years in relation to life expectancy. In anattempt to calculated ‗quality of lived years‘, the WHO introduced an approach that allows forthe evaluation this, called the DALE (Disability adjusted life expectancy). DALE does not onlyuse length of years to indicate health and well-being status of an individual or a nation, butincorporate the number of years lived without disabilities. The institution found that these 231
    • accounted for a 14 % reduction in life expectancy for poorer countries and 9 % for moredeveloped nations.Jamaica is a developing country, which means that, according to the DALE, both sexes areexperiencing 14 years of unhealthy life expectancy. In spite of this, yearly on average (since1990), there are 565 men who cross the threshold of the life expectancy in Jamaica (72 years atbirth). In addition, there are 1842 men who cross the 60+ years bar; 30, 8% are older than theirlife expectancy at birth. Males and females are living longer, but the former seek health care lessfrequently (Table 9.2). Table 9.2 shows that males reported less illness/injury than females,sought less medical care, and spent more time in health care facilities, all of which accounts forthe disparity in life expectancy between the sexes.Insert Table 9.2: Seeking Medical Care, Self-reported illness, and Gender composition ofthose who report illness and Seek Medical Care in Jamaica (in %age), 1988-2007Irrespective of the self-reported health conditions given by males, they experience higher rates ofmorbidity and mortality than women in Jamaica.15 The Jamaica Ministry of Health‘s publicationshowed that of the five leading causes of death– malignant neoplasms, cerebrovascular disease,heart disease, diabetes mellitus and homicide – men outnumbered women in 3 of them.Malignant neoplasms is 39% greater for men than women; cerebrovascular 14% higher forfemales than males; heart disease was 71.2 per 100 000 for men and 66.1 per 100 000 forwomen; and diabetes mellitus was 64% higher for females than males.15In 2007, approximately 11% of men were older than 60 years (N = 132 931, Table 9.3); 40.2% ofaged Jamaicans reported suffering from at least one dysfunction (N=118 603); 13.1% of menreported ill-health (N=173 135); 75.1% of aged people who reported ill-health had recurring ill-health (N=89 071); and 72 % elderly who had self-rated ill-health sought medical care – N=85 232
    • 394.16 It can be extrapolated from the data that approximately 5% of the 13.1% of self-assessedhealth conditions are accounted for by aged men. Furthermore, it can be extrapolated from thesestatistics that 3.8% of elderly aged men expressed having recurring ill-health. Has the rationalefor not studying older mens ill health conditions been due to the fact that only 5% were subjectto such conditions?Insert 20.3Many studies have been done on aged Caribbean nationals, in particular Jamaicans.16-33 Anextensive review of the literature showed that none have examined men‘s health, or those factorswhich influence good health of older men (60+ years) in Jamaica. In spite of pressure by theWHO and some scholars in a drive to examine the social determinants of health33-38 theCaribbean, in particular Jamaica, no work has been done on this subject area. This paper isinnovative, as it seeks to investigate the social, psychological and environmental determinants ofthe health status of older men. Studies on older Caribbean nationals are not the same as aninvestigation of the health status of older men (60 years) in Jamaica. The aims of this paper wereto 1) ascertain factors that influence good health status of aged men (ages 60+ years) in Jamaica,2) determinants of good health status of older men, 3) to determine the potency of each variable,and 4) distinguish between determinants of the men.Theoretical frameworkMany studies have employed multivariate analyses in the examination of health status.16, 17, 26, 39-44 The use of econometric analysis in the study of health was developed by Michael Grossman.44This approach simultaneously captures biomedical and non-biomedical variables, unlike thebivariate analysis that is only able to investigate two variables. Based on the WHO‘s definition,health45 is inclusive of biomedical, socio-economic and psychological factors. Health, therefore,is determined by many factors, and the use of an econometric model makes it possible to identifythese. A multivariate model has a fundamental advantage over bivariate relations, as health is amultidimensional phenomenon; this model is able to capture more variables and withoutexcluding some variables which cannot be accommodated in a bivariate association. 233
    • The theoretical framework that underlines the current work was developed by Bourne, 17 which isa modification of Michael Grossman44 and Smith and Kingston‘s works.43 Grossman was thefirst to establish an econometric model which evaluated the health status of people. The modelencapsulates some variables that determine health status of people in the world (Eqn. 1).Ht = ƒ (Ht-1, Go, Bt, MCt, ED) (1) in which the Ht – current health in time period t, stock of health (Ht-1) in previous period, Bt– smoking and excessive drinking, and good personal health behaviours (including exercise –Go), MCt,- use of medical care, education of each family member (ED), and all sources ofhousehold income (including current income). Grossman‘s model was further expanded upon bySmith and Kington to include socioeconomic variables (Eqn. 2).Ht = H* (Ht-1, Pmc, Po, ED, Et, Rt, At, Go) (2) Eqn. (2) expresses current health status Ht as a function of stock of health (Ht-1), price ofmedical care Pmc, the price of other inputs Po, education of each family member (ED), all sourcesof household income (Et), family background or genetic endowments (Go), retirement relatedincome (Rt ), asset income (At,). Given that particular conditions influence the aged that are some different from other agecohort, Bourne used econometric analysis to build a model that captures variables that influencesubjective well-being of elderly Jamaicans. Bourne‘s model is as follows (Eqn. 3):Wi =ƒ (lnPmc , ED, Ai , En, G, MS, AR, P, N, lnO, H, T, V) (3) 234
    • In Eqn. 1 Wi is well-being of the Jamaican elderly, is a function of cost of medical(health) care (Pmc), the educational level of the individual, age (Ai , where i is the individual),the environment (En), gender of the respondents (G), marital status (MS), area of residents (AR),positive affective conditions (P), negative affective conditions (N), household crowding (.average occupancy per room) (O), home tenure (H), property ownership, (T), crime andvictimization, (V). This paper will examine aged men‘s health status, and so the Bourne model isideal to use in examining this research.MethodsThe current research used secondary data collected jointly by the Planning Institute of Jamaica(PIOJ) and the Statistical Institute of Jamaica (STATIN). For this paper, the sub-sample was1,423 aged men (person aged 60+ years). The mean age of the sub-sample was 71.14 years(SD=7.97 years). Another sub-sample was extracted from the survey, which constituted 633 men73+ years (men living beyond the life expectancy, for Jamaica it is 72+ years). The two sub-samples were extracted from a larger, nationally prevalence study, conducted between June andOctober 2002, of some 25018 respondents. Stratified random sampling techniques wereemployed to design the survey (. the Jamaica Survey of Living Conditions (JSLC)), and detailedself-administered questionnaires were used to collect the data from the respondents. Thequestionnaire was modeled from the World Bank‘s Living Standards Measurement Study(LSMS) household survey. There were some modifications made to the LSMS as the JSLC ismore focused on policy impacts. The questionnaire covered questions on socio-demographic,economic and wealth variables, crime and victimization, social welfare, health status, healthservices, nutrition, housing, and physical environment. Interviewers who collected the data weretrained to address the questions and concerns of interviewees. Data were stored and retrieved inthe SPSS program (SPSS Inc; Chicago, IL, USA); and for the present research descriptivestatistics were used to provide certain socio-demographic characteristics of the sub-sampledpopulation. 235
    • Based on the principles of parsimony (all variables that should be included were included andnot those which should be excluded were not included), the final model would only constitutethose variables that were statistically significant (. p < 0.05). This was attained by the using thehealth literature and the variables that were included within the framework of the current dataset.Demographic characteristics were provided for the sample and the sub-sample of men 60+ yearsand 73+ years. Logistic regression was used to establish 1) a model for good health status ofaged men in Jamaica; 2) Wald statistics to examine the contribution of each significant variablein the model; and 3) the odds ratios interpreted to address the difference within each variable.Multivariate analysis (logistic regression) was used because the researcher wanted to test anumber of variables simultaneously, and the fact that the dependent variable was binary; themost fitting statistical technique was logistic regression. The model that was tested in this paperis (Eqn. 4):Wi =ƒ (Pmc, ED, Ai, En, MS, AR, P, N, O, H, V) (4)In Eqn. 4 Wi is well-being of the aged men in Jamaica which is a function of cost of medical(health) care (Pmc), the educational level of the individual, age (Ai), where i is the individual),the environment (En), marital status (MS), area of residents (AR), positive affective conditions(P), negative affective conditions (N), household crowding (. average occupancy per room) (O),home tenure (H), crime and victimization, (V). Property ownership (T) was omitted, owing tothe number of missing cases (in excess of 15%). The study examined aged men‘s health status,and Bourne‘s model was considered ideal for use in this research. 236
    • The results were presented using unstandardized coefficients, Wald statistics, Odds ratio (OR)and confidence interval (95% CI). The predictive power of the model was tested using Hosmerand Lemeshow test46 to examine goodness of fit of the model. The correlation matrix wasexamined in order to ascertain if autocorrelation (or multicollinearity) existed between variables.Based on Cohen and Holliday,47 the correlation can be weak (0 - 0.39), moderate (0.4-0.69), orstrong ( 0.7-1.0). This matrix was used to exclude (or allow) a variable in the model. Waldstatistics were used to determine the magnitude (or contribution) of each statistically significantvariable in comparison with the others, and the OR for the interpretation of each significantvariable.MeasureHealth: The self-rated health status of an individualGood health: This variable is derived from a number of questions which enquired aboutparticular health conditions. It is a binary variable where 1=not reporting an ill-health and 0 =reported at least one health condition.39Age: This is the total number of years lived since birth, measured from one birthday to the next.Psychological condition: This is the psychological state of an individual, sub-divided intopositive and negative affective psychological conditions.Positive affective psychological condition: This denotes hopefulness, optimism and lifesatisfaction. For this paper the variable was measured using a number of responses with regardsto being hopeful and optimistic about the future and life generally.Negative affective psychological condition: It means the degree to which an individualexperiences feelings of hopelessness, pessimism and fear. In this paper these were measured 237
    • from a number of responses from a person experiencing loss of a breadwinner and/or familymember, loss of property, loss of income, failure to meet household and other obligations.Household crowding: This indicates the average occupancy of persons per room - the total number of individuals in a household divided by the number of rooms occupied by the household (excluding the kitchen and bathroom).Married: A binary variable - where 1 = those who indicated being married, and 0 = otherwisePoverty level : A binary variable - where 1 = those people who are in two poor quintiles (. poorest and poor), and 0 = otherwise (. those in quintiles 3 to the wealthiest, or quintile 5)Crime: Crime index = Σ kiTj,This equation represents the frequency with which an individual witnessed or experience acrime, where i denotes 0, 1 and 2: 0 indicates not witnessing or experiencing a crime; 1 meanswitnessing 1 to 2 crimes; and 2 indicates seeing 3 or more crimes.Ti denotes the degree of the different typologies of crime witnessed or experienced by anindividual: j = 1 valuables stolen; 2 = attacked with or without a weapon; 3 = threatened with agun; j = 4 sexually assaulted or raped. The summation of the frequency of crime by the degreeof the incident ranges from 0 to a maximum of 51.Aged: An individual who has celebrated 60 years or more.Area of residence: The general geographic locale in which an individual resides.1 = Kingston Metropolitan Areas are all the areas which are 100% urban, 0 = otherwise1 = Peri-urban areas are places which are not 100% urban; 0 = otherwiseThe Reference group is from a rural area 238
    • ResultsDemographic Characteristic of sampled population:Men 60+ yearsOf the population of 1 432 aged respondents, the mean age was 71.14 years ± 7.97 years (Table9.4). A substantial majority of the population was married (50%); owned their own homes(85%); resided in rural areas (68%); and reported good health (63%). The majority men had atmost primary level education (62%); however, 3 % had attained tertiary level education, and98.6% reported that they were the head of their household. Per capita income quintile was evenlydistributed, with 23.8% being in the wealthiest quintile. Furthermore, crime seems to have aminimal affects on the respondents.Results:Demographic Characteristic of sampled population:Men 73+Of the population of 633 men aged 73+ years, the mean age was 78.5 years ± 5.64 years (modeyear= 77yrs, median = 77 yrs). A substantial majority of the population was married (48.8%, N= 302), 23.6% never married (N=146) and 22.6% widowed (N = 140). Most owned their ownhomes (88%, N = 557). In terms of area of residence, 70.9% (N=449) resided in rural areas;19.3% (N=122) in peri-urban areas; and 9.8% (N=62) in urban areas. A little more than half(53.5%; N=333) reported good health. The majority of aged men had at most primary leveleducation (67.4%, N = 402); only, 2.7% had attained tertiary level education. Almost all the men(98.4%) indicated that they were the heads of their households.Per capita income quintile was evenly distributed, with the minority being in the wealthiestquintile (23.4%,N = 148), and the poorest quintile (21.6%, N = 137). In addition, crime seems to 239
    • have a minimal affects on men 73+ years. The average consumption per person in the men 73+yearscohort was JA.$77 877.07 (SD=$72 014) – USD1.00 = Ja. 50.97.Analysis of Logistic Regression on Good Health of Men 60+ yearsOf the 16 predisposed variables that were used in the model (Table 9.5), 5 were statisticallysignificant (p < 0.5). The 5 factors that determine good health of older men in Jamaica – age,secondary education, health insurance ownership, area of residence and positive affectivepsychological conditions – accounted for 27.4% of the model (chi square test (19) = 289.45, p-value = 0.001, -2 log Likelihood = 1,419.72). Of the 5 predictors of good health, 3 negativelyinfluence health. These are age, secondary level education and health insurance. The model hadstatistically significant predictor power (model χ2 = 289.45, p < 0.001, Homer and Lemeshowgoodness of fit χ2 = 12.84, p = 0.117) and correctly classified 73% of the sample (correctlyclassified 93% of those who had good health and 40% of those who did not report poor health).Of those variables that negatively determine good health, ownership of health insurance carriesthe most weight in determining good health (Wald statistic=122.88, 95% CI: 0.03 to 0.09, p =0.001), followed by age (Wald statistic=39.2, 95% CI: 0.93 to 0.97, p = 0.001). Embedded inthese findings is the revelation that an individual who possessed health insurance is 0.06 times(odd ratio) less likely to experience good health compared to someone who does not have thesame. Similarly, as older men age, he is 0.95 (odds ratio) less likely to have good healthcompared to a younger aged man. In addition, those who had obtained a secondary education, incomparison to primary level education, is 0.64 times (odds ratio) less likely to report good health(95% CI: 0.49 to 0.84). Furthermore, there is no statistical difference between men who had atmost primary level education compared to with tertiary level education, suggesting that thosewith primary level education have better health. 240
    • With respect to factors which have a positive affect on health, also positively affected the men‘spsychological conditions (Wald statistic = 11.67, 95% CI: 1.04 to 1.16) and accounted for morevariability than area of residence. On examining positive affective psychological conditions, themore an aged man experiences a positively affective condition; he is 1.1 times more likely toreport good health. If an aged man experiences a positively affective condition, he is 1.1 timesmore likely to report good health. Findings revealed that men who reside in rural areas sufferfrom diminished good health. This means that those in peri-urban areas, 1.5 times (odds ratio,95% CI: 1.06 to 2.13) more likely to report good health compared to an aged man who dwelledin rural Jamaica. The aged men who resided in the Kingston Metropolitan Area were 1.6 times(odds ratio, 95% CI: 1.02 to 2.52) more likely to report good health compared to those in ruralJamaica.Analysis of Logistic Regression on Good Health of men 73+ yearsWhat factors account for good health of men in the men 73+ years? Table 9.5 shows that, of the15 predisposed factors that tested for the initial model (good health of men 73+ years), 5 explainthe variability in good health. These determine 27.7% of the variability in good health – (chiSquare (18) = 132.21, p-value = 0.001, Nagelkerke R square = 0.277, -2 log Likelihood =653.92). They are: age, secondary level education, ownership of health insurance, area ofresidence and positive affective psychological conditions. Three of the explanatory variablesnegatively contribute to good health (age, secondary level education and health), and twopositively affect good health (area of residence and positive affective psychological conditions).The model had statistically significant predictor power (model χ2 = 132.21, p < 0.001, Hosmerand Lemeshow goodness of fit χ2 = 14.474, p = 0.070), and correctly classified 71% of thesample (correctly classified 84.9% of those who had good health and 55.1% of those did notreport poor health). 241
    • Ownership of health insurance carries the most weight in determining good health (Waldstatistic=53.6, 95%CI: 0.029-0.129) followed by secondary level education with reference toprimary level education (Wald statistic = 8.38, 95%CI: 0.357-0.820), living in peri-urban areas(Wald Statistic =7.609, 95%CI: 1.23-3.396) and the least, dwelling in Kingston MetropolitanArea (Wald statistic=4.396, 95%CI: 1.053-4.577). Embedded in these findings are the realization1) that good health of men 73+ years are eroded with years of life; 2) those with primary leveleducation enjoy a better self-reported health than those with secondary and tertiary leveleducation; 3) owning health insurance does not positively contribute to good health, it is only anindicator of those who are likely to have poorer health; 4) men 73+ years who dwell in Peri-urban areas are more likely to enjoy greater self-reported good health, followed by those whoresided in Kingston Metropolitan Area, and lastly by those in Rural areas; and finally 5) men73+ years that are experiencing more positive affective psychological conditions are 1.1 timesmore likely to report good health.DiscussionAll of the United Nations‘ and World Health Organizations‘ Reports, coupled with those of theJamaican Ministry of Health, and the Jamaica Survey of Living Conditions that have beenpublished on population, ageing, health or gender issues, have shown that women outlive men.The disparity in the life expectancy rate between the sexes is 6 years in Jamaica, and 8 yearsusing data on the world. Living longer means more years and defying the odds of mortality. Thisoccurrence is accounted for by healthy lifestyle practices, implying that unhealthy lifestylepractices lead to higher mortality and morbidity in men than women. In spite of these realities,there are men living beyond the life expectancy in their respective geopolitical area of residence.In Jamaica, the life expectancy for men is 72.3 years. The term the researcher has coined thatrefers to men who are alive beyond the life expectancy of their nation‘ is men 73+ years. 242
    • Over an 18-year period (ending 2007), there were 40,948 men 73+ years in Jamaica, and theaverage yearly increase of men 73+ years the period was 565. This means that there are menliving beyond the expected life expectancy, morality, and disease-causing morality rate. Inaddition to the aforementioned, an average of 565 men crosses over in the men 73+ years cohortyears annually. In spite of the high mortality and morbidity of men, this paper providesinformation on what constitutes good health for older men.Literature has shown that the health status of people, as they become older, lessens.48, 49-52 Thispaper concurs with this finding. This paper found that 63% of men 60+ years reported goodhealth compared to 53.5% of men 73+ years, indicating that health decreases with ageing. Thispoint was further reinforced by the finding in which age was a factor of good health in each ofthe models. Age as a factor was ranked as the second most influential in determining ‗good‘health (or lack thereof) for men 60+ years compared to being one of the four influential for men73+ years. However, age is not the only factor that affects good health of elderly men.Other studies have shown that education influences good health and that tertiary level educationis positively associated with better health. This paper agrees that education influences goodhealth, and that there is no difference between the health status of elderly men with primary andtertiary level education. Another interesting finding to emerge from this paper is the fact thatolder men with primary level education in Jamaica have better self-reported health than thosewith secondary education. This contravenes other research that have shown that better qualityeducation determines higher quality of health, but this is not the case for men who are livingbeyond 59 years.Poverty, overcrowding, consumption and marital status in other studies17, 19, 24, 26, 43 have shownto influence good health; however, and in this paper this is not the case for elderly men. The factthat living beyond a particular year of birth (60 years) means that the individual has surpassedthe need for certain material possessions and appetite for some foods; therefore, having financial 243
    • resources or not, does not influence current health status – this goes for consumption, as well asother aforementioned variables that are not statistically significant and so not having financialresources (or having) does not influence current health status and this goes for consumption andthe other aforementioned issues that are not statistical significant (p > 0.05). Studies done on theelderly have indicated that overcrowding, consumption and marital status determine well-being,but in this paper it was found not to be the case. The current work has refined the factors whicheffect elderly men and established that they are somewhat different from those that influence thehealth and well-being of elderly Jamaicans.Although poverty does not directly relate to good health of aged Jamaicans, good health has beenfound to differ based on area of residence. In 1997 the prevalence of poverty in the country was9.9%, and 10 years later (2007) it had increased by 50.5% (to 19.9%).53 Despite this exponentialdecline in prevalence of poverty, 71.3% of the stock of poverty is accounted for by rural areas.Based on the data for 2007, 46.6% of elderly Jamaicans dwelled in rural areas, 20.9% in peri-urban areas, and 32.5% in Kingston Metropolitan Area.53 Within the context of this paper, it wasfound that the state of health of elderly men in rural areas was worse than other areas ofresidence, and that poverty indirectly influences health. Furthermore, the best health is likely tobe experienced by other town dwellers, but not those who dwell in the Kingston MetropolitanArea (100% cities). The stock of poverty for elderly residents of urban areas was 2.2 times(19.9%) greater than that of the distribution of poverty in peri-urban areas (8.9%), indicating thatpoverty indirectly determines good health of aged residents.It has well established that positive affective psychological conditions are correlated tohealth,17,54-60 and this was concurred by this paper. Lyubomirsky54 shows that happier peopleview life in a positive manner. This attitudinal state explains how decisions are influenced, andmoods experienced. With a positive attitude, a better quality of life is experienced, as theindividual thinks, acts, builds, and carries out his/her life‘s task with a more self-assurance.55The contrary is also true - a pessimistic individual is more likely to have a lower self-esteem,less self-fulfillment, and less self-actualized than someone who is optimistic. DeNeve and 244
    • Cooper56 have found that happier people are more optimistic and positive in nature. Diener andSeligman57 point out that moods are not stationary, thus happy people can have negative moods,but they do not dwell on the negatives indefinitely. Harris and Lightsey58 have established thatnegative affective conditions such as guilt, fear, anger, and disgust, inversely affect subjective,well-being - just as positive factors directly influence well-being.59 However, this was not thecase for aged men in Jamaica. The literature has shown that the elderly seeks more health carethan any other age cohort, so their psychological state is directly influenced by their physicalcondition. If an elderly individual does not perceive that he/she has control over an illness ordisability, it may result in self-destructive behavior60 which will negatively influence well-being.McCarthy offers a further justification for the correlation between psychological state andsubjective well-being, when he writes that diabetic patients are six to seven times more likely tosuffer from psychiatric illnesses, anxiety and depression than non diabetic patients. In thecurrent work, it was found that aged men who are experiencing positive affective psychologicalconditions are 1.1 times more likely to report good health, and that this variable minimallycontributes to good health for Jamaican elderly men.Ownership of health insurance coverage does not only indicate health seeking behaviour, it alsomeans that men who have surpassed 60 years purchased more health insurance if they believedthat they were more likely to become ill. Hence, health insurance is not a preventative measure;instead it is a product that is more demanded by this cohort of men who are more likely to reportill-health. This finding denotes that men 60+ years who own this product, are using it as a costreduction mechanism because they are aware that as a result of their ill-health, the frequencywith which they will need to visit health facilities will increase.ConclusionIn sum, the good health of men 60+ years deteriorates as they become older. This paper hasshown that there is no difference between the factors that determine good health of aged men andmen 73+ years. Good health is strongly influenced by ownership of health insurance coverage, 245
    • but not by positive affective psychological conditions. Men 60+ years and men 73+ years whoresided in rural Jamaica reported the least good health; and that the greatest self-reported goodhealth was experienced by those in peri-urban areas. This paper is the first of its kind, no existingliterature with which do a comparative study in. This limitation however, does not hamper itfrom providing insight into the health status of men 60+ years and the factors which predict goodhealth for this group, as well as men 73+ years.References 1. United Nations. World Population Ageing 1950−2050. New York: UN; 2002. 2. United Nations. World Population Prospect: The 2004 Revision. New York: United Nations; 2005. 3. Statistical Institute of Jamaica. Demographic Statistics, 2006. Kingston: Statistical Institute of Jamaica; 2007. 4. Courtenay WH. Key determinants of the health and wellbeing of men and boys. International Journal of Men‘s Health. 2003;2:1−30. 5. Seltzer MM, Hendricks JA. On your marks: Research issues on older women. In: Hendricks JA, editor. Health and economic status of older women. New York: Baywood Publishing; 1989. 6. U.S. Preventive Services Task Force. Guide to clinical preventive services 2nd ed. Baltimore: Williams & Wilkins; 1996. In: Courtenay WH, editor. Key determinants of the health and wellbeing of men and boys. Int J of Men‘s Health. 2003;2:1−30. 7. World health Organization. Healthy ageing: Practical pointers on keeping well. Regional Office for the Western Pacific, Manila, Philippines: WHO; 2005. 8. Herzog AR. Physical and mental health in older women: Selected research issues and data sources. In: Hendricks JA, editor. Health and economic status of older women: Research Issues and Data Sources. New York: Baywood Publishing, 1989; p. 112-130. 9. Schoen C, Davis K, DesRoches C, Shekhdar A. The health of adolescent boys: Commonwealth Fund survey findings. New York: Commonwealth Fund; 1998 10. Friedman HS, editor. Hostility, coping, and health. Washington, DC: American 246
    • Psychological Association; 1991.11. Kopp MS, Skrabski A, Szedmak S. Why do women suffer more and live longer? Psychosomatic Medicine. 1998;60:92−135.12. Weidner G, Collins RL. Gender, coping, and health. In: Krohne HW, editor. Attention and avoidance. Seattle: Hogrefe and Huber, 1993; pp. 241-265.13. Sutkin L, Good G. 1987. Therapy with men in health-care settings. In Scher M, Stevens M, Good G, Eichenfield GA, editors. Handbook of counseling and psychotherapy with men. Los Angeles: Sage Publications; 1987.14. WHO. WHO Issues New Healthy Life Expectancy Rankings: Japan Number One in New ‗Healthy Life‘ System. Washington D.C. & Geneva: WHO; 2000.15. The Health Promotion and Protection Division, Ministry of Health Jamaica (MOH). Epidemiology Profile of Selected Health Conditions and Services in Jamaica, 1990−2002. Kingston: MOH; 2005.16. 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;2:18−27.17. Bourne PA. Determinants of well-being among the Jamaican elderly. Master of Science thesis. Jamaica, Department of Sociology, University of the West Indies, Mona, 2007. ; 2007.18. Grell GAC, editor. The elderly in the Caribbean. Proceedings of a Continuing Medical Education Symposium; 1984 June 3-5; Kingston, Jamaica. University Printery;1987.19. Eldemire D. A situational analysis of the Jamaican elderly, 1992. Kingston: Planning Institute of Jamaica; 1995.20. Eldemire D. The elderly – A Jamaican perspective. In: Grell GAC, editor. The elderly in the Caribbean. Proceedings of a Continuing Medical Education Symposium; 1984 June 3-5; Kingston, Jamaica. University Printery;1987, p. 45-60.21. Lawson SC. Culture and Aging: The case of Jamaican Elderly persons. Paper presented at: the Conference on Caribbean Culture; 1996 March 4-6; Mona, Jamaica. Mona: The 247
    • University of the West Indies, Mona Campus; 1996. p. 1-37.22. Brathwaite FS. The Elderly in Barbados. Bridgetown Barbados: Caribbean Research Publications, Inc,; 1986.23. Brathwaite FS. Housing services for the Elderly in Barbados. Bulletin of Eastern Caribbean Affairs. 1995; 20:18−25.24. Bourne P. Using the biopsychosocial model to evaluate the wellbeing of the Jamaican elderly. West Indian Med J. 2007;56:(suppl 3):39−40.25. Eldemire D. The elderly and the family: The Jamaican experience. Bulletin of Eastern Caribbean Affairs. 1994;19:31−46.26. Hambleton IR, Clarke K, Broome Hl, Fraser HS, Brathwaite F, Hennis AJ.Historical and current predictors of self-reported health status among elderlypersons in Barbados. Rev Panam Salud Publica. 2005;17:342−353.27. Barrett V. Analysis of the Jamaica government‘s policy (1981–1986) on institutional and community programmes for the elderly. Kingston: B.Sc. Public Administration, University of the West Indies, Mona; 1987.28. Crandon IW, Carpenter R, Branday JM, Harding HE, Simeon DT, Pencle F. Surgery in the Elderly: A prospective study in a developing country. Workshop Proceedings, Ageing Well: A Life Course Perspective, the University of the West Indies, Mona and WHO/PAHO Collaborating Centre on Ageing and Health; 2003.29. McDonald A. Surgery in the Elderly: What, Where and How? Workshop Proceedings, Ageing Well: A Life Course Perspective, the University of the West Indies, Mona and WHO/PAHO Collaborating Centre on Ageing and Health; 2003.30. Wright-Pascoe R. Reducing clinical complications for Diabetes and Hypertension in the Older Population. Workshop Proceedings, Ageing Well: A Life Course Perspective, the University of the West Indies, Mona and WHO/PAHO Collaborating Centre on Ageing and Health; 2003.31. Aquart A. An In-Hospital Morbidity of Older Persons. Workshop Proceedings, Ageing Well: A Life Course Perspective, the University of the West Indies, Mona and WHO/PAHO Collaborating Centre on Ageing and Health; 2003.32. Eldemire-Shearer D. Organization of Long-term Care Services for Seniors. Workshop 248
    • Proceedings, Ageing Well: A Life Course Perspective, the University of the West Indies, Mona and WHO/PAHO Collaborating Centre on Ageing and Health; 2003.33. WHO. The Social Determinants of Health. [home page on the Internet] 2008 [cited 2009 April 28]. Available from: http://www.who.int/social_determinants/en/.34. Kelly MP, Morgan A, Bonnefoy J, Butt J, Bergman V. The social determinants of health: Developing an evidence base for political action. Final Report to World Health Organization Commission on the Social Determinants of Health from Measurement and Evidence Knowledge Network. [home page on the Internet]. 2007 [cited 2009 April 29]. Available from: http://www.who.int/social_determinants/resources/mekn_final_report_102007.pdf.35. Wilkinson R, Marmot M, editors. Social determinants of health: the solid facts. 2nd Edition, WHO: Copenhagen. [home page on the Internet]. 2003 [cited 2009 April 29]. Available from: http://www.euro.who.int/document/e81384.pdf.36. Graham H. Social Determinants and their Unequal Distribution Clarifying Policy Understanding. The MelBank Quarterly. 2004;82:101−124.37. Marmot M, Wilkinson RG, editors. Social Determinants of Health. 2nd ed. New York: Oxford University Press; 2003.38. Solar O, Irwin, A. Towards a Conceptual Framework for Analysis and Action on the Social Determinants of Health. Geneva: Commission on Social Determinants of Health; 2005.39. Bourne PA, McGrowder DA. Rural health in Jamaica: examining and refining the predictive factors of good health status of rural residents. Rural and Remote Health. 2009;9 :1116. [Pub Med].40. Blanchflower DG, Oswald AJ. Well-Being Over Time In Britain And The USA. J of Public Economics. 2004;88:1359−1386.41. Hutchinson G, Simeon DT, Bain BC, Wyatt GE, Tucker MB, LeFranc E. Social and Health determinants of well-being and life satisfaction in Jamaica. Int J of Soci Psychiatry. 2004;50:43−53.42. Di Tella R, MacCulloch R, Oswald AJ. The Macroeconomics of Happiness, mimeo. Harvard: Harvard Business School; 1998. 249
    • 43. Smith JP, Kington R. Demographic and Economic Correlates of Health in Old Age. Demography. 1997;34:159−170.44. Grossman M. The demand for health- a theoretical and empirical investigation. New York: National Bureau of Economic Research; 1972.45. World Health Organization. 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: World Health Organization; 1948.46. Homer D, Lemeshow S. Applied Logistic Regression. 2nd ed. John Wiley & Sons Inc., New York; 2000.47. Cohen L, Holliday M. Statistics for Social Sciences. London: Harper and Row; 1982.48. Manton KG, Land K. Active life expectancy estimates for the U.S. elderly population: A multidimensional continuous-mixture model of functional change applied to completed cohorts, 1982−1996. Demography. 2000;37:253−265.49. Neugarten BL. Time, age and the life cycle. Am J. Psychiatry. 1979;136:887−894.50. Erber J. Aging and older adulthood. New York: Waldsworth, ThomsonLearning; 2005.51. Quadagna J. Aging and the Life Course. An Introduction to Social Gerontology.2nd ed. New York: McGraw-Hill; 2002.52. Flieger K. Why do we age? In: Cox H. editor. Aging, 7th ed.Guilford: DushkinPublishing, 1991; p. 213-249.53. The Planning Institute of Jamaica (PIOJ), Statistical Institute of Jamaica (STATIN). Jamaica Survey of Living Conditions, 1989−2007. Kingston: PIOJ, STATIN; 1988−2008.54. Lyubomirsky S. Why are some people happier than others? The role of cognitiveand motivational process in well-being. Am Psychologist. 2001;56:239−249.55. Leung BW, Moneta GB, McBride-Chang C. Think positively and feel positively:Optimism and life satisfaction in late life. Int J of Aging and human 250
    • development. 2005; 61:335−365.56. DeNeve KM, Cooper H. The happy personality: A meta-analysis of 137 personality traits and subjective well-being. Psychological Bulletin. 1998;124, 197−229.57. Diener E, Seligman MEP. Very happy people. Psychological Science. 2002;13:81–84.58. Harris PR, Lightsey OR, Jr. Constructive thinking as a mediator of therelationship between extraversion, neuroticism, and subjective well-being.European J of Personality. 2005; 19:409−426.59. Fromson PM. Self-discrepancies and negative affect: The moderating roles ofprivate and public self-consciousness. Soci Behavior and Personality.2006;34:333−350.60. McCarthy FM. Diagnosing and treating psychological problems in patients with diabetes and hypertension. Cajanus. 2000; 33:77−83. 251
    • TABLE 9.1: Life Expectancy at Birth of Jamaicans by Sex: 1880-2004 Average Expected Years of Life at BirthPeriod: Male Female1880-1882 37.02 39.801890-1892 36.74 38.301910-1912 39.04 41.411920-1922 35.89 38.201945-1947 51.25 54.581950-1952 55.73 58.891959-1961 62.65 66.631969-1970 66.70 70.201979-1981 69.03 72.371989-1991 69.97 72.641999-2001 70.94 75.582002-2004 71.26 77.07Sources: Demographic Statistics (1972-2006) 252
    • TABLE 9.2:Seeking Medical Care, Self-reported illness, and Gender composition of those who report illness andSeek Medical Care in Jamaica (in %age), 1988-2007 Reporting Reporting Mean Mean Seeking Seeking Illness- Illness- Days Days Seeking Health Medical Medical Men Women Of Of Medical Insurance Care - Care - Illness Illness Year Care Coverage Men Women Men Women 1988 NI NI NI NI NI NI NI NI 1989 54.6 8.2 44.7 52.8 15.0 18.5 10.6 11.1 1990 38.6 9.0 37.9 39.2 16.3 20.3 10.2 10.2 1991 47.7 8.6 48.5 47.4 12.1 15.0 10.0 10.3 1992 50.9 9.0 49.0 52.5 9.9 11.3 10.7 10.9 1993 51.8 10.1 48.0 54.7 10.4 13.5 10.7 10.1 1994 51.4 8.8 49.0 53.4 11.6 14.3 10.3 10.4 1995 58.9 9.7 59.0 58.9 8.3 11.3 10.6 10.7 1996 54.9 9.8 50.5 58.5 9.7 11.8 10.0 11.0 1997 59.6 12.6 60.0 59.3 8.5 10.9 11.0 10.0 1998 60.8 12.1 57.8 62.8 7.4 10.1 11.0 11.0 1999 68.4 12.1 64.2 71.1 8.1 12.2 11.0 11.0 2000 60.7 14.0 57.4 63.2 12.4 16.8 9.0 9.0 2001 63.5 13.9 56.3 68.2 10.8 15.9 9 10 2002 64.1 13.5 62.1 65.3 10.4 14.6 10.0 10.0 2003 NI NI NI NI NI NI NI NI 2004 65.1 19.2 64.2 65.7 8.9 13.6 11.0 10.0 2005 NI NI NI NI NI NI NI NI 2006 70.0 18.4 71.7 68.8 10.3 14.1 9.7 10.0 2007 66.0 21.2 62.8 68.1 13.1 17.8 10.6 9.3 Source: Jamaica Survey of Living Conditions, various issues NI - No Information was available 253
    • TABLE 9.3.Number of Older men (60+ years) and difference over each year in Jamaica: 1990-2007Year Older men Difference over Older men (ages Difference over (ages 73+ yrs) year before 60+ years) previous year1990 31,336 - 101,603 -1991 32,441 1,105 110,350 8,7471992 32,966 525 111,742 1,3921993 33,488 522 113,116 1,3741994 34,073 585 114,706 1,5901995 34,635 562 116,263 1,5571996 35,158 523 117,600 1,3371997 35,605 447 118,721 1,1211998 36,022 417 119,751 1,0301999 36,505 483 121,001 1,2502000 37,003 498 122,297 1,2962001 37,459 456 123,478 1,1812002 37,940 481 124,728 1,2502003 38,541 601 126,370 1,6422004 39,149 608 128,031 1,6612005 39,754 605 129,683 1,6522006 40,033 279 131,250 1,5672007 40,948 915 132,931 1,681Source: Calculations for men 73+ years were done by the author, and the figures were extracted fromDemographic Statistics, 2007. 254
    • TABLE 9.4: Sociodemographic Characteristics of Sample (N=1,432): Men 60+ years % NGood Health: No 37.6 528 Yes 62.6 878Marital status Married 50.2 703 Never married 30.3 425 Divorced 2.1 30 Separated 2.3 32 Widowed 15.1 211Retirement Income: No 93.0 1320 Yes 7.0 99Health Insurance: No 87.1 1212 Yes 12.9 180Per capita Income Quintile 1=Poorest 18.6 265 2 17.7 252 3 20.1 286 4 19.7 281 5=Wealthiest 23.8 339Home tenure: Squatted or rent free 9.8 139 Rented or leased 5.8 82 Owned 84.5 1201Area of residence: Rural area 68.0 968 Peri-urban areas 20.1 286 URBAN AREAS 11.9 169Household Head: No 1.4 20 Yes 98.6 1402Educational level: Primary and below 62.3 843 Secondary 34.3 462 Tertiary 3.0 41Age (Mean ± SD) 71.14 years ±7.97 yearsAverage Consumption per person (Mean ± SD) $80,654.69 ± $75,029.21Household crowding (Mean ± SD) 1.15 ± 0.89Crime (Mean ± SD) 1.5 ± 7.0; 255
    • TABLE 9.5:Logistic Regression: Variables Predicting Good Health of Men 60+ years and 73+ years in Jamaica 60+ years 73 years or over 95.0% C.I. 95.0% C.I. Variable Odds ratio Lower Odds ratio Lower Upper Age 0.949 0.933 0.965*** 0.961 0.929 0.994* Secondary level 0.640 0.488 0.840** 0.541 0.357 0.820** Tertiary 2.327 0.816 6.633 1.755 0.378 8.140 †Primary and below 1.000 1.000 Medical Expenditure 1.000 1.000 1.000 - - - Married 0.959 0.731 1.259 0.963 0.651 1.424 Poor 1.174 0.854 1.613 1.269 0.792 2.032 Household Head 1.129 0.113 11.321 0.871 0.583 1.301 Environment 0.929 0.706 1.222 0.061 0.029 0.129*** Health Insurance 0.055 0.033 0.092*** 2.044 1.230 3.396** Peri-urban areas 1.505 1.062 2.134* 2.195 1.053 4.577* Urban areas 1.605 1.021 2.523* 0.283 0.073 1.104 †Rural areas 1.000 House tenure: Rent 0.758 0.360 1.595 0.500 0.231 1.085 Owned 0.911 0.577 1.438 0.718 0.487 1.060 †Squatted 1.000 Social support 0.807 0.621 1.050 0.986 0.755 1.286 Crowding 1.056 0.896 1.243 0.975 0.939 1.012 Crime Index 0.994 0.977 1.011 1.000 0.933 1.071 Negative Affective 0.976 0.934 1.021 1.097 1.010 1.191* Positive Affective 1.098 1.041 1.159** 1.000 1.000 1.000 Consumption per person 1.000 1.000 1.000 1.000 1.000 1.000 Chi Square (df = 19) = 289.45, p = 0.001 Chi Square (df = 18) = 132.21, p = Nagelkerke R square = 0.274 0.001 -2LL = 1,419.72 Nagelkerke R square = 0.277 Hosmer and Lemeshow goodness of fit χ2=12.843, P = 0.724 -2LL = 653.92 Hosmer and Lemeshow goodness of fit χ2=14.47, P = 0.7†Reference group*p < 0.05, **p < 0.01, ***p < 0.001 256
    • 257
    • Jamaica: 1993 Jamaica: 2009 3. Per cent of Tot al Popul at i on 3. Per cent of Tot al Popul at i on Male Female Male Female 70-74 70-74 60-64 60-64 50-54 50-54 40-44 40-44 30-34 30-34 20-24 20-24 10-14 10-14 0-4 0-4 0 1 2 3 4 5 6 6 5 4 3 2 1 0 0 1 2 3 4 5 6 77 6 5 4 3 2 1 0 Per cent Per cent 258
    • 259
    • Chapter 10Health in Older Adulthood Paul Bourne, Chloe Morris, Denise Eldemire-Shearer, Kenneth James, Desmalee Holder- Nevins, & Jeneva PowellOlder men‘s health status is of increasing concern given the rates of prostate cancer,genitourinary disorders and the presence of risk factors such as smoking in earlier life. Yet,there is limited research on the health status of older men. This paper provides informationon the self-reported health status of older men from a recent pioneer work of older men‘shealth status in Jamaica. Two thousand older men were surveyed in a cross-sectional study inthe parish of St. Catherine. Cluster sampling with probability proportional to population sizewas used to obtain the sample. Seventy –four percent reported health status as‗good/excellent‘. The data revealed that there was no statistical association between self-reported health of older men and age-group, area of residence and marital status (p>0.05).On the other hand, there was a positive correlation between health status and tertiary leveleducation (p<0.05). Cancer (was the most frequently reported disorder (16.6%), followed bykidney/bladder issues (12.7%) and hypertension (9.2%) and prostate conditions (7.3%).Greater attention to cancer, kidney/bladder issues and prostate conditions is warranted.IntroductionIt has been noted that the perception exists that except for issues related to reproduction,health problems, and needs, there is little difference in the health of men and women and thatthe solutions are essentially the same (Kalache & Lunenfeld 2002). As a result of lobbygroups of women from all over the world and the 1995 Beijing Conference, research onwomens health needs, rapidly mushroomed. Increasing evidence on important differences 260
    • between men and women from the cellular to the societal level has been generated (Kimura1987). Interestingly, according to Kalache and Lunenfeld (2002), the strong emphasis onwomens issues has (though almost by default) revealed areas of mens health that require justas much attention. The issue of older men‘s ageing and health has been spearheaded on the internationalstage by the World Health Organization (WHO). WHO has provided leadership in the area ofresearch and policy in the area of care of older persons. Older men‘s health status is ofincreasing concern given the rates of prostate cancer, genitourinary disorders and thepresence of risk factors such as smoking in earlier life. Yet, the literature revealed limitedresearch on their health status in the Caribbean and in particular in Jamaica. Currently the majority of older people live in developing countries. As thedemographic transition gathers momentum in the poorer regions of the world, an even greaterproportion of the world‘s men will live in countries and regions with the least resources torespond to their needs. The global approach can be only extensively reduced in a meaningfulway if poverty is driven by an understanding of older men and women in poor regions.(Lunenfeld & Gooren 2002). Both from a physiological and from a psychosocial perspective,the determinants of health as we age are intrinsically related to gender (Kalache 1997). Worldwide, there has been increasing interest in working with men on sexual andreproductive health concerns. Nevertheless collaboration among those who champion men‘shealth has been limited beyond conventional medical problems such as erectile dysfunctionor prostate cancer (Baker 2001). Baker further suggests that the idea that men have specifichealth needs, experiences, and concerns related to their gender as well as their biological sex 261
    • is relatively novel. Additionally he notes that even in those countries where emphasis hasbeen placed on men‘s health issues, programs have largely remained small scale operations.In the Caribbean, information and understanding of health and ageing issues among oldermen is relatively limited. Programmes specifically addressing the health of older men aresparse, and if present are rudimentary. In Jamaica, diseases of the prostate, especially prostate cancer are a significant causeof morbidity and mortality in older men more than other age cohorts. The average age-adjusted incidence (adjusted to the standard US population) of prostate cancer in Kingston,Jamaica was 304/100,000 men, the highest rate in the world. The cancers are moresignificant clinically with greater morbidity in Jamaica than in the United States (Glover et al1998). Men are poor consumers of health care services, therefore if their needs are to beunderstood one way is to listen to their self-report on their health status. Self-rated health is a complex variable that captures multiple dimensions of therelation between physical health and other personal and social characteristics. It is veryconsistent in its capacity to predict mortality (Idler, et al, 1997). It has also been stronglyassociated with successful aging (Roos. et al, 1991). Self-rated health is very easy to obtainthrough a single-item question and, consequently, it is often included in health surveys and asan outcome in many studies, resulting in a large body of research (Javier, Barriuso-Pastor,Valderrama Emilana 2008). This paper focused on self-reported health status of older menage 55+ years in Jamaica. Within the context that men live 6 years less than women inJamaica (Bourne 2008) and 8 years less globally (UN 2007), we believe that it is timely tounderstand men‘s health from their perspective. 262
    • MethodologyThis paper used cross-sectional data to examine self reported health in the Jamaica. Theresearch was conducted in the Parish of St. Catherine.The Statistical Institute of Jamaica (STATIN) maintains a list of enumeration districts (ED)or census tracts. STATIN determined that 50 men (55 years and older) in each enumerationdistrict in the parish of St. Catherine would be interviewed yielding a sample size of 2000.Households and the geographic direction in which to proceed to interview men 55+ yearswere selected using a random starting point within each cluster consistent with standardcluster sampling techniques. St. Catherine had approximately 33,674 males 55+ years andolder (preliminary census data 2001. A structured questionnaire was administered to maleinterviewees. The questionnaire consisted of 132 questions:Data was entered into an SPSS version 12 database and subjected to relevant analysis.Results: Socio demographic characteristics of the sampleThe sample consisted of 2000 older men, with majority of them (64%) between ages 55 and69 years (64%). In terms of residence 49.1% (N= 491) and 51.9% (N=1019) of therespondents were from rural and urban areas respectively. By proportion, married older men were 44.7% (894); while 6.8% (136) were incommon-law unions. There was no significant difference in the marital status of men 55 and 263
    • over when disaggregated by age. When marital status was examined by rural and urbandistribution, there was a statistically significant difference (χ2=16.69; p=0.002). More urbanmen were single and more rural men were widowed There was no association betweenmarital status and self-reported heath status. Although only 41.2% (824) of older men studied, owned the house in which theylived; 88.2%, (1763) of the time, older men were heads of household in which they lived.There was a statistically significant difference (χ2=19.96 P = 0.01) in home ownership whenrural and urban men were compared. Rural men were more likely to own their homes. Less than 1% (17) of the sample lived alone, approximately 33%, (650) of older menlived with one other person, while approximately two thirds of older men had at least two ormore other persons living in the household. The number of persons in the household in whichthe men lived ranged from 1 to 10 with the median number of persons being 2 (inter-quartilerange 1-4). There was no statistically significant difference in the number of persons livingin households by urban/rural distribution. About 74% (1489) of the population surveyed were ―not working/ retired. Most of thepopulation was retired 53.9% (1077). There was a statistically significant associationbetween age and employment status (X2 =19.13.p. =0.001), with greater proportions of thosenot working/ retired men being observed at older ages There was a statistically significant association between occupational categories andurban/rural distribution (χ2 =20.96.p=0.002) is proportionately more clerks and craft-relatedworkers were found in urban areas and more tradesmen were found in rural settings. 264
    • Older men in the study stopped working for various reasons, chief of which was thatthey had reached the statutorily designated age of retirement, of sixty-five years.Employment was still evident beyond the statutory age of retirement. However nearly one-fifth (18.2%) of the 70-74 age group were still working and 14.9 % and 16.2% reported thatthey were still working in the 75-79, and 80+ years age group respectively. The majority ofmen 92.9% reported that their highest education was at the primary school level or less. While there was no statistically significant association between age category andhighest level of education, it was noted that increasingly, proportions of younger men tendedto report achieving higher levels of education.Self-Reported Health Status by Age GroupWith regard to self reported health status, most men perceived themselves as being in goodhealth as illustrated in Figure 10.1 below with 55% respondents indicating that their healthwas good and 19% said it was excellent.There was no statistically significant differences with regard to self reported health statuswhen these were examined by age-group, urban-rural residence and marital status. Onlyhighest level of education was found to be associated with self-reported health status with theleast optimal displayed category (fair) being reported by significantly more men whosehighest level of education was basic school or no formal education (p<0.05). 265
    • Figure 10.1: Self-reported health status by men 55+ yearsSelf–report by residence and age groupOf the sample who reported an excellent health status, 20.5% was from urban St. Catherinecompared to 17.5% from rural zones. Table 10.1 revealed that there was no differencebetween respondents who reported fair health from urban (25.4%) or rural zones (25.8%).There was no statistically significant difference as shown in the distribution of self-reportedhealth status, and residence and age cohort see Table 10.1. 266
    • Table 10.1: Self-reported health status characteristics by residence, and age-group (%). Variables Excellent Good Fair Health health Health (N= 480) (N=1038) (N = 357) Urban 17.5 57.1 25.4 Rural 20.5 53.7 25.8 55-59 16.6 56.9 26.4 60-64 16.7 59.5 23.8 65-69 19.7 55.3 25.0 70-74 23.4 51.7 24.9 75-79 21.8 50.6 27.6 80+ 18.5 53.8 27.7Self reported factors that contribute to men’s healthIn describing their views of health, more than 50% of respondents indicated that being physicallywell with no known form of sickness was what good health meant to them. Twenty point sixpercent (20.6%) and (13.3%), respectively indicated that it meant having a healthy diet and theability to care for themselves. 267
    • With regard to the question of factors that contributed to one‘s health, 40% of the men indicateddiet as an important factor. Exercise was cited by 31% of interviewees, and sleep and rest by11% of the sample. Having regular check-ups was identified by only 5.1% of men as acontributory factor to health status. The individual‘s age and religious practices were recognizedas contributing factors by 4.6%, and 4.4% respectively. The state of family life and gettingregular check up were recognized as contributory factors by only 2.2% and 2.3% of the meninterviewed.Figure 10.2 Self- reported distribution of factors which contribute to men‘s health 268
    • Disease condition reported (%) Figure 10.3 below shows the distribution of diagnosed diseases (self-reported) in men 55 years and over. Men in the study were diagnosed with several diseases, kidney/bladder diseases (12.7%); hypertension (9.2%), prostate problems (7.3%), diabetes mellitus (6.5%) and heart disease (5.3%). Cancer (regardless of cause) was the leading diagnosis; reported by 16% of the older men surveyed. Figure 10.3: Disease condition reported (%) reported ―diagnoses‖ by age-groupSelf-reported health status by diagnosed health condition/disease, visits to healthfacilityPersons with diagnosed disease tended to report more favourable health ratings than thosewho did not. The only exception to this pattern was those diagnosed with Kidney wheremen with the disease gave less favourable self-ratings than those without the disease. 269
    • The findings showed no correlation existed between doctor visits and self-reported healthstatus (p>0.05). However, with respect to visits to health centre and health status, therewas statistical association (p<0.05) those who did not visit the health centre had betterhealth ratings.Table 10.2 Self-reported health status by diagnosed health condition/disease, visits to healthfacility Variables Excellent Good Fair p-value Health Health Health (N = 357) (N=1038) (N= 480) Cancer + 20.8 54.8 24.4 χ2=21.61, - 9.9 58.3 31.8 p=.001* Hypertension + 43.5 50.8 5.6 χ2=92.53, - 16.5 55.8 27.7 p=.001* Heart Disease + 31.1 59.4 9.4 χ2=20.43, - 18.3 55.1 26.6 =.001* Prostate + 23.7 62.6 13.7 χ2=11.50, - 18.7 54.8 26.6 .002* Diabetes + 34.1 50.0 15.9 χ2=21.84, - 18.0 55.7 26.3 p=.001* Kidney + 8.5 50.2 41.3 χ2=40.19, - 20.5 56.1 23.5 p=.001* Other + 27.2 55.3 17.5 χ2=7.31, - 18.5 55.4 26.1 p=0.026* Visited doctor + 19.5 55.1 25.4 NS. in ≤ year - 18.9 55.4 25.6 Visit to health + 12.0 52.4 35.6 χ2=30.64, centre in ≤ year - 20.8 56.1 23.2 p=0.001* NS= not statistically significant p>0.05 +=yes - =no 270
    • Percentage (%) distribution of self-report of older men diagnosed with Diabetes,Hypertension, Cancer by location, visit to health facilities.Embedded in the finding is the fact that respondents who indicated been diagnosed withcancer had the least visits to private doctor and public health facilities compared todiabetic and hypertensive individuals. Table 10.3: Percentage (%) distribution of self-report of older men diagnosed with Diabetes, Hypertension, Cancer by location, visit to health facilities Diagnosed Diagnosed with with Diagnosed Diabetes Hypertension with Cancer (Self report) (Self report) (Self report) Characteristics N = 129 N = 183 N = 336 Rural 44.2 60.1 48.2 Urban 55.8 39.9 51.8 Visit Private Doc. in <year 26.4 47.0 19.2 Visit Health Centre in < year 26.4 19.7 17.9 271
    • Self-report of ever having a prostate examination by men’s ageWhen the respondents were asked if they have ever had a prostate examination, 35%revealed ‗yes‘. Of those who had mentioned prostate test or check, 22.6% were 55 to 59years compared to 17.9% of men 60 to 64 years (Figure 10.4). Figure 10.4: Self-report of ever having a prostate examination by men’s ageSelf-reported health status was compared with past smoking behaviour and revealed astatistically significant association - χ2(df=2)=11.743, p<0.05, c=0.079, with a very weakcorrelation. Table 10.3 showed that 28.6% (N=301) of the respondents who smoked inthe past reported fair health compared to 52.8% (N=555) who said good and 18.6%(N=195) who indicated an excellent health status. On examination of the table, it wasfound that 7% more respondents who smoked in the past had fair health compared tothose who had not smoked in the past. Similarly, more respondents who had not smokedin the past reported an excellent self-reported health status. 272
    • Table 10.4 Self reported health status by smoked in the pastSelf-rated Smoked in the pastHealth TotalStatus Yes No 195 162 357 Excellent (18. (19.7) (19.0%) %) Good 555 483 1038 (52. (58.6 (55.4%) %) %) 301 179 480 Fair (28. (21.7) (25.6%) %)Total 1051 824 1875χ 2(df=2)=11.743, p<0.05, c=0.079Table 10.4 revealed that a statistical correlation existed between self-reported healthstatus and self-reported lung disease - χ2(df=2)=97.684, p<0.001, with there being aweak association, c=0.223. Of the sample who reported having lung disease (N=223),36.3% (N=81) indicated that they were in excellent self-reported health compared to61.9% (N=138) who claimed good and 1.8% (N=4) who mentioned fair self-reportedhealth. Further examination of the findings revealed that of those who claimed not tohave lung disease, 19.0% (N=357) of them reported an excellent self-reported health. 273
    • Table 10.5: Self-rated Health Status by Self-reported Lung Disease Self-reported Lung Diseases Total Self-rated Health Yes No Status Excellent 81 357 276 (36 (19.0%) (16.7) %) Good 138 900 1038 (61.9%) (54.5%) (55.4%) Fair 4 476 480 (1.8%) (28.8%) (25.6%) Total 223 1652 1875χ2(df=2)=97.684, p<0.001, c=0.223.DiscussionA Plethora of studies that have examined Caribbean societies and those in the Westernculture have shown that men have a greater economic wellbeing Rudkin, 1992. Thereality that men have greater economic wellbeing comes from the cultural premise that 274
    • they have greater economic power, and family heredity is substantially passed on to boysthan girls. Historically women were primarily care givers, nurturers, the bedrock uponwhich family culture was passed on to the children, and this means that the men were theeconomic providers. Being the provider, the passing on of economic assets were inkeeping with this cultural role. Wyess, 2001. UNRISD Contemporary societies have evolved, and so have the people. The economicdisparities between the sexes have been reducing, but the provider role is stillsubstantially in embodied in maleness. Can we assume that older men would have a goodquality of life because of the aforementioned arguments? Or, are older men the protectedsex and so should not be studied by Caribbean scholars? As public health practitioners, we must examine how to better serve our clients andby so doing, this requires that we understand both males‘ and females‘ perspective inorder to address their concerns within the context of better quality of life in betterphysical environments. Using life expectancy figures for the sexes in Jamaica, femalesoutlive males by 6 years (Bourne, 2007) and globally, the feminization of longer life is 8years (United Nations, 2007). It is within this context that we cannot claim that economicwellbeing translates to better quality of life. A comprehension and careful review of Caribbean health literature in particularJamaica revealed that older men‘s health is rarely examined outside of sexuality andreproductive health. Within the context of the current literature, this paper provides theplatform upon which policies and programs can be fashioned for older men. In order tounderstand the rationale and the importance of this paper, we will provide an important 275
    • finding in the study that only 19% of the sample reported that their health was excellent.While 55% of the sampled respondents in study indicated at least good health, which issimilar study a study done in India. There Swain (2007) found that 74.8% of elderlypersons surveyed reported their health status as good, very good or excellent. Although feeling good is not an objective assessment of health status, manyscholars have argued that self-reported health study is a good proxy of health status(Dianer 1984, Diener & Suh 1997, Garrity, 1978, Dianer, Suh, Lucus & Smith 1999Diener 2000, Canadian Community Health Survey 2005; 984; Cummins 2005. There is athat Mor, et al 1994 concluded a study which pointed out that a self-reported healthstatus was strongly correlated with successful ageing, this finding provides some insightinto the non-economic wellbeing of Jamaican older men and their ageing process. With regard to self- reported health status and age groups as men got older fewerexpressed that their health was excellent and good. Forty three percent of the men diagnosedwith hypertension said that their health was excellent. Many men with chronic diseases ratedtheir health as excellent and none rated their health as poor regardless of diagnosis. Are themen‘s ratings of their health status a reflection of denial of their health conditions or are theyeternal optimists? Individuals who live in a health state of less than perfect health often adapt over time totheir disease and subsequently they assign higher ratings and higher utilities to their health statethan an external observer would expect. A second factor may also be at work. It is not culturallyacceptable for Jamaican to be ‗whining in self-pity‘. This may partially explain why none of the 276
    • men interviewed indicated their health status as ‗poor‘, preferring the use of the term ‗fair‘ insuch cases. The men‘s perception of their health status was a direct reflection of what wasconsidered good health. More than half of the men interviewed alluded to good healthmeaning that an individual had no known sickness. This perception may contribute to thelower/inadequate utilization of health care services or the presentation of men to healthfacilities only when they are overtly or extremely sick. It means that for silent killers suchas hypertension and occult cancer (colon and prostate), screening opportunities for earlydetection are not necessarily highly valued and will be often missed. It helps explain whypreventive or routine visits to health providers are apparently not perceived as priorities byolder men. Men mentioned healthy diets and the ability to take care of one‘s self as theprimary factors that contributed to good health. These answers suggest that men are nottotally ignorant when it comes to health matters. This already desirable existingunderstanding provides a good starting point for health promotion programs to build on inthe quest for improved health literacy. Simultaneously, there needs to be promotion of theimportance of screening and preventive visits and the expansion of men‘s comprehensionof silent and occult disease. With regard to prostate cancer, approximately 65% had never had a prostatetest/examination done. Culturally, there is considerable resistance to prostate examinations(digital) as well as colonoscopy procedures. Many Jamaican perceive prostate examinationsas ‗de-masculinizing‘ and hence there is significant hesitation to request such examinations 277
    • or to discuss it with doctors. George and Fleming (2004) in their research study describedprostate cancer as a ‗taboo‘ subject among men; and further that men thought it inappropriateand not masculine to be open about health. This could very well apply to Jamaican man; forthe older men such matters are private, not to be openly discussed. Some older men alsorevere doctors and may fail to take the initiative to raise healthcare issues unless they deemthem specifically related to an acute problem for which they are seeking help. It is noteworthy that cancers were identified as being the disease of mostimportance to the older men in the study. Jamaica has been cited as having the highestincidence rate of prostate cancer in the world. In this paper 16% of men had some type ofcancer and 80% of those were diagnosed within the last twelve months (Glover et al1998). The Jamaica Cancer Society (MOH 2004) reported a general increase in clientsaccessing the services of the society but the increase by gender was not specificallyaddressed. Is this increase a result of education campaigns? It is to be noted that cancer isdreaded by most persons, and the fears of treatment and long suffering could possible besome of the reasons for the increased utilization of Jamaica Cancer Society‘s services. Genitourinary health issues remain of considerable importance to men. Manyhealth issues fall into this group of conditions; benign prostate, hyperplasia, prostatecancer, erectile dysfunction, infertility in the ageing male, urinary incontinence, andtesticular cancer. These areas represent the most intimate concerns of men. Many ageingmen will experience urinary problems ranging from nocturia, increased frequency ofmicturition, urgency, hesitancy, poor stream, and post-micturition dribbling to loss ofbalder control resulting in incontinence, and retention. Population studies have showed the 278
    • frequency of a moderate-to-severe lower urinary tract symptom to be 8-31% in men intheir 50s, increasing to 27-44% of men in their 70s (Lunenfeld 2002). Additionally men may fear that if something is found to be wrong with theprostate, it will often require surgery and their lives will be of lesser quality. The latterfact is not unique to Jamaica as Remzi (2004), who studied the treatment of prostatecancer in an Austrian population, found that older men may be more risk adverse and lesswilling to sacrifice quality of life for prolongation of life. Yet prostate cancer is one of thetreatable cancers. In this research, we found that among the age cohorts the highestpercentage of men who had a prostate examination/test done was in the 55-59 years agegroup. Health promotion messages have been advocating that ―a test in time can preventyour death by prostate cancer‖. In this paper it was noted that it is also this age group thathas the highest level of education. Consequently, this cohort of men are likely to be moreknowledgeable and more health conscious and thus may exhibit better health seekingbehaviour with regard to screening for prostate problems. This research revealed that the reasons for not doing a prostate examination/test werenot recommended by doctor (41%), fear of examination (22%), and 5% did not know aboutit. Foster (2004) in a study of prostate cancer among men in a selected area in Jamaica,produced similar findings. The knowledge gap was clear as 34.6% of the men stated thatthey believed that women were also at risk getting prostate cancer. The findings of this largerstudy in conjunction with those of Foster, underscore the need for (i) education of menregarding prostate cancer and screening; and (ii) greater sensitization among health providersof the need to routinely raise the matter of prostate health with older men. What cannot be 279
    • ignored is the misinterpretation by many that there is no difference between prostate cancerand prostate problems. Men‘s rating of their health status can be explained by drawing upon Murray(1996) who points out that coping with adversity (in this case disease and in particularchronic disease) and re-adjusting expectations are part of an observed phenomenon thatinfluences the valuation of health states. Individuals who live in a health state of less thanperfect health often adapt over time to their disease and subsequently they assign higherratings and higher utilities to their health state than an external observer would expect. Asecond factor may also be at work. It is not culturally acceptable for Jamaican to be‗whining in self-pity‘. This may partially explain why none of the men interviewedindicated their health status as ‗poor‘, preferring the use of the term ‗fair‘ in such cases. As discussed previously, the self reported health status does not necessarilycorrelate with other objective measures and persons often report better health status levelsthan expected. In keeping with this observation, Swain (2007) found that thirty onepercent of those perceived their health as excellent or very good were reported to besuffering from a chronic disease. A similar pattern of excellent health status beingreported by men with chronic disease was noted. Men with major chronic diseases eventended to rate their health better than those without. Lower education levels in thisJamaican study were found to be associated with lower self-reported heath status ratings.This probably reflects the well-known relationship of socioeconomic status and health;poorer socioeconomic status being associated with poorer health. This paper found noassociation between self-reported health status and age, marital status, or urban/rural 280
    • residence. In contrast, Swain found an association with age, but that study included asignificant proportion of females.ConclusionGiven the reported disease pattern for men, programs focused on healthy lifestyles,behaviour change, screening for chronic diseases, treatment of complications as well asrehabilitation become need to strengthened and/or developed. These not only can yielddividends in terms of personal health but can help reduce admissions to hospital, length ofstays at such institutions and attendant health care costs.ReferencesBaker, P. (2001). The international mens health movement has grown to the stage that it can start to influence international bodies. British Medical Journal, 323, 1014-1015. Retrieved on August 6, 2006 from http://www.bmj.com/cgi/content/full/323/7320/1014Bourne, PA. (2007). Determinants of Well-being of the Jamaican Elderly. Unpublished MSc. Thesis, The University of the West IndiesCummins, RA, 2007 Moving from the quality of life concept to theory. Journal of Intellectual Disability R49:699-706esearchDienner, E 2000. Subjective well-being: The science of happiness and a proposal for a national index. American Psychological Association 55: 34-43 http://www.wcfia.harvard.edu.conferancesDienner, E., and E. Suh. 1997. Measuring quality of life. Economic social subjective indicators. Social Indicators Research 40:189-216Dienner, E, Suh, M., Lucas, E. and Smith , H. 1999, Subjective well-being. Three decades of progress. Psychological Bulletin 125:276-302 281
    • Dienner,E.1984.SubjectiveWell-being Psychological Bulletin, 95:542-575Foster, F. (2004). Barriers to prostate cancer screening: A Jamaican perspective. Unpublishedresearch project, University of The West Indies, Mona, Jamaica.Garrity TF, Somas GW, Marx MB. Factors influencing self-assessment of health. Soc Sci Med 1978; 12:77-81Gender and cash child support in Jamaica -- Wyss 33 (4): 415 ... Key Words: Jamaica • Child support • Gender. References . Variations in the economic well-being of divorced women and their children rrp.sagepub.com/cgi/content/refs/33/4/415George, A.,& Fleming, P. (2004). Factors affecting mens help-seeking in the early detection of prostate cancer: implications for health promotion. The Journal of Mens Health & Gender, 1(4), 345 – 352. Retrieved on March 11, 2008 from http://www.resolutehealth.com/TEXT/sdarticleGeorgeandFleming.pdfGlover, F.E. Jr., Coffey, D.S., Douglas, L.L., Cadogan, M., Russell, H., Tulloch, T., et al. (1998). The epidemiology of prostate cancer in Jamaica. Journal of Urology, 159(6), 1984-1986.Idler EL, Benyamini Y1997: Self-rated health and mortality: a review of twenty-seven community studies. J Health Soc Behav 1997, 38:21-37 Retrieved on July 17, 2008 from http://www.jstor.org/stable/295535?seq=1Javier Damian, Barriuso- Pastor Roberto, Gama Valderrama Emilana 2008 BioMed Central | Full text | Factors associated with self-rated health in older people living in institution... Self-rated health is very easy to obtain through a single-item question and, consequently, it is often included in health surveys and as an outcome in many .. Retrieved on July 2 2008 from www.biomedcentral.com/1471-2318Kabeer, Naila (1996) Gender, Demographic Transition and the Economics of Family Size: Population Policy for a Human-Centred Development: The Social Effects of Globalization No.: 7 UNRISDs Contribution to the Fourth World Conference on Women Retrieved on July 15, 2008 from http://www.unrisd.org/80256B3C005BCCF9/(httpPublications)/A3C36A448455838C802 56B67005B6B77?OpenDocumentKalache, A. & Kickbusch, I. (1997). A global strategy for healthy aging. World Health, 50, 4- 282
    • Kalache A, & Lunenfeld . (2002) Health & the ageing male. In Men, ageing & health World Health Organization life Course, Achieving Health Across the Lifespan. Retrieved on October 10, 2005 from http://whqlibdoc.who.int/hq/2001/WHO_NMH_NPH_01.2.pdfKaplan, R.M., Anderson, J.P., & Wingard, D.L. (1991). Gender differences in health-related quality of life. Health Psychology, 10 (2), 86-93.Kimura, D. (1987). Are men‘s and women‘s brains really different? Canadian Psychology, 28, 133-147Lunenfeld B & Gooren L (eds.). (2002). Textbook of Men‘s Health. The Parthenon Publishing Group. New York: LondonMor V, Wilcox V, Rakowski W, Hiris J: Functional transitions among the elderly:patterns, predictors, and related hospital use. Am J Public Health 1994, 84:1274-1280.Ministry of Health Annual Report 2004. (2005 November) Policy, Planning andDevelopment and Evaluation Branch.Murray C. (1996). Rethinking DALYs. In C. Murray& A. Lopez (Eds.), The global burden of disease.(pp).Cambridge, MA: Harvard University Press.Planning Institute of Jamaica (2007). Social and Economic Survey Jamaica 2007 Planning Institute of Jamaica: pp ixRemzi, M., Waldert, M. & Djavan, B. Prostate cancer in the ageing male . The Journal of Men’s Health & Gender, 1(1), 47 – 54.Roos NP, Havens B: Predictors of successful aging: a twelve-year study of Manitoba elderly. Am J Public Health 1991, 81:63-68Rudkin L 1992 Gender differences in economic well-being among the elderly of Java, Indonesia. [Unpublished] 1992. Presented at the Annual Meeting of the Population Association of America, Denver, Colorado, April 29 - May 2, 1992. [2], 30 p. Retrieved January 14, 2009 from http://www.popline.org/docs/1078/101288.html 283
    • Saxena S, Eliahoo J., & Majeed A. (2002). Socioeconomic and ethnic group differences in self reported health status and use of health services by children and young people in England: Cross-sectional study. BMJ 325:520.Statistics Canada, Canadian Community Health Survey 2005, 2003, 2000/2001; Statistics Canada, National Population Health Survey) http://www.statcan.gc.ca/pub/82-221- x/2007002/defin/4150809-eng.htmSwain, P. (2007). Health status among elderly in Northeast India. Journal of The Indian Academy of Geriatrics, 3 (1), 8-14.United Nations 2007: World Population Ageing, 2007 and United Nations.2005c: World Population Prospective: The 2004 RevisionVictor R. G., D. Leonard, P. Hess, D. G. Bhat, J. Jones, P. A. C. Vaeth, J. Ravenell, A. Freeman, R. P. Wilson, and R. W. Haley. 2008. Factors Associated With Hypertension Awareness, Treatment, and Control in Dallas County, Texas. Arch Intern Med, June 23, 2008; 168(12): 1285 - 1293.World Health Organization and Life Course. ( 2001). Men, aging and health: Achieving health across the lifespan. 01WHO/NMH/ NPH 01.2. Ageing and Life Course Unit. p. 1 Geneva : Author. Retrieved on May 8 2002 from http://whqlibdoc.who.int/hq/2001/WHO_NMH_NPH_01.2.pdfWorld Health Organization. (2002a): Gender Policy Integrating Gender Perspectives in the work of WHO. World Health Organization: GenevaWyss Brenda (2001) Gender and cash child support in Jamaica Department of Economics, Wheaton College, Norton, Review of Radical Political Economics, Vol. 33, No. 4, 415-439 Retrieved June 12, 2008 from http://rrp.sagepub.com/cgi/content/abstract/33/4/415 284
    • Chapter 11Self-rated Wellbeing of Elderly Jamaicans Paul A. BourneIn this paper we critically examine two existing models on self-rated health status and/orwellbeing of aged people. Secondly, having evaluated the limitations of those models, we soughtto provide a new model that is a better proxy of subjective wellbeing of elderly than theexamined models. The current research has a population of 3,009 respondents (ages 60 years andolder) drawn from a nationally representative survey of 25,018 respondents. The survey was aself-administered questionnaire, and it was conducted between July-October 2002 from by wayof stratified random sample of the population of Jamaica. The cross-sectional survey wasconducted by a reputable statistical institution within the country. Data were stored and retrievedusing SPSS 12.0. Descriptive statistics were used to provide a description of the sampledpopulation; and crude multiple regression was used to test the general hypothesis after which afinal model was established that explains subjective wellbeing of elderly Jamaicans. Stepwiseregression was used to ascertain the explanatory contribution of each factor in the final model.We found that 13 of the 17 predisposed variables were found to be factors of wellbeing of agedJamaicans. The 13 factors accounted for 65% of the variability in wellbeing (i.e. adjusted R-squared). The 5 most significant factors are household consumption per person, loneliness,retirement income, Area of residence and positive affective psychological conditions. Householdconsumption per person accounted for 48.8% of the explanatory power of the model followed byloneliness (i.e. 7%), retirement income (2.5%), Living in KMA (1.8%), Living in Other Towns(1.5%), and positive affective psychological conditions (1%). We have found that unlikeHambleton and his colleagues‘ work and Bourne‘s earlier studies, wellbeing of the elderly issubstantially a factor of household consumption per person than current diseases (see Hambletonet al.2005) or household crowding (see Bourne 2007a,2007b). None of the aforementionedCaribbean research found the importance of loneliness on the wellbeing of the elderly, and wefind that this is the second most important factor followed by retirement income. Thus, policy onimprovement in the wellbeing, quality of life or the treatment of aged people must understand theimportance of those factors; and the role meting ones household consumption has on thewellbeing of the individual. 285
    • IntroductionMany people see the elderly as useless, irrelevant and obsolete so much so that there is aJamaican cosmology that forwards that aged people should remained outside of the publicthoroughfare and more indoors as they distort the fluidity with which contemporary societyfunctions. Ageing is an indicator of the commencement of particular health conditions and theslowing down of physical functioning (see for example, PIOJ 2007; Erber 2005; Brannon andFeist 2004; Caldwell 2001; Eldemire 2001; Bogue 1999), suggesting that bone density declinewith the acceleration of ageing and time (Twomey, Taylor, & Furniss 1983). Thus, ageing issynonymous with frailty and increased health conditions. One researcher refines thecharacteristics of ageing, when he shows that there is a positive association between healthproblems and ageing as well as physical disability and ageing and demand for health care andageing. (See Table 11.1a). Ageing does mean more that immobility, frailty and increased dysfunctions as it alsosignifies lowered employment, loss of income form work and other reduced resources, cognitiveissues, and modifications of social networks. A Caribbean scholar contradicts the normalcosmology on the physiological and psychological incapacitation of the elderly, when she arguesthat ―The majority of Jamaican older persons are physically and mentally well and living infamily units‖ (Eldemire 1995a, i). In an earlier study, she finds that as much as 81% of elderlydo not require assistance from someone to carryout their normal functions in life (Eldermire1994). Another study, using stratified random survey of 875 elderly Trinidadians andToboggans, the findings reveal that only 46.5% of the elderly needed assistance to carry-out theirdaily activities; and that about two-thirds of the elderly less than 80 years reported an health 286
    • status of average to very good while 55% of those 80 years and older indicate the same as theiryounger aged counterparts (PAHO 1989). Although ―it is well known that the death rate increases almost exponentially with agethrough most of the adult age range in humans‖ (Horiuchi and Wilmoth 1998, 391), oneswellbeing and/or health status is a function of genetic, ecological, social, and cultural factors(Pacione 2003; Grossman 1972; Smith and Kington 1997; Bourne 2007a, 2007b; PAHO andWHO 1990). A study conducted by Pan American Health Organization (PAHO, 1990) on thehealth of Adults and Trinidad and Tobago Elderly reveals that the young elderly (ages 60 to 70years) identify that their main concern was economic in nature, more so than health related(PAHO, 1990, 28). Another study done in the Caribbean, Barbados, shows that 82% of elderlylive in their own homes, only 5.3% are institutionalized in private homes, 8% are lonely and27.1% are living alone (Brathwaite 1995). What is this saying about elderly people in theCaribbean? Eldemire in a cross-sectional study of 1,329 elderly (people 60 years and older) of which659 were males and 666 females, uses simple frequency analysis to forward the status of theJamaican seniors (Eldemire 1997). Among the findings of that research include that 59.8% of theelderly report that they are very active, 63.7% remark that they enjoy life, 40.9% that they havenever experienced loneliness, 74.6% owned their own homes and 71.1% was that walking dailyis a common activity. Although Eldemire‘s work did not use multivariate analyses in establishingrelationships among various socio-economic elements that affect the status of the elderly, thework provide invaluable information on the status of this age cohort of people as it was anexploratory one. Nevertheless, Eldemire (1997) highlights the need for further research when 287
    • she make the statement that ―it was difficult to determine if loneliness caused unhappiness, as26.1% of persons [elderly – ages 60 years and older] who said they did not enjoy life were neverlonely and 32.5% of people who were often lonely said they enjoyed life‖ (1997, 75), whichbrings into focus the need for modeling to unearth this phenomenon. In a joint publication by the Pan American Health Organization (PAHO) and the WorldHealth Organization (WHO), their work substantiates many of the findings of Eldemire‘s study(PAHO and WHO 1997). PAHO and WHO in seeking to promote health and wellbeing ofseniors, analyze a number of socio-economic factors ( for example, living arrangements,exposure, opportunities for health protection, ability to access quality health care, labour forceparticipation, educational achievement, urbanization, gender differential, family composition,family support) and health status and found associations. In an earlier study, Eldemire in anarticle captioned The Elderly- A Jamaican Perspective notes that income, employment, amongothers issues were ‗common problems‘ affecting quality of life of the elderly (Eldemire 1987a). Notwithstanding Eldemire‘s propositions as are in the aforementioned paragraphs, whenageing comes with a mixture of health conditions, joblessness, frailty, low physical fitness,institutionalization, hospitalization, dependence and low social integration, the quality of life ofaged people therefore must be examined from a quantitative perspective by capturing all theabove variables in a single wellbeing or health status model. The standard of living of people isaffected by a plethora of conditions, and many of those conditions are negative factors. It followsthat any assessment of the wellbeing of this group must include as many of the variables that arelikely to influence this cohort‘s wellbeing as any exclusion of a variable may result in a lowexplanation power of the overall model. 288
    • Research on the elderly in the developing world suggested that the elderly face anincreasing need of medical care, social and economic conditions (McEniry et al. 2005; Eldermire1992, 1997; Posner 1995; Palmore 1981; International Association of Gerontology 1955) morethan the younger folks because of degeneration of the human body as it ages. The issue ofwellbeing is progressively becoming a popular area of discourse in contemporary social sciencesbut the foci are still predominantly from the perspective of biomedical studies. Quality of life isindeed multi-dimensional and spatio-temporal, and so it is simplistic to research the manner in asingle space. How must this be done? One of the principles of statistical method in model building is specification.Specification forwards that all variables the researcher must ensure that all the variables thatshould be included must be included and not should be included that should be excluded fromthe model. While this platform is the bases upon which models are used and built; sometimes avariable is excluded because of non-response (i.e. high non-response 30% and more). Althoughthis can be rectified by different statistical technique that can be used to replace the missingcases, some researchers argue that within the Jamaican context replacing missing values do notreflect the views of the non-respondents and so provide a distortion when missing values arereplaced in any statistical technique. Outside of the aforementioned issue of replacement ofmissing data, sometimes because of the use of secondary dataset particular variables whichimportant are omitted from the analysis. No one study can involve all the variables that canshould be incorporated in a model, which explains the limitation of a study and therecommendation for further study by the research in question. Thus, let us examine some studies,and establish the rationale for the current work. 289
    • In a nationally representative survey of 1,508 elderly Barbadians (ages 60 years andolder), Hambleton and his colleagues (2005) found that 38.2% of the variation in wellbeing ofaged Barbadians can be explained by historical socioeconomic indicators, current socioeconomicindicators, current lifestyle risk factors and disease. Lifestyle behaviours (including exercise,conditions relating to smoking or non-smoking) accounted for 7.1% of the variability inwellbeing; historical conditions (such as, socioeconomic experiences early in life), 5.2%; currentdiseases, 33.5%; and current socioeconomic conditions (e.g. education of the family members,household room density, all sources of income – including pensions and retirements, socialnetworks) accounted for 4.1%. Hambleton et al.‘s work revealed that current dysfunctionsaccounted for 88% of the variability in wellbeing model. Careful examination of Hambleton andcolleagues‘ study highlights one of the reasons for the high explanation of current diseases. Weobserve that the dependent variable was self-reported health status (which is a proxy of healthconditions) and independent variable of the current dysfunctions will show a strong positivecorrelation. Thus, both variables are measuring a similar phenomenon; and therefore onevariable cannot be used as dependent and the other as an independent indicator. We also found some addition issues in current socioeconomic indicators as self-reportedincome was used a ‗good‘ indicator and this was further bolstered by imputed monthly incomeand a self-reported financial adequacy. It has been long established in Caribbean societies inparticular Jamaica that self-reported income is not a good indicator of wellbeing for two reasonsas one people are afraid to report their true income because they believe that such informationmay be forwarded to governmental agencies; and secondly, owing the non-response rate thatmay occur from asking such as question which is as a result of the aforementioned argument.This was also the case in Hambleton and colleagues‘ research as non-response rate for self- 290
    • reported income was 25.2%. Bogues (1999) writes that ―National income statistics [i.e. for theUSA] show that the average annual household income of the elderly is about one-third [i.e. 33%]less than that of working adults household of the same race‖ (p. 18); and this argues for the non-use of income statistics for this age cohort in any statistical analysis as there will be a high non-response rate. What is the rationale for the omission of income statistics for the aged in statisticalanalyses? Some researchers argue that the cutoff point for non-response cannot surpass 15%.Within the limitations of aforementioned work, we believe that people consumption is a betterproxy for income; and the non-response rate for this variable is usually very low as connectionbetween income and consumption is infrequently made by many people. Again we will reiterate that no one study can provide all the answer or for that matter iseven irrefutable as time and other constraints change the outcome and the validity ofinformation. Hence, we will evaluate study that was done in 2007. In an abstract in the WestIndian Medical Journal, using secondary data of 2320 elderly Jamaicans (ages 65 years andolder), Bourne (2007a) developed a model that explained 36.8% of the variability in wellbeing.Wellbeing was constructed using health conditions and population income quintile. Theexplanatory variables of most importance were area of residence (β=0.227), cost of medical care,(β=0.184); positive affective psychological conditions, (β=0.138); ownership of property,(β=0.135) and crime, (β=0.110). The model did not incorporate income as a variable because thenon-response rate was approximately very high; as such no variable was used to proxy income. Modifying the initial model that was presented in West Indian Medical Journal, Bourne(2007b) lowered the age for the elderly to 60 years and beyond, which brought the sampledpopulation to 3,009 respondents. The new model was an expansion of the initial presentation 291
    • made to the 16th Annual Research Conference in 2007, and findings revealed that 40.1% of thevariance in wellbeing can be explained by 11 factors. Of the 11 factors, the 5 most importantones were household crowding; environment; educational level; area of residence and cost ofmedical (health care). Once again modified model excluded consumption which is a proxy forincome as well as other variables. In keeping with specification that was previously explained,despite the limitations of modified model by Bourne there is some base upon which anothermodification will emerge once more. In this paper we critically examine two existing models onself-rated health status and/or wellbeing of aged people. Secondly, having evaluated thelimitations of those models, we sought to provide a new model that is a better proxy of subjectivewellbeing of elderly than the examined models. Thus, the theoretical framework that will use inthis paper last model by Bourne that accounted for 40.1% of the variance in wellbeing of agedJamaicans.Theoretical Framework The current research is a modification of a theoretical framework developed by Bourne(2007a, 2007b). Using secondary data of 3,009 elderly (ages 60 years and older) Jamaicans,Bourne theorizes that wellbeing of aged Jamaicans is a function of particular social,psychological, and environmental variables. He expresses this as follows (see Eq. (1) : Wi = =ƒ (lnPmc , ED, Ai , En, G, MS, AR, P, N, lnO, H, T, V) ……………….Eq.(1) Where Eq. (1) is Wi is wellbeing of the Jamaican elderly i, is a function of logged cost ofmedical (health) care (Pmc), the educational level of the individual, age (Ai , where i is theindividual), the environment (En), gender of the respondents (G), marital status (MS), area of 292
    • residents (AR), positive affective conditions (P), negative affective conditions (N), loggedhousehold crowding (i.e. average occupancy per room) (O), home tenure (H), propertyownership, (T), crime and victimization, (V). Bourne‘s work (2007a) accounted for 40.1% of the variance in wellbeing of the agedJamaica; with the 5 most influential ones being (1) household crowding (β=-0.229); environment(β=-0.190); area of residence (β=0.164(; and cost of health care (β=0.148). From statistical data only a small percentage of aged Jamaicans are employed, inparticular the old elderly (75 years to 84 years) and oldest elderly (ages 85 years and over).Within this context, Bourne‘s omission of employment and income from his model wasunderstandable. Notwithstanding the rationale for the omissions, wellbeing is influenced byconsumption expenditure and total expenditure by the household; and this means two criticalvariables were omitted from wellbeing. It can be deduced from Denise Eldemire‘s works (1987a,1987b, 1994, 1995, 1996, 1997) that social support is primary to the wellbeing of the elderly‘ssurvivability and this was omitted by Bourne. Hence, in wanting to derived a close proxy forwellbeing of aged Jamaicans, in this paper we will include consumption expenditure; lonelinessand social support are crucible to the wellbeing of elderly people. In addition to theaforementioned variables, elderly people receive retirement incomes that were also omitted fromEq. (1). Ergo, we will seek to modify Bourne‘s model by the inclusion of the omissions - asfollows, (see Eq. (2) as well as excluded cost of medical care as 66% of the cases were in thiswork: Wi = =ƒ (ED, Ai , En, G, MS, AR, P, N, lnO, H, T, V, lnC, SS, HSB, L, R) ….Eq.(2) 293
    • Where lnC denotes logged household consumption expenditure per person; SS representssocial support; HSB identifies health seeking behaviour; loneliness (proxy by living alone), (L);and R indicates retirement income.Method The current research has a population of 3,009 respondents (ages 60 years and older)drawn from a nationally representative survey of 25,018 respondents. The survey was a self-administered questionnaire, and it was conducted between July-October 2002 from by way ofstratified random sample of the population of Jamaica. The cross-sectional survey wasconducted by a reputable statistical institution within the country. Data were stored and retrievedusing SPSS 12.0. Descriptive statistics were used to provide a description of the sampledpopulation; and multiple regression was used to test the general hypothesis after which a finalmodel was established that explains subjective wellbeing of elderly Jamaicans. The entertechnique was used in multiple regression to established the general wellbeing model; and thestepwise was used to ascertain the explanatory power of each factor in the modelMeasuresElderly (i.e. aged, or seniors, older adulthood): This terminology refers to the chronological agebeginning at 60 years and beyond. Elderly cohort: This is a non-dichotomous variable, withthree categories. These are as follows: (1) Young elderly (60 – 74 years); (2) Old elderly (75 –84 years), and (3) Oldest elderly (85+ years).Wellbeing Index = ½ [MR] - ½[Σ Hi], where higher values denote more subjective wellbeing.The index ranges from a low of -1 to a high of 14. Scores from 0 to 3 denotes very low, 4 to 6indicates low; 7 to 10 is moderate and 11 to 14 means high wellbeing. Material Resources, (MR) 294
    • is the summation of all the household durable assets owned by the individual excluding propertyand home; and health, (H), is the summation of all self-reported dysfunctions (i.e. ailments orillnesses) and injuries suffered in the past 4-weekCrime Index = Σ kiTj, where Ki represents the frequency with which an individual witnessed orexperience a crime, where i denotes0, 1 and 2, in which 0 indicates not witnessing orexperiencing a crime, 1 means witnessing 1 to 2, and 2 symbolizes seeing 3 or more crimes. Tidenotes 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= threatenedwith a gun, and 4= sexually assaulted or raped. The summation of the frequency of crime by thedegree of the incident ranges from 0 and a maximum of 51.Physical Environment: This is a dummy variable, which in response to questions – (1) Has this household been affected by landslides, floods, or other natural disasters during the last 12 months) - No (2) was recoded as 0, Yes (1) remained as -1 and not stated was declared as missing; and (2) ‗What do you know or believe has caused these health effects?‘Negative Affective Psychological Conditions: The summation of the 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. The Negative Affective Psychological Conditions Index ranges from 0 to 15.Positive Affective Psychological Conditions: The summation of the number of responses with regards to being hopeful, optimistic about the future and life generally. The Positive Affective Psychological Conditions Index ranges from 0 to 8.Household crowding: (proxy by the average occupancy of persons per room). Total number of 295
    • individuals living in a household (Household size – all members) divided by the number of room occupied by that household [excluding the kitchen and bathroom(s)].Loneliness (or Lonely Elderly). This is a dummy variable proxy by living alone.Social Support. This variable is conceptually defined as not having living child/(ren), and/orgrandchild/(ren).Findings: Demographic Characteristics of Population The population is 3,009 elderly respondents, of which 47.5% were males (N=1,423) with52.7% females (N=1,586). The sample was predominantly young old (53.9%, N=1,251), with11.9% being oldest old (N=276). The overall wellbeing of the sample was very low (i.e. meanwellbeing being 3.9 ± 2.3). Further examination revealed that 19.7% of elderly Jamaicans werelonely (i.e. living alone, N=593), 44% indicated that they do not have any social support with25.3% (N=759) declared that they received no retirement income (this include NationalInsurance or private pension) and 15.7% reported that they either were living in a rented house orsquatted on the land. (See Table 11.2a). Notwithstanding classification of the sample withregard to home tenure, 76.9% (N=1,940) owned property (i.e. land and buildings excludingdwellings). Furthermore, the population was dominantly rural residents (66.8%, N=2,010), withprimary and level education (63.2%, N=1,793), with the elderly having the least wellbeing (3.8[out of 14) ± 2.3; N=2,320] when compared to the general population [4.2 (out of 14) ± 2.1;N=25, 1018] and the working age population [4.5 (out of 14) ± 2.1; N=13,610]. One of the demograp