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  • 1. Human Ageing, Health, Health Utilization and Policy Implications: An introduction to Behaviour and Practices Paul Andrew Bourne
  • 2. Human Ageing, Health, Health Utilization and Policy Implications: An introduction to Behaviour and Practices i
  • 3. Human Ageing, Health, Health Utilization and Policy Implications: An introduction to Behaviour and Practices Paul Andrew Bourne Director Socio-Medical Research Institute ii
  • 4. ©Paul A. Bourne, 2011First Published in Jamaica, 2011 byPaul Andrew Bourne66 Long Wall DriveStony Hill,Kingston 9,St. AndrewNational Library of Jamaica Cataloguing DataHuman Ageing, Health, Health Utilization and Policy Implications: Anintroduction to Behaviour and PracticesIncludes indexISBNBourne, Paul AndrewAll rights reserved. Published , 2011Cover designed by Paul Andrew Bourne iii
  • 5. List of Acronyms and InitialsAARP American Association of Retired PersonsAIDS Acquired immunodeficiency syndromeBMI Body Mass IndexCI Confidence IntervalDALE Disability Adjusted Life ExpectancyDHEA DehydroepiandrosteroneDNA Deoxyribonucleic acidED Enumeration Districtet al OthersGDP Gross Domestic ProductHSB Health Seeking BehaviourJADEP Jamaica Drug for the Elderly ProgrammeJSLC Jamaica Survey of Living Conditionskg KilogramLFS Labour Force SurveyLFS Labour Force SurveyLSMS World Bank’s Living Standards Measurement Studym meterMOH Ministry of HealthNHF National Health FundOR Odds Ratio iv
  • 6. P ProbabilityPAHO Pan American Health OrganizationPIOJ Planning Institute of Jamaica ()PSU Primary Sampling UnitQoL Quality of LifeQoL Quality of LifeRGD Registrar General DepartmentSD Standard deviationSES Socioeconomic statusSPSS Statistical Packages for the Social SciencesSTATIN Statistical Institute of JamaicaUS United StatesUN United NationsUNDP United Nations Development ProgrammeUWI The University of the West IndiesWHO World Health Organization v
  • 7. Table of Contents pageList of Acronyms and Initials ivList of Figures ixList of Tables xiiPreface xxAcknowledgement xxvDedication xxviPart I: Human Ageing 1 Introduction1 Historical Overview On Human Ageing2 Population Ageing and the State of the Elderly in JamaicaPart II: Health: An introduction 47 Introduction3 Health measurement4 A conceptual framework of wellbeing in some Western nationsPart III: Health status: Using health data 975 Paradoxities in self-evaluated health data in a developing country6 Variations in health, illness and health care-seeking behaviour of those in the upper social hierarchies in a Caribbean society7 Self-reported health and medical care-seeking behaviour of uninsured Jamaicans vi
  • 8. 8 Social determinants of self-reported health across the Life Course9 Social Determinants of Health in a developing Caribbean nation: Are there differences based on municipalities and other demographic characteristics?10 Health Inequality in Jamaica, 1988-200711 Hospital Healthcare Utilisation in middle-income developing country12 Inflation, Public Health Care and Utilization in Jamaica13 Self-evaluated health and health conditions of rural residents in a developing country14 Self-reported health and health care utilization of older people15 An Epidemiological Transition of Health Conditions, and Health Status of the Old-Old-To-Oldest-Old in Jamaica: A comparative analysis16 Happiness, life satisfaction and health status in Jamaica17 Dichotomising poor self-reported health status: Using secondary cross- sectional survey data for Jamaica18 Retesting and refining theories on the association between illness, chronic illness and poverty: Are there other disparities?19 Modeling social determinants of self-rated health status of Hypertensive in a middle-income developing nation20 Comparative Analysis of Health Status of men 60+ years and men 73+ years in Jamaica: Are there differences across municipalities?21 Medical Sociology: Modelling Wellbeing for Elderly People in Jamaica22 Health Determinants: Using Secondary Data to Model Predictors of Wellbeing of Jamaicans23 The changing faces of diabetes, hypertension and arthritis in a Caribbean population vii
  • 9. 24 Health status of patients with self-reported chronic diseases in JamaicaPart IV: Psychology of Ageing 65825 Ageing and the MindPart V: Mortality 68226 Impact of poverty, not seeking medical care, unemployment, inflation, self- reported illness, and health insurance on mortality in Jamaica27 Decomposing Mortality Rates and Examining Health Status of the Elderly in JamaicaPart VI: Policy Framework 75528 Agenda setting, Development of legislation, Implementation and Policy Modification29 Major Health Determinants: Are they ignored in the way in which Caribbean Health Services are organized?Part V: Health Insurance Coverage 780 30 Determinants of self-rated private health insurance coverage in JamaicaPart VI: Poverty, Wealthy and Health 80531 Health Disparities and the Social Context of Health Disparity between the Poorest and Wealthiest quintiles in a Developing CountryPart VII: Old-to-Oldest Elderly 83732 Good Health Status of Old-to-Oldest elderly People in Jamaica: Are there difference in rural-urban area?Glossary 866 viii
  • 10. List of Figures pageFigure 1.1: Selected regions and their percent of pop. 65+ years 13Figure 2.1: Ranked Order of the five leading causes of mortality in the population 65 yrs and older, 1990 33Figure 2.2: Leading causes of self-reported morbidity in the population of seniors, by gender in Barbados and Jamaica. 34Figure 2.3.: Percentage distribution of 5 main causes of deaths by age: 2002-2004 36Figure 3.1: The relation between health policy and health, and the roles of health determinants 55Figure 10.1: Percentage of Men Seeking Medical Care by Percentage of Menreporting Illness 254Figure 10.2: Percentage of People Seeking Medical Care by Prevalence of Poverty 255Figure 10.3: Percentage of Men Seeking Medical Care by Percentage of Menreporting Illness 256Figure 10.4: Percentage of Women Seeking Medical Care by Percentage of Womenreporting Illness 257Figure 10.5: Percentage of people Seeking Medical Care by Percentage withHealth Insurance 258Figure 10.6: Ownership of Health Insurance and Prevalence of Poverty 259Figure 11.1: Public-Private Health Care Utilisation in Jamaica (in %), 1996-2002,2004-2007 Source: Taken from Jamaica Survey of Living Conditions, various issues 283Figure 11.2: Remittances By Income Quintiles and Jamaica (in Percent): 2001-2007Source: Extracted from the Jamaica Survey of Living Conditions, 2007 284Figure 12.1: Inflation By Public Health Care Utilization 299Figure 12.2: Inflation by Private Utilization Care 300Figure 12.3: Cost of Medical care for Public and private health Care 301Figure 12.4: Public and private health Care Utilization 302Figure 12.5: Visits to Public Health Care Facilities and the Number of ReportedIllness/Injury 303Figure 12.6: Health Insurance Coverage and Inflation 304Figure 12.7: Incidence of Poverty and Inflation, 1988-2007 305 ix
  • 11. Figure 12.8: Public Health Care Utilization and Incidence of Poverty 306Figure 12.9: Private Health Care Utilization and Incidence of poverty 307Figure 12.10: Illness/Injury and Inflation 308Figure 12.11: Cost of Public and private health Care Cost and Inflation 309Figure 12.12: Seeking Medical Care By Inflation 310Figure 12.13: Seeking Medical Care and Incidence of Poverty 311Figure 12.14: Seeking Medical Care and Health Insurance 312Figure 14.1. Caribbean Elderly population as a percentage of total population 367Figure 14.2. Jamaica Elderly population as a percentage of total population 367Figure 14.3. Percentage of population 80+ years with health insurance coverage,2002 and 2007 375Figure 15.1. Diagnosed health conditions, 2002 and 2007 429Figure 15.2. Self-reported illness (in %) by Income Quintile, 2002 and 2007 430Figure 16.1: Percentage change in elderly population by five year age groups, 1991-2001 432Figure 19.1. Health seeking behaviour (in %) by marital status and sex 533Figure 26.1. Not seeking medical care (in %) by Year 714Figure 26.2. Annual Mortality (No. of people) in Years 715Figure 26.3. Not Seeking Medical Care (in %) by Prevalence of poverty rate (in %) 716Figure 26.4. Not Seeking Medical Care (in %) by Unemployment rate (in %) 717Figure 26.5. Not Seeking Medical Care (in %) by Illness/Injury (in %) 718Figure 26.6. Mortality (No of people) by Not Seeking Medical Care (in %) 719Figure 26.7 Prevalence of poverty rate (in %) and Unemployment rate (in %) 720Figure 26.8. Not Seeking Medical Care (in %) by Health Insurance Coverage (in %) 721Figure 26.9. Mortality (No. of people) by Prevalence of Poverty (in %) 722Figure 26.10. Mortality (No. of people) by Unemployment rate (in %) 723 x
  • 12. Figure 26.11. Prevalence of poverty rate (in %) by Inflation rate (in %) 724Figure 26.12. Not Seeking Medical care (in %) by Inflation rate (in %) 725 xi
  • 13. List of TablesTable 2.1: Observed & Forecasted Percentage of Elderly 65 years or over in Selected Regions, and the World Countries: 1950, 1975, 2025 and 2050. 14Table 2.2: Observed & Forecasted Percentage of Elderly 60 years or over in Selected Regions, and the World Countries: 1950, 1975, 2025 and 2050. 15Table 2.3: Characteristics of the Three Categories of Elderly, and Ageing transition 18Table 2.4: Percentage of Estimated or Projected Populations of Selected Caribbean Nations, 1980, 2000, 2005 and 2020 24Table 2.5: Total Fertility Rate for Selected Caribbean Nations, Caribbean, and Latin American: 1950-1955 to 2045-2050 26Table 2.6: Life Expectancy at Birth of both Sexes for Selected Caribbean Nations, the Caribbean, and Latin American 27Table 2.7: Life Expectancy at Birth of Jamaicans by Sex, 1880-2004 28Table 2.8: Jamaica: Selected demographic variables, Labour Force Participation (in %). 30Table 5.1 Socio-demographic characteristic of sample by sex of respondents 118Table 5.2 Socio-demographic characteristic of sample by educational level 119Table 5.3 Socio-demographic characteristic of sample by self-reported illness 120Table 5.4 Stepwise Logistic Regression: Good self-rated health status by sociodemographic, economic and biological variables 121Table 5.5 Table 5.5. Stepwise Logistic Regression: Self-reported illnessby sociodemographic and biological variables 122Table 6.1. Demographic characteristics of sample 143Table 6.2. Particular variables by social hierarchy 144Table 6.3. Logistic regression: Moderate-to-very good health status by particular variables 145Table 6.4. Logistic regression: Self-reported illness by particular variables 146Table 6.5. Logistic regression: Self-reported health seeking behaviour by particular variable 147 xii
  • 14. Table 7.1: Socio-demographic characteristics of sample 167Table 7.2: Sociodemographic characteristic by Sex 168Table 7.3. Health status by Self-reported dysfunction 169Table 7.4. Ordinary Logistic Regression: Correlates of Good Health Statusof Uninsured Jamaicans 170Table 7.5. Ordinary Logistic Regression: Correlates of Medical Care-Seeking Behaviour of Uninsured Jamaicans 171Table 8.1: Good Health Status of Jamaicans by Some Explanatory Variables 189Table 8.2: Good Health Status of Elderly Jamaicans by Some Explanatory Variables 190Table 8.3: Good Health Status of Middle Age Jamaicans by Some Explanatory Variables 191Table 8.4: Good Health Status of Young Adults Jamaicans by Some Explanatory Variables 192Table 9.1: Demographic characteristic of sample 216Table 9.2: Self-rated health status By Sex 217Table 9.3: Diagnosed Self-reported illness By Sex 218Table 9.4: Typology of Self-reported Diagnosed Illness By Sex 219Table 9.5: Diagnosed Self-reported illness By Age group 220Table 9.6: Self-rated Health Status by Age group 221Table 9.7: Predictors of Self-rated Health Status of Jamaicans 222Table 9.8: Predictors of Self-rated Health status of men in Jamaica 223Table 9.9: Predictors of Self-rated Health status of women in Jamaica 224Table 9.10: Predictors of Self-rated Health Status of Jamaicans in Urban Areas 225Table 9.11: Predictors of Self-rated Health Status of Jamaicans in Other towns 226Table 9.12: Predictors of Self-rated Health Status of Jamaicans in Rural Areas 227Table 10.1: Life Expectancy at Birth of Jamaicans by Sex: 1880-2004 249Table 10.2: Inflation, Public-Private Health Care Service Utilization, Incidence ofPoverty, Illness and Prevalence of Population with Health Insurance(in per cent), 1988-2007 250 xiii
  • 15. Table 10.3: Seeking Medical Care, Self-reported illness, and Gender composition of thosewho report illness and Seek Medical Care in Jamaica (in percentage), 1988-2007 251Table 10.4: Public Health Care Visits (using the JSLC, data) and Actual Health Care Visits(using Ministry of Health Jamaica, data), 1997 and 2004 252Table 10.5: Self-reported Health Status per 1,000 by Population, Men and Women;Sex-Ratio of Self-reported Health Status, and Female to Male Ratio of Self-reportedHealth Status, 1989-2006 253Table 11.1 Discharge, Average Length of Stay, Bed Occupancy and Visits toPublic Hospital Health Care Facilities, 1996-2004 285Table 11.2 Inflation, Public-Private Health Care Service Utilisation, Incidence of Poverty,Illness and Prevalence of Population with Health Insurance (in per cent), 1988-2007 286Table 11.3 Hospital Health Care Utilisation (Using Jamaica Survey of LivingConditions Data) By Income Quintile (%): 1991-2007 287Table 11.4 Demographic Characteristic of Sampled Population, n=1,936 288Table 11.5 Public Hospital Health Care Facility Utilisation by Area of Residence(in percentage), n =1,936 289Table 11.6 Public Hospital Health Care Facility Utilisation By Per Capita PopulationIncome Quintile (in per cent), N=1,936 290Table 11.7.1 Descriptive Statistics of Negative Affective Psychological Conditionsand Per capita Income Quintile 291Table 11.7.2 Multiple Comparison of Negative Affective Psychological Condition byPer Capita Income Quintile 291Table 11.8.1 Descriptive Statistics of Total Positive Affective Psychological Conditionsand Per Capita Income Quintile 292Table 11.8.2 Multiple Comparisons of Positive Affective Conditions by Per Capita IncomeQuintile 292Table 11.10 Logistic Regression: Predictors of Public Hospital Health Care facility utilisationin Jamaica 293 xiv
  • 16. Table 11.11 Public Hospital Facility Visits (using the JSLC and Ministry of Health Jamaica)By 1997 and 2004 294Table 12.1: Inflation, Public and private health Care Service Utilization, Incidence ofPoverty, Illness and Prevalence of Population with Health Insurance(in per cent), 1988-2007 328Table 12.2:Annual Inflation in Food and Non-Alcoholic beverages and Health Care Cost,2003-2007 329Table 12.3: Percentage of Households Receiving Remittances By Region, 2001-2005 330Table 12.4: Percentage of Households Receiving Remittances By Quintile, 2001-2005 331Table 12.5: Mean Patient Expenditure ($) on Health Care in Public and Private Facilitiesin the Four-Week Reference Period, JSLC 1993-2004, 2006 332Table 12.6: Purchased medication and Seeking Medical Care (Per Cent), 19-2006 333Table 12.7: Distribution of Poverty By Region (Per cent), 1997-2007 333Table 12.8: Distribution of Elderly Population (ages 60 years and older) ByRegion (Per Cent), 1997-2007 334Table 13.1. Demographic characteristics, 2002 and 2007 345Table 13.2: Self-reported health conditions by particular social variables 347Table 13.3. Health care-seeking behaviour by sex, self-reported illness, health coverage,social hierarchy, education, age and length of illness, 2002 and 2007 349Table 13.4. Stepwise Logistic regression: Social and psychological determinantsof self-evaluated health, 2002 and 2007 351Table 13.5. Stepwise Logistic regression: R-squared for social and psychologicaldeterminants of self-evaluated health, 2002 and 2007 352Table 14.1. Sociodemographic characteristic of sample 389Table 14.2. Diagnosed health conditions by area of residence 390Table 14.3. Health status by area of residence 391Table 14.4. Health status by self-reported illness, 2007 392 xv
  • 17. Table 14.5. Health status by gender 393Table 14.6. Health status by gender 394Table 14.7. Health status by health care-seeking behaviour 395Table 14.8. Health status by health insurance coverage 396Table 14.9. Diagnosed health conditions by health care seeking behaviour 397Table 14.10. Health status by Annual total expenditure, 2007 398Table 14.11. Self-reported health conditions by total expenditure, 2002 and 2007 399Table 14.12. Self-reported health conditions by medical care expenditure(public and private health care expenditure), 2002 400Table 15.1. Socio-demographic characteristics of sample 418Table 15.2. Self-reported illness by sex of respondents, 2002 and 2007 419Table 15.3. Self-reported illness by marital status, 2002 420Table 15.4. Self-reported illness by marital status, 2007 421Table 15.5. Self-reported illness by Age cohort, 2002 and 2007 422Table 15.6. Mean age of oldest-old with particular health conditions 423Table 15.7. Diagnosed Health Conditions by Aged cohort 424Table 15.8. Self-reported illness (in %) by health status 425Table 15.9. Health care-seeking behaviour and health status, 2007 426Table 15.10. Health care-seeking behaviour by health status controlled for aged cohort 427Table 15.11. Logistic regression on Good Health status by variables 428Table 17.1. Socio-demographic characteristic of sample, n = 6,783 486 xvi
  • 18. Table 17.2. Very poor or poor and moderated-to-very poor self-reported health statusof sexes (in %) 487Table 17.3. Odds ratios for very poor or poor and moderate-to-very poor self-reported healthof sexes by particular variables 488Table 17.4. Odds ratios of poor health status by age cohorts 489Table 18.1: Demographic characteristic of sample, 2002 510Table 18.2. Particular variable by social hierarchy, 2002 511Table 18.3. Self-reported injury, normally go if ill/injured, why didn’t seek care for currentillness, length of illness and number of visits to health practitioner by social hierarchy, 2002 512Table 18.4. Logistic regression: Self-reported illness by particular variables 513Table 18.5. Logistic regression: Self-reported chronic illness by some variable 514Table 19.1. Sociodemographic characteristics of study population, n = 206 534Table 19.2. Sociodemographic characteristics and health care utilization byself-rated health status 535Table 19.3. Sociodemographic characteristics and health care utilization byPopulation Income Quintile 536Table 19.4. Logistic regression: Variables of self-rated health status 537 xvii
  • 19. Table 20.1: Life Expectancy at Birth of Jamaicans by Sex: 1880-2004 560Table 20.2: Seeking Medical Care, Self-reported illness, and Gender compositionof those who report illness and Seek Medical Care in Jamaica (in %age), 1988-2007 561Table 20.3 Number of older men (60+ years) and difference over each year inJamaica: 1990-2007 562Table 20.4 Sociodemographic characteristics of sample (n =1,432): Men 60+ years 563Table 20.5 Logistic regression: Variables predicting good health status of men 60+ yearsAnd 73+ years in Jamaica 564Table 21.4.: Profile of the surveyed respondents: Variables used in Wellbeing Model 575Table 21.1: Life Expectancy at Birth of Jamaicans by Sex: 1880-2004 587Table 21.2: Jamaica: Selected demographic variables, Labour Force Participation (in %) 588Table 21.3: Growth Rate of Selected Age Group and for Total Population of Jamaica, usingCensus data: 1844-2050 589Table 21.5: Wellbeing Equation of the Jamaican Elderly 590Table 22.1: Percentage and (count) of Marital Status by Gender of respondents 604Table 22.2: A Multivariate Model of Wellbeing of Jamaicans 605Table 22.3: Decomposing the 39.3% of the variance in Wellbeing of Jamaicans,using the squared partial correlation coefficient 606Table 23.1: Operational definitions of particular variables 627Table 23.2. Demographic characteristic of sample, 2002 and 2007 628Table 23.3. Self-reported diagnosed chronic illness by sex of respondents, 2002 and 2007 629Table 23.4: Particular demographic and health variable by diagnosed chronic illness,2002 and 2007 630Table 23.5. Age of respondent by particular chronic illness, 2002 and 2007 631Table 24.1: Socio-demographic characteristics of sample 653Table 24.2: Diagnosed chronic recurring illness by age group 654 xviii
  • 20. Table 24.3: Diagnosed chronic illness by social class 655Table 24.4: Crowding, income and annual consumption expenditure bydiagnosed chronic disease 656Table 24.5: Logistic regression: Predictor of poor health status of patients who reportedchronic disease 657Table 26.1. Annual Inflation in Food and Non-Alcoholic beverages and Health Care Cost,2003-2007 711Table 26.2. Inflation, Public-Private Health Care Service Utilization,Incidence of Poverty, Illness and Prevalence of Population with Health Insurance (in per cent), 1988-2007 712Table 26.3. Seeking Medical Care, Self-reported illness, and Gender composition of thosewho report illness and Seek Medical Care in Jamaica (in percentage), 1988-2007 713Table 27.1: Socio-demographic characteristic of the respondents 748Table 27.2: Age-specific death rates by older ages and crude death rate, 1998-2007 749Table 27.3: Life expectancy at birth of Jamaicans by sex: 1880-2004 750Table 27.4: Mortality sex ratio by older ages and population, 1998-2006 751Table 27.5: Health status by Age group 752Table 27.6: Diagnosed (chronic) illness by age cohort 753Table 27.7. Poor health status of elderly Jamaicans by some explanatory variables 754Table 30.1: Demographic characteristic of sample by area of residence 801Table 30.2: Good health status by social standing (Per capita population quintile) 802Table 30.3: Good health status by age group 803Table 30.4: Logistic regression: Private health insurance coverage by some variables 804 xix
  • 21. xx
  • 22. PrefaceAgeing is not a recent issue in the world as it goes back centuries, to the beginning of humanexistence. The ageing reality was first studied by Denise Eldemire-Shearer (formerly, DeniseEldemire) in Jamaica in the early 1990s. While Denise Eldemire-Shearer’s pioneering work(PhD thesis in 1993) evaluated the epidemiology of ageing in Jamaica, it failed to explore theassociation between ageing and self-rated health status, social determinants of health among theaged population, the relationship between self-reported illness and self-rated health, and many ofthe subsequent works (quantitative and qualitative inquiries) equally did not research thosecritical issues in the discourse of ageing studies. Despite the works having left a gap in theliterature, they provided a comprehensive understanding of ageing, meaning of ageing from anon-medical perspective and an understanding of aged Jamaicans which have aided in theformulation of countless Ageing Policies. The pursuit of truth which is critical to science, albeit social or pure, means thatacademics CANNOT behave as though the gap is filled and nothing is left to research in thediscipline of Ageing Studies as this is not the case. By failing to evaluate self-rated health statusamong the aged as well as social determinants of health of this cohort, the pursuit of truthdictates that scientific inquiry is needed in those areas. An established gap in the literature onAgeing Studies symbolizes the importance of further research as these can provide germanerationale for future policy formulation and intervention programmes. In 2003 a workshop proceedings on ‘Ageing well: A life course perspective’ addressedplethora of germane issues (such as Active ageing: WHO perspectives; Caribbean Ageing andPolicy Implications; Psychological Dimensions of Ageing; Age-friendly primary Health Care: xxi
  • 23. Ministry of Health’s Perspective; Surgery in the Elderly: A prospective Study in a DevelopingCountry; Surgery in the Elderly: What, Where and How: Reducing Clinical Complications forDiabetes and Hypertension in the Older Population; Diagnostic and Management Approaches toDementia) but none of the articles pursuit the truth of Self-rated Health, Health Care Utilization,social determinants, particularly among the aged – people 60+ years old). In the entirepublication (Ageing Well…) there was an absence of critical empirical studies on the agedpopulation that could aid policy makers with crucial information for effective policy planningand intervention programmes. Although those topic pursued by the various scholars were vital tothe general health of the elderly, more research on different tenets of the aged are unavoidableand cannot continue unresearched when data are able that could aid policy formulation andunderstanding of this aged cohort. In 2005 an entire text on ‘Health Issues in the Caribbean’ edited by Owen Morgan twoarticles and/or studies appeared on ageing, one by Denise Eldemire-Shearer and Yvonne Stewart.Again like early publication in 2003 none of the articles inquired the self-rated health and ageingas well as health care utilization among the elderly. If science is about the pursuit of truths,principles of verifications, logic, precision, then the absence of systematic inquiry on ageing andhealth, ageing and health care utilization, will not advance the understanding of the aged inJamaica, for policy planning and evaluations. Although science continues unabated in our world,we are failing to provide truths in health literature, particularly on the aged. The elderly is agrowing group that ignorant of information will not help understanding the population. Indevelopment planning, ageing and population ageing cannot be excluded for other matters (suchas growth and development, inflation, unemployment, chronic illness and standard of living). xxii
  • 24. The current text fills the gap in the literature by systematically exploring healthmeasurement, health and ageing, ageing and health care utilization, particularly among agedJamaicans. Knowledge cannot be expounded upon by unresearched phenomena, supporting thepurpose of this book to enhance the revolutionary nature of science in explaining what is, ageingand self reported health. The structure of this book, therefore, substantially reflects an expansionof Denise Eldemire-Shearer’s pioneering work, current works by Janet LaGrande, Chloe Morrisand Eldemire-Shearer. The difference of this work is a gradual progression of a usefulframework for understanding ageing, health and ageing, health care utilization and ageing inJamaica. The book commences with an overview of ageing, definitions of health, determinants ofhealth, health care utilization and disparity in health of the aged males and females in Jamaica. This book is written for audiences of health care practitioners, academics, health andapplied demographers, gerontologists, social workers, sociologists, students of sociology anddemography, policy formulators, health care administrators, psychologists (applied and clinical),elderly, and general readers who wish to understanding the phenomena expounded upon in thisvolume. Econometric tools are used throughout this text that may challenging for some readers,but the author tried to thoroughly explain these issues in a matter than can be grasped by allreaders, with or without statistical skills. In producing this work, it makes use of data from secondary cross-sectional surveys,previously published works in the age of health, health care utilization, ageing, and health andageing to illustrate and demonstrate the practices and behavior of the aged in Jamaica. Like KarlPearson, the author somewhat subscribe to the proposition that good health is inherited ratherthan nurtured by a particular socio-physical milieu, but also thinks that this may not necessarilybe the care among the aged. These thinking led to the examination of plethora of matters on xxiii
  • 25. health and health care utilization, with particular emphasis on the aged, in order to provide acomprehensive understanding of the phenomena instead of merely hold unsubstantiatedpositions. As a scientist the author cannot claim truths with verifications, that is the basis uponwhich many of the inquiries emerge and new positions are formed. Ageing is a reality that is highly dreaded in many societies, because people believe it isthe slowing and closing of life’s gift. Ageing is a part of the life’s trajectory, which means thatthere is nothing to fear or be apprehensive about as it is certain at the beginning of life that thereis a high probability ageing will occur. Ageing is sometimes refers as ageism (ie. a negativereality) primarily because of the observation of many who are elderly. Ageing does notcommence at 60+ years, it begin at birth and continues throughout life. Some seek a panacea forageing; they desire its disappearance because of its perceived negatives, mythologies andmisnomers. Ageing gracefully is rarely forwarded by many people in societies, even though thisis aired by agencies, people fear death which account for the negative psychological dislike forageing beyond 60 years. Empirical evidence showed that some health conditions are more likely to emerge beyonda particularly chronological age, which increases the psychological negative of ageing at 60+years. It is not the mere onset of health conditions that pose the fear for many, but it is theincreasing likeliness of morality on the introduction of those conditions. With this realty, ageingbeyond a certain chronological value is not a welcoming thing for some people. The seniorsyears merely reflects the commulative status of earlier years coupled with the socio-physicalenvironment, indicating that the objective is not to fear ageing but it is to mindful of thosesituations and how we can make amendments in order to discount poor health in the later years. xxiv
  • 26. No discourse on ageing and/or health can be completed without an examination of thehealth status of the fasting growing aged cohort in Jamaica, the old-to-oldest elderly. With ruralpoverty being twice that of urban poverty, more elderly residing in rural geopolitical zones, old-to-oldest elderly are mostly unemployable or unemployed, comorbidity increases with advancedage, we need knowledge on the health status of this people and factors that account for good self-rated health status. Chapter 32 provides a comprehensive examination of the aforementionedissues, illness affecting the old elderly versus the oldest-elderly, and the statistical associationbetween illness, poverty and old-age. Now we have a better understanding of those factors that account for old-to-oldest elderlygood health. While the data were goodly fitted for the model, the explanatory power was low ofthose identified predictive factors. This means that good health of this age cohort is notinfluenced by income or social standing, and that there is a need to examine lifestyle risk factors;disease indicators and psychological conditions as this may provide more answers to good healthof Jamaicans 75 years and older. A quantitative assessment has provided use with answers; it isclear from the findings that more information is needed on this age cohort. The researcherrecommends the use of qualitative methodologies to provide in-depth understanding of thosefactors that determine good health of this age cohort. All the chapters were carefully and deliberately chosen in keeping with the focus ofhuman ageing, health, health utilisation and policy formulation. The majority of the chaptershave some advanced statistical techniques, but the author tried to ensure that information providewill give a thorough understanding without any knowledge of advanced statistics. The authorhopes that the information can commence the discourse on human ageing, policy changes, policyimplementations and the rebranding of human ageing in Jamaica. xxv
  • 27. AcknowledgementsJamaica continues to log behind in the study of self-rated (or reported) health among the aged.Because science cannot be advanced without pursuing truths, it follows that the gaps in theliterature must be met with immediacy in order to provide meanings and guidelines for policymakers and other scientists, and science. This book emerged out of a stay with my aged mother(Ms. Janet “Medda” Green), brother (Mr. Kervin Roger Smith), niece (Janet Smith), nephew(Kevin Smith) and hearing about the comorbidities experienced by the ageing uncle (Mr. GeraldGreen). During the holidaying with ageing mother and being cognizant of the realities of ageing,I was awoken to the realization that ageing is process as I saw the ease with which my motherslept and work with small intervals between. Like her older brother (Mr. Gerald Green), mymother experienced comorbidities such as hypertension, heart conditions, circulatory problemsand respiratory conditions, yet works assiduously in the days and awake in the nights as hungryas an unfed tiger. Ageing became a reality that I began interfacing with, but realize that it wasnot to be dread as both my mother and her brother were lovers of the age, say it as a time aoffering some ‘good’ to the younger generation and challenging many of the stereotypes andfears of ageing, ageism was social construct that they fail to accept and one that bars the psychefor exploring further unchartered areas. This book is, therefore, a verification of the pursuit of truths on health and ageing inJamaica, and is the inspiration of my holiday experience, family, relatives including Uncle Mr.Gerald Green. The creation of this volume is to examine many issues unresearched in the pastand is totally due to the aforementioned individuals and science, the pursuit of truths. xxvi
  • 28. Dedication This volume is dedicated to Janet Green, Gerald Green, Kervin Smith, Evadney BourneAged people, Jamaicans, Young people xxvii
  • 29. Human Ageing, Health, Health Utilization and Policy Implications: An introduction to Behaviour and Practices xxviii
  • 30. Part I: Human Ageing 1
  • 31. IntroductionFor millennia, the pursuit of truths on longevity (human ageing) were primarily centered around1) lifespan, 2) biology (including genetic and embryology), 3) morbidity and comorbidity 4)functionality (physical and cognitive), 5) mortality, and 6) changes in population structure andcomposition. The majority of those issues were embedded in the biomedical model. The theoriesthat emerged during the earlier years substantially addressed cause of biological ageing(including functional ageing). Because it was long established that ageing was associated withincreased health conditions and mortality, many studies were geared toward pathogens andfinding the curse for morbidities. Those gave rise to plethora of demographic andepidemiological studies on life expectancy, which was in keeping with a logical assessment ofhuman ageing, using empiricism. For centuries, there have been a gradual development of empirical works outside of thehistorical undercurrents of human ageing (lifespan, life expectancy, longevity, genetics,embryology, mortality, and morbidities), these have given currency to inquiries on social ageing(as such as happiness, lifestyle, perceptions, quality of life, health status, ageism). Theperspectives of aged people extend beyond the live years to experiences (including sexuality),social programmes, and taxation. A pioneer in Jamaica who has been investigating humanageing is Denise Eldemire-Shearer (formerly Denise Eldemire). She has dedicated the majorityof academic studies to the examination of human ageing issues, outside of the traditionalbiomedical model. Professor Eldemire-Shearer has expanded the non-biomedical studies onhuman ageing by including areas like health status, challenges of ageing, ageing realities, stressand employment status (as well as productivity). 2
  • 32. Although Eldemire-Shearer layed the foundations for the revoluation and development inthe literature on human ageing in the Caribbean, particularly Jamaica, her works were notdirected towards modeling the health status, self-health conditions, and chronic disease, usingeconometric analyses. The use of economietric techniques, Ian Hambleton and colleaguesintroduced this to the study of self-rated health status of aged Barbadians. Outside of IanHambleton and colleagues’ study, Paul Bourne has conducted plethora of research on health ofthe aged. The gradual development of scientific studies on health and human ageing in Jamaica,outside of the biomedical model, has provided a more comprehensive understanding andknowledge of the elderly. This volume has not explored the cultural biases and negatives onageing, ageism, but sought to evaluate health and ageing mainly using secondary cross-sectionalsurvey data. The negative perspectives of ageing include 1) worthless burden, 2) can beabandoned for young people, 3) tax burden or liability including economic cost, 4) diseaseinfected, 5) low productivity, 6) humoured and ridiculed by others, and 7) discriminated againstby the society. The negative perceptions of the ageing influence the treatment of the aged. TheJamaican society is one of culture that has many things negative to ascribe about the elder. LikeJamaica, Turish men fear the onset of ageing, as they believe that during this period theeconomic challenge will be intensified because of the turmoil in the nation (McConatha, et al.,2004). This is not the case in societies like Japan, China, and/or Mexican Americans, AsianAmericans, Kung of Botswana, Housa of Nigera as ageing carries with it a high degree ofpresitige and great respect (AARP, 1995; Holmes and Holmes, 1995; Kalavar, 2001; Foos andClark, 2010; Sokolovsky, 1999). A study conducted by Wilks and Colleagues (2008), using data on Jamaicans aged 15-74 3
  • 33. years old, found that 53% of men aged 65-74 years had sexual relations at least once per monthcompared to 4.2% of females of the same age; 18.5% of elderly males (aged 65-74 years old)reported having diabetes compared with 29.6% of elderly females of the same age; 60.5% elderlymales reported hypertension and 66.1% of females. The elder is an individual who is normal,with more experiences, sexually and physically active like the young, but who have a higherprobability of being influenced with health conditions than their younger aged people. Clearly peoples’ perception on ageing is culturally based and varies across society and/orcultures. Negative views on older people affect the negative attitude toward ageing and thetreatment of them, but these are not of what this volume seeks to address. The text is in responseto the gap in the literature on health and ageing, with the primary purpose of providing empiricalstudies on the phenomena in order to guide principles, theories and develop issues on adultageing in Jamaica. Human ageing is a reality that commenes the day one is born, continues over the lifespanand end at death. Regardless of peoples’ perception of ageing, their attitude toward ageing,human ageing must be understood as the population ages. Knowledge on ageing is critical todevelopment as are inflation, monetary policy, national debt and unemployment. Ageing,therefore, is an important phenomenon that explains current practices, behaviours and lifestylesof the past. This volume examines issues on ageing, population ageing in the Caribbean,particularly Jamaica, health status, health conditions, utilization, and hospitalization ofJamaicans, with emphasis on the elderly. 4
  • 34. ReferencesAARP. (1999). The AARP grand parenting survey. Washington, DC: Author.Bourne, P.A. 2009. Growing Old in Jamaica: Population Ageing and Senior Citizens’ Wellbeing. Kingston: Department of Community Health and Psychiatry, Faculty of Medical Sciences, the University of the West Indies, MonaErber, Joan. 2005. Aging and Older Adulthood. Canada: Waldsworth, Thomson Learning Inc.Foos, P.W., & Clark, M.C. (2010). Human aging, 2nd ed. Boston: Pearson Education.Holmes, E.R., & Holmes, L.D. (1995). Other cultures, elder years, 2nd ed. Thousand Oaks, CA: Sage.Kalavar, J.M. (2001). Examining ageism: Do male and female college students differ? Educational Gerontology 27, 507-513.McConatha, J.T., Hayta, V., Riesser-Danner, L., McConatha D. (2004). Turkish and US attitudes toward aging. Educational Gerontology 30, 169-183.Sokolovsky, J. (1997). The cultural context of ageing, 2nd ed. New York: Bergin and Garvey Publishers.Wilks R, Younger N, Tulloch-Reid M, McFarlane S, Francis D. (2008). Jamaica health and lifestyle survey 2007-8. Kingston: Tropical Medicine Research Institute, University of the West Indies, Mona. 5
  • 35. Chapter1 Historical Overview On Human AgeingIn the earlier centuries, pandemic and pestilence destroyed millions of peoples. One suchpandemic was the Oriental or bubonic plague (a rate-based disease, fleas that lived on humansand rats). In early 1330s, it exterminated many lives in Hong Kong and later spread throughoutChina, the continent of Asia and then to Europe. In October 1347, the pestilence was brought toEurope by a group of Italian merchants who had traveled to China on business. On their return tothe ports of Sicily, many of them were found suffering from the plague and some were dead. Thepestilence had traveled all the way Northern Europe to England. In August of the fourteenth century (1348), the people of England named it the ‘Black Death’. It eradicated approximately 40 million people worldwide. Some scholars argue that this disease ‘wiped out’ about one-third to one-half of European’s and Asian’s human population (Rowland 2003), and five years it slaughtered 25 million Europeans. The disease stayed with people until it disappeared in the 1600s. Then during the 1700s, smallpox slew an estimated 100 peoples worldwide. Following those pandemics and plagues, the discoveries of peninsulin along with propersanitation and public health have seen a significant reduction in mortality. Whereas low mortality 6
  • 36. is not synonymous with all nations – because of warfare and famine- low death rates have beenthe experience of a plethora of the developed societies. This reality is also happening in manydeveloping and emerging nations. Accompanying mortality decline is the issue of the fertilitytransition that began in the France in the 19th century. This has spread throughout Europe,America and Canada, Japan, China, Barbados and Jamaica to name a few countries. Manydeveloped societies are now experiencing what is referred to as ‘below replacement levelfertility. This is where the society automatically replenishes itself by approximately 2.1 births perwomen of child-bearing age (15 – 49 years). There are societies like Barbados, Trinidad and Tobago, Japan, France, Sweden, andCanada among others that have a total fertility rate of approximately 1.6 children per woman ofchild-bearing age, which is an indicator of below replacement level fertility. This coupled withdeclining mortality further explains the next inevitable population challenge, old ages.Population ageing is not simply longer live, but is the health challenges that face not only theindividual but the cost of health, the possibility of reduced economic growth, shifts in diseasepatterns and prevalence and the increasing pressure that it is likely to place on the working agepopulation. The question that few Jamaicans have been asking themselves is ‘what are the scope,implications and challenges of population ageing’ within our declining state (increasingly lessresources). Indicators of population ageing Demographers refer to ageing of world population as demographic ageing (or populationageing, or ageing population). There are a few yardsticks that are used in this process. One, theyuse the median age of the population. This is where one-half of population within a geographicspace is either above or below a certain age (median age). Two, some use the proportion of the 7
  • 37. human population that is 65 years (some say 60 years) and older, which is 8 – 10 %. For thepurpose of this paper, I will use the latter (8 -10% of the population 60 and 65 years and older).As a demographer, the chronological valuation for old age (or ageing population) is 65 years andbeyond; and so, this will be used throughout this paper except in a further cases, and when this isthe case, I will specify to this end. Population ageing means longer life and not necessarily quality living. In this article, Iuse ageing totally in the sense of longer life. With this said, there is an indication that Jamaica’spopulation have been ageing, and when did this began? Another germane question that is ofsignificance is ‘Is there a gender disparity in longer life, and which sex is likely to live longer inJamaica?’ I will begin with life expectancy as the symbolic representation of population ageing. Implications of population ageing Furthermore, Jamaica like Montserrat and Barbados are experiencing the return of someof those people who migrated in the 1950s-1960s, who are elderly along with the continuousnegative migration of young people, thereby increasingly expanding the population ageing inthose societies. This is an explanation of the population ageing occurring within many of theCaribbean nations. Therefore, many Caribbean countries began experiencing population ageingin 1960s but it has recently begun to be of concern because of the emphasis of this matter on theworld stage. Ageing inevitable means longer life, that affects the population composition andstructure. In that as the population ages, the base of the population pyramid narrows, while theupper portion expands. If reduced fertility continues without any major catastrophe in the future,what we are likely to experience is people living longer, and the death rates at older ages willbegin to naturally increase thereby changing the population age structure further. Another result 8
  • 38. of this demographic ageing is increased disability that will result. Whereas technologicaladvances have added years to people’s lives, it has not reduced ailments. So people will beliving longer, but with more disability. Global life expectancy has risen from 47 years in 1950-1955 to 65 years and beyond in 2000-2005 and 2005-2015, which is similar for Jamaica,Trinidad and Tobago, Bahamas and Barbados (United Nations 2006:87-89; United Nations 2005:xxii: STATIN 2003). One of the probabilistic results of ageing is the reduction on the workingaged and the youthful population. These provide shifts in the population pyramid as it contractsat younger ages and expand at older ages. This is reiterated in a publication of the CaribbeanFood and Nutrition Institute (1999:191) that stated, “By the year 2050, there will be olderpersons than children in the world, the majority of whom will be females and widowed orwithout a partner. The Caribbean is likely to mirror this phenomenon…” The Statistical Instituteof Jamaica pointed out that those societies that were at the early stage of the demographictransition in which fertility remains high and mortality decline are now experiencing increasingin younger population. However, for those that at the late stage, where fertility is declining andmortality is stationary, the younger sector of the population is smaller than the segment 60 yearsand older (STATIN 2003). This is in keeping with the global perspective on demographictransition. Within the 21st century, population ageing and shifts in health status of the population aresynonymous constructs, along with the deviations between living longer and living healthier.Notwithstanding these realities, scientific study on the aged population is more recent than theconstruct itself. Erber credited a Belgian mathematician and astronomer, Adolphe Quetelet, in1835, for studying the different stages that men pass through during their lifetime. The work is apivotal landmark in the study of the ageing process. As population ageing is reality in the 9
  • 39. Caribbean, Jamaica and other developed nations that have begun in earnest to project the likesocio-economic of “greying” populations within the general setting of aged dependency, supportratios and many issues associated with demographic transition. In 1884, an Englishman named Francis Galton who was both a mathematician andmedical doctor researched ‘physical and mental functioning’ of some 9,000 people between theages of 5 and 80 years (Erber 2005:4). As mathematician like his predecessor, AdolpheQuetelet, Galton want to measure human life span, physical and mental functioning of people.Therefore, he sponsored a health exhibition that would allow him to have data for analysis. Thisbegs the question – what explains that fascination of man in seeking to understand ageing, and inparticular, his/her intrigue with the aged and their wellbeing? 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, in particular general wellbeing, have not taken front stage on theradar of demographers unlike many other demographic issues. This is especially true for theCaribbean. There are signs indicating that population ageing in the 21st century is affecting manyindustrialized societies. These societies are affected through low fertility, which speaks to thefuture problems of – high age dependency ratios, high support ratio, and future changes inpopulation size and structure. Among the challenge of low fertility in industrialized nations arethe difficulties that it posses for population replacement, reduced juvenile dependency, lowerpotential fertility, and increased old-age ratio. There are some non-demographic issues that spill 10
  • 40. offs of population ageing such as the consequences for future pension allocations, hospitalizationexpenditure for the aged. A demographer, Alain Marcoux, measured population ageing in an article titled‘Population ageing in developing societies: How urgent are the issues?’ as a specified valuationof the general population being 60 years and older. The benchmark that was used to establish thissituation is the proportion of the population who are aged 60 years and over exceeds 10%)whereas another group of scholars Gavrilov and Heuveline used 65 years and beyond thatexceeds 8-10%. These include for example - Germany, Greece, Italy, Bulgaria and Japan;U.S.A; Sweden – Figure 1.1, below). Interestingly, Greece and Italy’s aged population (people60 years and older) in 2000 stood at least 24% of the total population, which indicate completionof the fertility and mortality transition, and the high burden being placed on the workingpopulation. Those societies’ fertility decline began early and their mortality at older ages hasbeen declining; this justifies their ageing population. The issue of the ageing of a population cannot be simply overlooked as such; a situationwill affect labour supply, pension system, health care facilities, products demanded, mortality,morbidity, and public expenditure among other events. It [ageing] is not simply about mortality,fertility and/or morbidity. The phenomenon is about people, their environment and how theymust coexist in order to survive, and how institutions that do exist to enhance longevity. Ageing,therefore, is here to stay. In order to grasp the complexities of this phenomenon, Lawson’smonograph adequately provides a summative position on the matter. She noted that: Actually, it is predicted (U.N) that developing countries are likely to have an older generation crisis about the year 2030, that is about the same time as most developed countries (Lawson 1996:1) 11
  • 41. This demographic transition is not only promogated by Lawson, but is concurred on byCowgill who believed that come the next half-century (2030), there is strong possibility thistransition will plague developing nations. This is no different for the developed nations. Threecenturies ago, the issue of ageing would not constitute one out of twenty-five of the totalpopulation, or even more than this as is the case in the 21st Century. According to Lawson, “Theworld is going to have to learn to live with populations containing a much higher proportion ofolder people…” The speed at which a population will age (60 years and over) in countries in theLatin America and the Caribbean (shift from 8 to 15 %) will be shorter than two-fifths theduration of time it took the United States and between one-fifth and two-fifths for WesternEuropean country to attain similar levels (McEniry et al. 2005; Palloni et al. 2002). The rate ofgrowth in the ageing populace in Latin America and the Caribbean is not only realty, but theissue is; will the elderly’s care and well-being reside squarely on the shoulders of the young? Seniors cannot be neglected as they will constitute an increasingly larger percentage oftotal population and sub-populations in different topography than in previous centuries.Furthermore, from all indications, in the developing world, the elderly population will continueto increase as a proportion of the globe’s population which is in keeping the world’s ageingstatistics. According to Randal and German, the numbers of aged living in developing countrieswill more than double by 2025, “reaching 850 million”. The Caribbean is not different asaccording to Grell, the English-speaking Caribbean from the 1970 census revealed that between8.8 and 9.8 percent of the populace were 60 years and older. A matter Lawson noted began inJamaica since the 1900. From a study commissioned by the Planning Institute of Jamaica, it was noted that theglobe’s population grew at a rate of 1.7 percent per annum, with the population of the seniors (60 12
  • 42. years and older) growing at 2.5 percent. A point of emphasis was the monthly growth rate forthe elderly in developing countries (3.3 %), with a projected population forecast of seniors forJamaica for 2020 to be 15 percent. From the World Development Indicators report, in 2003, 6.9percent of Jamaicans were 65 years and older. Eldemire noted that the increased aged populacein Jamaica began in the 1960’s. From statistical reports, the percent has continued to increasepost-2000. STATIN in ‘Demographic Statistics, 2004’ reported that 10 percent of Jamaica’spopulation are 60 years and older, which is supported by Eldemire contrary to the viewpoints ofGibbings. Despite the indecisiveness to reach consensus on a definition of ageing from theUnited Nations’ perspective on the elderly, ‘old age’ begins at 60 years while demographersconceptualize this variable as ages 65 years and older. “Where ‘Old age’ begins is not preciselydefined, the unset of older age is usually considered 60 or 65 years of age” (WHO 2002, 125).Nevertheless, this project is a partial fulfillment of a demography degree, and so will subscribe todemographic conceptualizations, primarily. Whereas, some developing countries will begin toexperience this come 2030 most societies would have been exposed to this by 2050. U.S.A Sw eden Major Area, region and country Germany Italy Europe Japan India China Latin America and the Caribbean Af rica World 0 10 20 30 40 Percentage of the Elderly (65+ years) 1950 2000 2050 Figure 1.1: Selected regions and their percent of pop. 65+ years Source: United Nations 2005: World Population Prospects: The 2004 revision (page 20) 13
  • 43. Chapter2 POPULATION AGEING and the STATE of the ELDERLY In Jamaica Introduction Ageing is not a recent phenomenon; it goes back centuries. Currently, the differences arepace and level. The distinction here is, pace denotes the rate of growth per annum; and levelrepresents the percentage of the population who are experiencing a certain event. These conceptswill be made clearer with the use of various illustrations throughout this paper. As in 2007, it isestimated that the percentage of people 65 years or over is estimated to be 7.5% and come 2050,the figure is projected to reach 16.1%, which is a 115% increase in 43 years. On the contrary,between 1950 and 2007, the percentage of people ≥ 65 years rose by only 2.2%. (Table 1.1).However, by 2030, 1 in every 8 (12.5% of the globe’s population) humans will be 65 years andolder, and this is coming from 6.9% in 2000. But there is a discourse as to whether or not ‘oldage’ begins are 60 or 65 years; hence, we will present the figures as if we were using 60 years.Thus, if we are to use 60 years and older, the trends are relatively similar to those for ages 65year or over. As in 1950, the world’s population aged 60 years and older was 1 in 15 (8.2%); butin 2007, the figure rose to 1 in 9 (10.7%), and the projected 21.7 percent (or 1 in 5) by 2050(United Nations, 2007:72) (Table 2). Based on percentages, the world’s elderly population (≥ 60years) between 1950 and 1975 increased by 0.4%. However, between 1975 and 2007, thepercentage of ‘old people’ rose by 2.1% but for 2025-2050, the increase is expected to be 6.6%. Insert Table 2.1. Presently, China, United States, Germany, India, Sweden, Italy, and Japan have in excessof 50 percent of the world’s population who are 65 years or older. But, does population-- ageingstop with those societies only? The yardstick for measuring an ageing population is having 8-10% of the population reaching at least 65 years. As of 2025, the Caribbean will have an 14
  • 44. estimated 11.4% of its population ≥ 65 years. Statistics show that the percentage of Caribbeanpopulation ≥ 65 years is more than that for the combined of Latin American and the Caribbean(See Tables 2.1, 2.2). “Since population ageing refers to changes in the entire age distribution,any single indicator might appear insufficient to measure it” (Gavrilov, and Heuveline, 2003:3),which appears to have befallen many Caribbean states. This is evident in the political landscapeof Caribbean nations as the issue of demographic ageing has not taken on as a serious issue asdebt burden, inflation, unemployment, crime and international relations. The rationale for thisdelay is embedded in perception that critical as that time. But this position is far from the truth.For the reason that, apart from the demographic transition that is taking place globally andequally within the Caribbean, there is another aspect to this phenomenon. As the implications ofageing range from pension schemes problems, higher health care costs and initiatives. These donot cease there, as there are two important issues that we have yet to address, how we will bedealing with production and productivity within the context of an ageing nation (‘shrinkinglabour force because of ageing’; ‘possibly the bankruptcy of social security systems’). Onemedium has written that two-thirds of people ≥ 65 years are alive today (BRW, 1999), whichstrengthens the issue of taking population ageing to the forefront of national debate. Thus, it isclear that population ageing is a global phenomenon; but what is the extent of this in Caribbeanstates? To further comprehend this phenomenon or to explain this unbounded demographicreality; I will contextualize this paper within a global framework, with particular emphasis onselected Caribbean and more so on Jamaica. Insert Table 2.2 Ageing Defined. Ageing is a significant but neglected dimension of social stratification and the life-course is an essential component of the analysis of status (Turner 1998:299) “Where ‘Old age’ begins is not precisely defined, the onset of older age is usuallyconsidered 60 or 65 years of age” (WHO 2002:125). The indecisiveness to reach consensus on adefinition of ageing in spite of the United Nations’ perspective on the elderly, which ischronological ageing that begins at 60 years, yet demographers and many statisticians continueto conceptualize this variable as beginning at age 65 years (Lauderdale 2001; Elo 2001; Mantonand Land 2000; Preston et al. 1996; Smith and Kington 1997; Rudkin 1993). This moot point 15
  • 45. will not be settled in this paper, but what will happen here is that the various perspectives will bepresented to the readers. As a demographer, however, I will primarily be using the chronologicalage of 65 years and older to present the commencement of ‘old age’ (or ageing). But one shouldkeep in mind (as Turner date outlines) that ageing is a ‘social stratification’ which is neglectedwithin the discourse of social stratification. In medieval times, Thane (2000) notes that ‘old age’ were defined as 60 years and older.She justified this by forwarding an argument for the established age. In medieval England, menand women ceased at 60 years to be liable for compulsory service under labour laws or toparticipate in military duties. Ancient Rome, on the other hand, ‘old age’ began from early 40 to70 years, with 60 years being “some sort of annus climactorius”. Demographers see the seniors -the elderly or the aged (old people) - as individuals 65 years and older, and not an individual whois 60 years of age. Western societies use 65 years and older to represent the elderly (seniors) asthis is the period when people become fully eligible for Social Security benefits. Irrespective ofthe commencement age of the elderly, there is a wholesale agreement that the aged at thebeginning of the next generation will be a real social challenge. One scholar emphasized thatthere is no absoluteness in the operational definition of the “elderly” (Eldemire 1995:1). Shecommented that from the World Assembly of Ageing (which was held in Vienna in 1982), the“elderly” is using the chronological age of 60 years and older ‘as the beginning of the ageingprocess’. Jamaica having signed the Vienna Declaration of Ageing, which defines ageing tobegin at 60 years, Eldermire questioned academics and other scholars for their rationale in using65 years. I will now classify the ageing in two main categories, (1) chronological and (2)biological ageing. Chronological ageing Within the study of demography, the elderly begins at the chronological age of 65 years –using the unit of analysis of time, based on the number of years and months that has elapsedsince birth (Erber 2005; Iwashyna et al. 1998; Preston, et al. 1996; Smith and Waitzman 1994).However, based on the monographs from other scholars (such as - Marcoux 2001; Eldemire1997; PAHO and WHO 1997; Eldemire 1995; Eldemire 1994; Barrett 1987), the issue of theaged begins at 60 years. Hence, the issue of the aged continues to battle from non-standardization. For those who use 60 years, they adopt this value because of the World 16
  • 46. Assembly on Ageing (in Vienna, Austria: July-August 1982), which postulates that ageingbegins at the chronological of 60 years. The Canadian statistical agency used age 65 years as the dividing line between “young”and “old” (Moore et al. 1997, 2; Smith and Waitzman 1994; Preston, et al., 1996). The issue ofusing the chronological age of 65 years to measure older adulthood according to one academiacomes from the minimum age at which the Social Security System begins disbursing paymentfor pension to people living with the United States (Erber 2005:12). It is argued that in 1935, theU.S. government modeled this from the German’s retirement system. This explains the use of 65years of age by many scholar, practitioners and non-professionals ever since. This approach sub-divides ageing into three categories. These are (i) young-old (ages 65 through 74 years), (ii) old-old (ages 75-84 years) and oldest-old (ages 85 years and beyond). However, is there a differencebetween biological and chronological ageing? Biological ageing Organisms age naturally, which explains biological ageing. This approach emphasizesthe longevity of the cells, in relation to the number of years the organism can live. Thus, in thisconstruction, the human body (an organism) is valued based on physical appearance and/or stateof the cells. Embedded in this apparatus is the genetic composition of the survivor. This occurswhere the body’s longevity is explained by genetic components. Gompertz’s law in Gavriolovand Gavrilova (2001) shows that there is a fundamental quantitative theory of ageing andmortality of certain species (the examples here are as follows – humans, human lice, rats mice,fruit flies, and flour beetles (, Gavriolov and Gavrilova 1991). Gompertz’s law went further 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 an adult, but that this becomes less progressive in advanced ageing.Thus, biological ageing is a process where the human cells degenerate with years (the cells diewith increasing in age), which is explored in evolutionary biology (see Charlesworth 1994). Butstudies have shown that using evolutionary theory for “late-life mortality plateaus”, can failbecause of the arguably the unrealistic set of assumptions that the theory uses to establish itself. Reliability theory, on the other hand, is a better fitted explanation for the ageing ofhumans than that argued by Gompertz’s law as the ‘failing law’ speaks to deterioration of human 17
  • 47. organisms with age (Gavrilov and Gavrilova 2001) as well as a non-ageing term. The latterbased on Gavrilov and Gavrilova (2001) can occur because of accidents and acute infection,which is called “extrinsic causes of death”. While Gompertz’s law speaks to mortality in ageingorganism due to age-related degenerative illnesses such as heart diseases and cancers, a part ofthe reliability function is Gompertz’s function as well as the non-ageing component. When the biological approach is used to measure ageing, it may be problematic as twodifferent individuals with the same organs and physical appearance may not be able to perform atthe same rates, which speaks to the difficulty in using this construct to measure ageing.Nevertheless, this construct is able to compare and contrast organisms in relation to the numberof years, a cell may be likely to exist. Erber (2005) argues that this is undoubtedly subjective, aswe are unable within a definite realm to predict the life span of a living cell (Erber 2005:9).Interestingly, the biological approach highlights the view that the ageing process comes withchanges in physical functioning. The oldest-old categorization is said to be the least physicalfunctioning compared to the other classification in chronological ageing. The young-old, on theother hand, are more likely to be the most functioning as the organism is just beginning thetransition into the aged arena (Erber 2005; Brannon and Fiest 2004). In order to avoid such pitfalls in constructions that may arise with the use of thebiological approach, ergo, for all intent and purposes, given the nature of policy implications ineffective planning, the researcher is forwarding the perspective that seniority in age commencesat age 65 years – using the chronological ageing approach. In summarizing the ageing transition, both chronological and biological ageing have asimilar tenet; in that, as we move from young-old to oldest-old, the body deteriorates and whatwas of low severity in the earlier part of the ageing process becomes crucial in the latter stage.Hence, at the introductory stage of the ageing transition, the individual may feel the same aswhen he/she was in the working age-population, but the reality is that the body is in a decliningmode. Because humans are continuously operating with negatives and positive, as he/shebecomes older – using the ageing transition (65 years and older) – the losses (or negatives)outweigh the positives. This simply means that the functionality limitation of the body falls, andso opens the person up to a higher probability of becoming susceptible to morbidity andmortality. Secondly, their environment, which may not have been problematic in the past, now 18
  • 48. becomes a health hazard. One University of Chicago scholar summarizes this quite well in Table2.3: Table 2.3: Characteristics of the Three Categories of Elderly, and Ageing transition Characteristic The Ageing Transition Young-old Aged Oldest-Old Heath problems Low Moderate High Physical disability Low Moderate High Demand for medical care Low Moderate High Demand for public service Low Moderate High Demands on children Low Moderate High Dependency on other Low Moderate High Social isolation Low Moderate High Source: This is taken from Essays in Human Ecology 4. Bogue 1999, 3. 1 Donald Bogue (1999) used aged (age 75 – 84 years) to refer to what this paper calls old-old Historical Issues on Population Ageing: Global Perspectives. Ageing has emerged as a global phenomenon in the wake of the now virtually universal decline in fertility and, to a lesser extent, of increases in life expectancy (Marcoux 2001:1) In the earlier centuries, pandemic and pestilence would destroy millions of lives. Anexample here is, in the fourteenth century, the ‘Black Death’, killed approximately 40 millionpeople worldwide. One scholar argues that this disease ‘wiped out’ about one-third to one-halfof European’s and Asian’s human population (Rowland, 2003). As during the 1700s, smallpoxkilled an estimated 100 peoples worldwide. This reality explains why population ageing was nota phenomenon then, as the deaths were high and widespread. Therefore, the person was notlikely to live beyond fifty years. Following those pandemics and plagues, the discoveries ofpeninsulin along with proper sanitation and public health have seen a significant reduction in 19
  • 49. mortality. Whereas low mortality is not synonymous with all nations, low death rates have beenthe experience of a plethora of the developed societies. This reality is also happening in manydeveloping and emerging nations. Accompanying mortality decline is the issue of the fertilitytransition that began in France in the 19th century. It is argued, that reduction in fertility isprimarily a cause of population ageing today as well as a steady decline in mortality rates. Even though, the ageing process is life long and though it may be constructed differentlywithin each society, 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, in particular general wellbeing, have not taken front stage on theradar of demographers, unlike many other demographic issues. The 20th century has brought with it massive changes in typologies of diseases wheredeaths have shifted from infectious diseases such as tuberculosis, pneumonia, yellow fever,Black Death (Bubonic Plague), smallpox and ‘diphtheria’ to diseases such as cancers, heartillnesses, and diabetes. Although diseases have shifted from infectious to degenerate, chronicnon-communicable illnesses have arisen and are still lingering within all the advances in science,medicine and technology. One demographer showing the extent of human destruction due to theBlack Death mentioned that this plague reduced Europe’s population by one-quarter (Rowland,2003:14). Accompanying this period of the ‘age of degenerative and man-made illnesses’ is lifeexpectancies that now exceed 50 years. So while people aged 70 years and beyond in manydeveloped and a few developing states, the question is - Are they living a healthier life – how istheir wellbeing within the increases in life expectancy? Alternatively, is it that we are just stuckon life expectancies and diseases as primary predictors of wellbeing – or health status? Before the establishments of the American Gerontology Association in the 1930s andtheir many scientific studies on the ageing process (Erber, 2005), many studies were done basedon the biomedical model (physical functioning or illness and/or disease-causing organism),(Brannon, & Feist, 2004:9). Many official publications used either (i) reported illnesses andailments, or (ii) prevalence of seeking medical care for sicknesses. Some scholars have still notmoved to the post biomedical predictors of health status. The dominance of this approach is sostrong and present within the twenty first century, that many doctors are still treating illnesses 20
  • 50. and sicknesses without an understanding of the psychosocial and economic conditions of theirpatients. To illustrate this more vividly, the researcher will quote a sentiment made by a medicaldoctor in ‘The Caribbean Food and Nutrition Institute Quarterly, 1999. A public healthnutritionist, Dr. Kornelia Buzina, says that “when used appropriately, drugs may be the singlemost important intervention in the care of an older patient … and may even endanger the healthof an older patient …” (quoted in the editorial of Caribbean Food and Nutrition Institute1999:180). A demographer, Alain Marcoux, measured population ageing in an article titled‘Population ageing in developing societies: How urgent are the issues?’ as a specified valuationof the general population being 60 years and older. The benchmark that was used to establish thissituation is the proportion of the population who are aged 60 years and over exceeds 10%(Marcoux 2001:1), whereas another group of scholars Gavrilov & Heuveline (Gavrilov, &Heuveline, 2003) used 65 years and beyond that exceeds 8-10%. These include for example -Germany, Greece, Italy, Bulgaria and Japan; U.S.A; Sweden (Goulding, & Rogers, 2003).Interestingly, Greece and Italy’s aged population (people 60 years and older) in 2000 stood atleast 24% of the total population (Mirkin, & Weinberger, 2001), which indicates the completionof the fertility and mortality transition, and the high burden being placed on the workingpopulation. Those societies’ fertility decline began early and their mortality at older ages hasbeen declining; this justifies their ageing population. This is not only confined to developedsocieties as it is spreading to the entire world. Demographic Trends: The Global perspective Globally, trends in population ageing are such that demographic ageing is seen as afundamental phenomenon of concern both inside and outside of the intelligentsia class. I willdisplay the issue in great detail below, as the figures will speak of the trends that we have seenmore so since the 1900s. And that this progression will continue in the next 50 years. The agedpersons >65 years and older in 1950 was 5.2%, and by 1995 the figure rose to 6.5%. But, duringthe 1950s-1960s, the 65+ age cohort rose by 0.1%, which may be marginal but it earmarks thebeginning a demographic phenomenon. In 1999, persons aged 65 years and older were 410.5 million, and one year later the figurerose to 420 million, which is a 2.3 percentage increase over the previous year. In addition during 21
  • 51. 2000 to 2030, it is estimated that aged persons >65 years, will rise from an approximated 550million to a projected 973 million (76.9%). By 2050, the persons aged 65 years and beyond, willbe some 13.8% of the world’s population. Currently, the developed nations sharedisproportionately more of the aged persons >65 years, this reality is not projected to change inthe future. However, by 2030, the absolute number of aged >65 years in the developing societiesis expected to triple, which will not be the same for the developed nations (from 249 million in2000 to 690 million by 2030). In summary, during 1950-2000, the elderly population (persons65+) increased by 1.7%. However, from 2000-2050, the same aged cohort will rise by 6.9%,which denotes a 100% increase in 50 years. The statistics reveal that come 2050 most of the aged population will be residing indeveloping countries. In addition, by 2030 the population 65-and older in developing societieswould have increased by 140 percent, which is 40% more elderly in developing nations than inthe world. Importantly, the aged are on the upper end of the ageing spectrum; and this affects thepopulation dynamics of the society. The total human population, within any geographic area,constitutes children, youth, working aged people and the elderly. With this said, the “graying”(spelling not consistent throughout) of a population is caused by fertility decline, reducedmortality and migration of the young and return of retirees coupled with increases in lifeexpectancies. Where the elderly population outgrows the younger population, this constricts thepopulation structure at younger ages and expanding it at older ages (Rowland, 2003:98). This isreferred to as demographic transition. It is the experience of many developed countries thatstarted with France, but has increasingly become a phenomenon for many developing nations. The demographic development of the world is not limited to the increase in persons 65years and older but the reduction of the children population (persons 0 – 14 years). In 1950, thechildren population was 34.3% of the globe’s population, and in 1975 the figure rose to 36.8%,and in 2007 the United Nations (2007:72) wrote that this is expected to be 27.6% and come2050, 20.2%. Accompanying this reduction in the children population is the increase in themedian age of the world’s population. As at the state of the 1950, this was 23.9 years, it fell to22.4 years in 1975 and is estimated to rise to 28.1 years in 2007 and project to reach 37.8 years,which is an indication of population ageing. The increase in proportion of people ≥ 65 andchanges in the median age can be simply explained by mortality changes, which demographers 22
  • 52. use life expectancy to explain. In life expectancy at birth during 1950-1955 was 46.6%, in 1975-1980, 59.9 years, and 2005-2010, 66.5 years and come 2045-2050 it is expected to reach 75.1years. In the more developed nations, currently (in 2007) estimated by the United Nations,2007:74), 20.7% of the population are persons ≥ 60 years, 15.5% are persons ≥ 65 years, and3.9% are persons ≥ 80 years. The life expectancy for people in these regions is more than theworld’s figure, as the United Nations (2007:75) writes that during 2005-2010, it is 76.2 years.However, in Northern Europe, it is 78.7 years, Southern Europe; it is 79.1 years, WesternEurope, 79.6 years, and in Northern America, 78.2 years. Thus, population ageing is indeed aglobal phenomenon and more so in developed nations, but what about the Caribbean and inparticular Jamaica? Demographic trends: Selected Caribbean Nations Ageing inevitably means longer life that affects the population composition and structure.Due to the fact that as the population ages, the base of the population pyramid narrows, while theupper portion expands. Demographers argue that this is substantially due to the fertility transitionand reduced mortality at older ages. If reduced fertility continues without any major catastrophein the future, what we are likely to experience is people living longer, and the death rates at olderages will begin to naturally increase thereby changing the population age structure further.Global life expectancy has risen from 47 years in 1950-1955 to 65 years and beyond in 2000-2005 and 2005-2015, which is similar for Jamaica, Trinidad and Tobago, Bahamas and Barbados(United Nations, 2006:87-89; United Nations, 2005: xxii: STATIN, 2003). One of theprobabilistic results of ageing is the reduction on the working aged and the youthful population.These provide shifts in the population pyramid as it contracts at younger ages and expand atolder ages. This is reiterated in a publication of the Caribbean Food and Nutrition Institute(1999) that stated, “By the year 2050, there will be (shouldn’t more go here) older persons thanchildren in the world, the majority of whom will be females and widowed or without a partner.The Caribbean is likely to mirror this phenomenon…” (Caribbean Food and Nutrition,1999:191). The Statistical Institute of Jamaica pointed out that those societies that were at theearly stage of the demographic transition in which fertility remains high and mortality decline arenow experiencing an increase in the younger population. However, for those that are at the latestage, where fertility is declining and mortality is stationary, the younger sector of the population 23
  • 53. is smaller than the segment 60 years and older (STATIN, 2003). This is in keeping with theglobal perspective on demographic transition. I will present a graphical display of the populations of the World and the Caribbean oftwo age cohorts, children (0-14 years) and elderly (65+), as an indication of the similarities thesedemographic trends. A further subdivision of selected Caribbean nations’ proportion of childrenand elderly populations are presented in Table 2.4.Table 2.4: Percentage of Estimated or Projected Populations of Selected Caribbean Nations,1980, 2000, 2005 and 2020 1980 2000 2005 2020Country 0-14 60+ yrs 0-14 60+ 0-14 yrs 60+ 0-14 60+ yrs yrs yrs yrs yrs yrsBarbados 29.6 14.1 22.5 14.1 18.9 13.2 19.4 19.3Guyana 40.9 5.7 30.2 6.3 29.4 7.4 23.0 11.3Jamaica 40.3 9.3 28.3 9.0 31.2 10.2 20.4 12.4Suriname 39.8 6.3 32.4 7.9 30.1 9.0 24.2 9.8Trinidad 34.3 8.1 28.6 8.4 21.5 10.7 23.5 13.3& TobagoCaribbean 36.7 8.6 29.9 9.9 27.7 10.7 24.2 14.2Source: United Nations. 2005c: World Population Prospects: The 2004 Revision Demographic development in the Caribbean has taken a similar path like the rest of theworld (Population Reference Bureau, 2007; STATIN, 2006; United Nations, 2005c). Over theyears, the movement has being such that mortality and fertility has been declining, and thepopulation 65 years and older has been increasing proportionately more than proportion who arechildren (See Tables 2.5, 2.6).. 24
  • 54. By the standard that if a population of aged person using ≥ 60 years exceeds 8-10% of thepopulation, there is the issue of demographic ageing. So since 1980, countries like Barbados,Jamaica, Trinidad and Tobago and generally the Caribbean have been experiencing thisphenomenon (Table 2.4). From the Table, by 2020, Barbados’ elderly population will be higherthan that of the Caribbean’s average. Among the factors of population ageing are mortality andfertility. Thus, merely using the proportion of persons who are either 65+ or 0-14 years is anindicator of demographic transition but mortality and fertility are critical determinants of ageingpopulation. According to the United Nations (2007:5), Decreasing fertility has been the primary cause of population ageing because, as fertility moves steadily to lower levels, people of reproductive age have fewer children relative to those of older generations, with the result that sustained fertility reductions eventually lead to reduction of the proportion of children and young persons in a population and a corresponding increase of the proportion in older groups (UN, 2007:5) The United Nations’ perspective has highlighted the importance of including fertility indemographic transition discourse as well as mortality. Statistics reveal that the total fertility rate(TFR) for 1970-1975 for the world was 4.49 and for 2000-2005, it fell to 2.65; whereas in LatinAmerica and the Caribbean between 1970-1975, it was 5.05 and this was further reduced to 2.55in 2000-2005 (United Nations 2005c, xxi). Concurrently, in 2005, total fertility in The Bahamasis 2.2, in Barbados it is 1.5, for Jamaica 2.3 and for Trinidad and Tobago, 1.6 (United Nations2006, 87-89). Barbados and the twin islands of Trinidad and Tobago are experiencing belowreplacement level fertility (Total Fertility Rate – TFR of 2.1 – United Nations 2000, 4), aproblem presently faced by many developed nations such as those in Southern and Easter Europeand the United States (United Nations 2005c, xxi). I have presented Table 5Table 5, for a moredetailed assessment of the total fertility trends of selected Caribbean States, the Caribbean andLatin America, in an effort for us to see the trend in this phenomenon, and the implications ofthis for population ageing come 2050. 25
  • 55. Table 2.5: Total Fertility Rate for Selected Caribbean Nations, Caribbean, and Latin American: 1950-1955 to 2045-2050 Countries 1950- 1975- 2005- 2025- 2045- 1955 1980 2010 2030 2050 Bahamas 4.1 3.2 2.2 1.9 1.9 Barbados 4.7 2.2 1.5 1.8 1.9 Belize 6.7 6.2 2.8 2.0 1.9 Dominican Rep 7.4 4.7 2.6 2.1 1.9 Guyana 6.7 3.9 2.1 1.9 1.9 Haiti 6.3 6.0 3.6 2.5 2.1 Jamaica 4.2 4.0 2.3 2.0 1.9 Suriname 6.6 4.2 2.4 2.0 1.9 Trinidad & 5.3 3.4 1.6 1.8 1.9 Tobago Caribbean 5.2 3.6 2.4 2.1 1.9 Latin America & 5.9 4.5 2.4 2.0 1.9 Caribbean Source: World Population Ageing 2007 Another determinant of the demographic transition is mortality. The mortality statisticsare used to compute the life expectancies, and so the researcher will use the latter as it is anindicator of the former. Mortality in the Caribbean has been falling and this can be seeing fromthe increased life expectancies, which are highly comparable with those in developed nations,which is beyond 71 years(United Nations 2007 – See Table 2.6, below). 26
  • 56. Table 2.6: Life Expectancy at Birth of both Sexes for Selected Caribbean Nations, the Caribbean, and Latin American Countries 1950- 1975- 2005- 2025- 2045- 1955 1980 2010 2030 2050 Bahamas 59.8 67.2 72.1 78.0 82.0 Barbados 57.5 71.4 76.4 79.2 81.4 Belize 57.7 69.7 71.7 74.0 78.0 Dominican Rep 45.9 61.9 68.6 73.8 77.7 Guyana 52.3 60.7 65.4 70.6 74.2 Haiti 37.6 50.6 53.5 62.2 70.1 Jamaica 55.8 70.1 71.1 75.0 77.7 Suriname 56.0 65.1 70.2 74.7 78.1 Trinidad & 59.0 68.3 70.1 74.1 78.5 Tobago Caribbean 52.2 64.5 68.7 73.2 76.9 Latin America & 51.4 63.0 72.9 76.8 79.5 Caribbean Source: World Population Ageing 2007 Demographic Trends: Jamaica The use of life expectancy, mortality, and total fertility rates are just some of the wayswith which demographic development can be shown. Instead of showing both mortality and lifeexpectancy, for this section of the paper the researcher will use life expectancy. As mortalityrates are used to calculate the life expectancy at various ages (Table 2.7). Another way ofdepicting population changes is through the use of a population pyramid. In this section, theresearcher will use Jamaica’s population pyramid since 2000 to depict the demographictransition occurring in this society, and then percentages of the elderly people with regard to thetotal population. It should be noted that the nation’s population pyramid in the year 2000showed a narrow top and a broad base. But by 2025, the population narrows at the base andbegins to expand at the middle, and come 2050, note how the population contrasts at the base aswe move toward an ageing population. Come 2050 and beyond, Jamaica’s oldest elderly will be substantially more females. The“graying” of the Jamaica’s population is coming, and has already made its way within the 27
  • 57. society. From a demographic perspective, relatively speaking a society is said to be oldwhenever the population of person aged 60 or over (and some scholars use 65 years or over)exceeds 8-10%, which is the case in Jamaica (Appendix I). This is not the only indicator as lifeexpectancy can be used to show population ageing. Jamaica’s life expectancy at birth for malesbetween 1879 and 1882 was 37.02 years and for females it was 39.80 years, between 2002 and2004 males’ life expectancy rose to 71.26 years and that of the females’ to 77.07 years, which isa clear indictor of demographic ageing (See Table 2.7). Table 2.7: Life Expectancy at Birth of Jamaicans by Sex, 1880-2004 Average Expected Years of Life at Birth Period: Male Female 1880-1882 37.02 39.80 1890-1892 36.74 38.30 1910-1912 39.04 41.41 1920-1922 35.89 38.20 1945-1947 51.25 54.58 1950-1952 55.73 58.89 1959-1961 62.65 66.63 1969-1970 66.70 70.20 1979-1981 69.03 72.37 1989-1991 69.97 72.64 1999-2001 70.94 75.58 2002-2004 71.26 77.07 Sources: Demographic Statistics (1972-2006) From records of the Population Division of the United Nations, Jamaica’s population 60years and older in 2050, using the medium (should it be median) variant, is likely to be 24% of 28
  • 58. the entire population, with 18.1% being 65 years and older, compared to approximately 5%being 80+ years. These shifts mean more degenerated conditions at older ages, increaseddisability and diminished quality of life. The disparity in gender composition speaks to thehigher morbidity in women and higher mortality for men (see Newman 2000: 8). In 2004, Jamaica’s old-aged population stood at 7.7 percent. According to WHO/SEARC(1999), India’s elderly population was 7.7 percent. During 2004-1991, the elderly population ofJamaica rose by 3.28 percent. When the elderly is strictly operationalized within ademographer’s space (65 years and beyond), on an average the elderly population grew by 3.62percent. The data in Appendix II reveal that for every 100 working-aged of the population thereare approximately 13 elderly that is dependent on them. This reality is within approximately 30percent of the population being children. Over the same period, the number of child-to-total-population grew by - 4.4 percent and by -10.08 percent for the youth. Within this context, thereis a need to analyze the labour force participation of aged Jamaicans as there would be socio-economic implications if this were to be declining in the nation. 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 that this to be 26.6% in 2007. This represents a 43% reduction in thenumber of people 65+ years who were actively involved in the labour force. When the labourforce participation rate is decomposed by sexes, the figures reveal a more telling disparity. Asfor females, in 1980, there were 30.4% of women actively involved within the labour force, but itis estimated to be 13.8% in 2007, which is a 55% reduction in the number of employed females.With respect to males’ involvement in the labour force, it is projected to fall to 41.4% in 2007,which is coming from 65.3% in 1980. The labour force participation rate for men will fall 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 (Table 2.8). Therefore, if we are to extrapolate a reduced 5 years for females, thelabour force participation rate will increase further by at least percentage points. 29
  • 59. Table 2.8: Jamaica: Selected demographic variables, Labour Force Participation (in %).Total (% of population4) 1950 1975 2007 2025 2050 60+ 5.8 8.5 10.3 15.0 23.6 65+ 3.9 5.8 7.6 10.3 17.7 80+ 0.2 0.8 2.0 2.3 5.6Female 1950 1975 2007 2025 2050 60+ 6.6 9.0 10.7 16.1 25.9 65+ 4.4 6.3 8.1 11.0 19.9 80+ 0.3 1.0 2.2 2.6 6.9Male 1950 1975 2007 2025 2050 60+ 5.0 8.0 9.9 13.8 21.3 65+ 3.2 5.3 7.1 9.7 15.4 80+ 0.2 0.6 1.8 2.0 4.3 1950 1975 2007 2025 2050Median age 22.2 17.0 24.9 30.7 39.3Labour Force Participation 1980 1990 2007 2010 2020 65+ 46.4 37.1 26.6 26.6 25.1 65+ 30.4 23.6 13.8 13.1 12.3 65+ 65.3 53.6 41.4 40.7 39.6United Nations, 2007:308-309 Another variable that can be used to indicate population ageing is the median age. Themedian age denotes a value that where one-half of the population is above or below that age.Continuing, the median age for Jamaica’s populace in 1950 was 22.2 years and it is estimated toreach 24.9 years in 2007 and come 2025 31 years, and by 2050 it should increase by another 8.6years. It should be note here, that demographers use a median age of 30 years to indicate anageing population. Thus, population ageing is without a doubt a Jamaican phenomenon like theNational debt problem and other social issues such as crime and teenage pregnancy. Without effective population planning for the elderly, come the next four decades, theold-aged population will become a burden to the working aged-populace in respect to medicalcare, nursing care, pension, other social insurance and survivability cost. With this impendingsocial reality, there is a high probability that the old-aged will be called on to provideincreasingly more of their needs for themselves within the construct of limited resources fromdeveloping societies. The physiological changes with ageing such as loss of hair, wrinkling ofthe skin, decrease in height, and loss of teeth are not the only issue of old age but there are othercritical factors that affect their wellbeing. State of the Elderly, with emphasis on Caribbean and Jamaica The Caribbean like many developed countries is now faced with the daunting task ofaddressing the “graying” of its population, because of mortality and fertility decline, which 30
  • 60. began1960s. To show that this is a challenge to geographic topography, the region launched itsfirst forum titled ‘The Caribbean Symposium on Population Ageing’ in November 2004 in Portof Span, Trinidad and Tobago, in order to strategize about this inevitable demographic transition,which began in earnest in developed societies. This is a precursor to its predecessor which washeld in Vienna in 1982 called ‘The First Assembly on Ageing’ and another named ‘SecondWorld Assembly on Ageing’, which was in Madrid in 2002. Like the developed world, theCaribbean islands are cognizant that policy implementation and mechanism are needed to forgean equitable solution for this phenomenon. With the Symposium comes the recognition thatageing is not limited to its call but that it affects the general society, future generations andpolitical decisions. Ergo, what is the state of the grayed population in Caribbean and more sowithin Jamaica. A study revealed that there is a statistical causal relationship between socioeconomicconditions and the health status of Barbadians. The findings revealed that 5.2% of the variationin reported health status was explained by the traditional determinants of health. Furthermore,when this was controlled for current experiences, this percent fell to 3.2% (falling by 2%).When the current set of socioeconomic conditions were used they account for some 4.1% of thevariation in health status, while 7.1% were due to lifestyle practices compared to 33.5% that wasas a result of current diseases (see Hambleton et al. 2005). It holds that importance place bymedical practitioners on the current illnesses – as an indicator of health status – is not unfoundedas people place more value on biomedical conditions as responsible for their current healthstatus. Despite this fact, it is obvious from the data – using 33.5% - that there are otherindicators that explain some 67.5% of the reason why health status is as it is. Furthermore, withan odds ratio of 0.55 for number of illness, there is clearly suggesting that the more peoplereported illness, the lower will be their health status. (See Hambleton 2005); and this was equallyso for more disease symptoms – odds ratio was 0.71) Accompanying the reduction in physical functioning which is a feature of biologicalageing (Erber 2005) is the fact that the Jamaican elderly spend the most number of daysreceiving medical care for illnesses and/or injuries (see PIOJ and STATIN 2002:4.1). In addition,they experience the highest rate of protracted illness the country, with the “… very young andthe elderly being the most vulnerable” (PIOJ and STATIN 1997:45). Embedded in this finding isthe poor health status of the elderly despite living longer. Essentially, this particular group is 31
  • 61. suffering from ill health caused by diabetes, stress, psychiatric disorders and chronic diseases,which translates into lower quality of life while their life is prolonged (see PIOJ and STATIN1994:22.1; 1990:20.1), which means they are living longer but suffering more - the high cost oflongevity of life. A Ministry of Health (MOH) report notes that the prevalence of chronic illnesses has alsoincreased with ageing and that this is even more pronounced for those 65 years and older, withmore males than females spending more time in health care facility (MOH, 2004:75), using thedischarge rate – 975.1 per 10,000 for males compared to 817.1 per 10,000 females. Interestingly,when a detailed analysis was done of the data, seniors who reside in rural areas were sufferingmore than their counterparts who live in other zones (PIOJ and STATIN 2000:58). A PIOJ andSTATIN (1995:32) report summarizes the wellbeing status of those 60 years and older, whenthey say “… our 60 year olds exhibited the highest prevalence of protracted illness/injuries”. Thesituation is speaksof is a state of well-being for the elderly that is not in keeping with thepositives of the advancement in medicine and medical technology. There is definitely a disparitybetween the seniors’ wellbeing reality and their lived years, which reiterates the need to measurewellbeing outside of the traditional biomedical model. From the findings of a cross-sectional study conducted by Powell, Bourne and Waller(2007) of some 1,338 Jamaicans, 19.0% of respondents perceived that their economic well-beingto be ‘very bad’. In addition, when they asked, “Does your salary and the total of your family’ssalary allow you to satisfactorily cover your needs”, 57.4% of them felt that this “does not cover”their expenses (Powell, Bourne and Waller 2007:29). What is the situation of the elderly seeingthat this group is even more (or equally) vulnerable than other age cohorts? The answer to this isembedded within JSLC reports. The JSLC (1997) makes it clear that the aged population(22.6%) and the children (less than five years – 14.7%) reported the highest number ofillness/injury, with those who resided in the rural areas being more vulnerable than those in otherzones are. In order to capture the severity of the issues faced by the Jamaican aged, if we are toconvert the mean number of days of reported illnesses into monetary terms, then the medicalexpenditure of the elderly would have helped to erode their well-being, along with the illnessesand their severity. Then, when retirement, loss of income, the cost associated with protractedailments, and the psychological challenges associated with ageing are collated and included inthe daily life of the elderly, within the context of a shrinking economy, rising prices, the poor and 32
  • 62. the elderly in particular the poor aged would be more vulnerable than other age groups withinthis society. There is an interconnection between economics and demography. In that,economists are concerned about human economic decisions at the micro and the macro level.The demographer, on the other hand, invests time in studying the science of human population.Therefore, while the demographer is not interested in the costing of decisions, the economistrequires a thorough understanding of the principles of the human population, in an effort toeffective comprehend how people within a particular geographic area are probable able to makedecision. The interconnectivity is evident that at the London School of Economics, thedepartment of demography is a subsection. A study on the elderly published in the Caribbean Food and Nutrition Institute’smagazine Cajanus found that 70% of individuals who were patients within different typologiesof health services were senior citizens (Caribbean Food and Nutrition Institute 1999; Anthony1999). Among the many issues that the research reported on are the six major causes ofmorbidity and mortality identified by the Caribbean Epidemiology Centre that is of paramountimportance to this discussion; the influence of - cerebrovascular, cardiovascular, neoplasm,diabetes, hypertension and acute respiratory infection (Figure 2.1). The diagram below depictsthe ranked order of the five leading causes of death for people 65 and over of selected Caribbeancountries in 1990. Trinidad & Tobago St. Lucia A cute respiratory inf ections Monts errat Hypertension Jam aica Diabetes Country Neoplasms Guyana Cardiovascular Dom inica disease Cerebrovascular disease Barbados Baham as 0 1 2 3 4 5 Ranked Order of 5 leading causes of mortalityFigure 2.1: Ranked Order of the five leading causes of mortality in the population 65 yrs and older, 1990Source: adopted from Caribbean Food and Nutrition Institute 1999: 222 33
  • 63. In seeking to explain the severity of the health status of Caribbean nationals, usingBarbados and Jamaica, the Caribbean Food and Nutrition Institute (1999) presents the 5-leadingcauses of morbidity as reported by seniors. The data revealed that the primary cause of illnessesin Barbados and Jamaica was hypertension. In both countries, hypertension was a femalephenomenon – in Barbados, females reporting 44.6% compared to 33.1% for males and inJamaica it was 55.4% for females and 30.3% of males (Figure 2.2, below). Stroke Heart disease Jamaica Female Diseases Jamaica Male Arthritis Barbados Female Dia betes Barbados Female Barbados Male Hyp erte nsion 0 20 40 60 Percentage Source: Figure taken from Caribbean Food and Nutrition Institute 1999:225. Figure 2.2: Leading causes of self-reported morbidity in the population of seniors, by gender in Barbados and Jamaica. The data in Figure 2.2 shows that hypertension and arthritis are morbidities thatsignificantly plague both men and women in both Caribbean countries. These chronic non-communicable diseases continue to interface within the functional lives of the elderly, whichmean that they are indeed living longer but are faced with lowered wellbeing. Secondly, if they 34
  • 64. are poor with proper and adequate health care coverage – which could be private or public - theimplications of the cost of care along with the daily living could further add stresses to the statusof life experienced by the elderly. Hence, living longer although it is directly related to reducedmortality, this does not speak to the lifestyle changes and their positive influences on thewellbeing of seniors. A study conducted by Costa, using secondary data drawn from the recordsof the Union Army (UA) pension programme that covered some 85% of all UA, show there is anassociation between chronic conditions and functional limitation – which include difficultywalking, bending, blindness in at least one eye and deafness (Costa 2002). Among thesignificant findings is – (i) the predictability between congestive heart failure of men andfunctional limitation (walking and bending). Although Costa’s study was on men, this equallyapplies to women as biological ageing reduces physical functioning, and so any chronic ailmentwill only further add to the difficulties of movement of the aged, be it man or woman. Like many developed countries, Jamaica is able to boast of its notable achievement inprogress made toward advancing the health status of its populace, during the twentieth century –the postponement of death, lowering fertility, high nutrition and sanitation and more importantlythe increasing life expectancy. Analyzing data on life expectancy indicate that the country’shealth status is reasonably good, as the values for life span is similar to those in some FirstWorld societies – over 70 years. Nevertheless, those positives are not sufficient to outweigh the increases in chronic non-communicable diseases - hypertension, diabetes, cardiovascular diseases, neoplasm, depressionand arthritis. These diseases are on the rise in the world and are no different in Jamaica. Theycontinue to plague those who are more so 60 years and older, of a particular socioeconomicstatus, and who live in rural Jamaica (Ministry of Health 2004, 133; Jamaica Social PolicyEvaluation 2003; Planning Institute of Jamaica [PIOJ] and Statistical Institute of Jamaica[STATIN] 2000:58). In an article published by Caribbean Food and Nutrition Institute, theprevalence rate of diabetes mellitus affecting Jamaicans is higher than in North America and“many European countries”. (Callender 2000:67). Diabetes Mellitus is not the only challengefaced by patients, but McCarthy (2000) argues that about 30% to 60% of diabetics also sufferfrom depression, which is a psychiatric illness. Such a situation further complicates the woes ofthe elderly as they seek to balance other psychosological conditions with the diabetes andhypertension along with the stress which is frequently associated with the illness. 35
  • 65. Furthermore, in attempting to contextualize the state of the Jamaican elderly, theresearcher will provide a diagram depicting the five main causes of death by different age groupsbetween 2002 and 2004. The diagram shows that while life expectancies are increasing, thatmortality from non-communicable diseases such as heart diseases, cerebrovascular diseases anddiabetes are indeed high for the elderly and are thereby lowering their wellbeing (Figure 2.3). In 2003, data presented by the Ministry of Health Jamaica in its ‘Annual Report’ showedthat of the patients who are 65 years and older, 29.7% of them were discharged from inpatientcare because of ‘circulatory system diseases’, and nutrition and endocrine ailments accounted for12.6%. While it is true that these diseases influence physical inactivity, the conditions of copingwith these as well as the cost of care undoubtedly should be aiding to lower the wellbeing statusof these people. 70+ Other heart disease 60-69 Ischaemic 50-59 Age cohorts Homocides 40-49 Diabetes 30-39 15-29 cerebrovascu lar under 15 0 20 40 60 80 Percent dis tribution of 5 m ain caus es of deathsFigure 2.3.: Percentage distribution of 5 main causes of deaths by age: 2002-2004Source: Adopted from the Demographic Statistics, 2005, (STATIN 2006:x). Findings from studies by the Planning Institute of Jamaica show that while the generalhealth status is commendable, increases in chronic illnesses are undoubtedly eroding the quality 36
  • 66. of life enjoyed by people who are 65 years and older (PIOJ and STATIN 2000:58-59; 1997:45).The report revealed that, “In 2000, the survey also demonstrated the importance of recurrent(chronic) illness as the cause of ill health among the elderly” (PIOJ and STATIN 2000:58). Howis the status of elderly within general setting of higher recurrence of chronic non-communicablediseases and their severity among senior citizens? Within the macho culture of Jamaica,generally, men do not seek preventative care because it is seen as weak. Such a position is learntfrom the culture, which states that boys should “suppress reaction to pain” (Chevannes 2001:37). State of the Elderly: Disparity in the Sexes Chevannes provided the explanation for this behaviour by men, that it is entrenched insocial learning theory. Where the young imitates the roles of society’s members through role-modeling of what constitutes acceptable and good roles which is supported by reinforcement(Chevannes 2001:17). The gender role of sexes is not limited to Jamaica or the Caribbean but astudy carried out by Ali and Muynck (2005) of street children in Pakistan found a similar genderstereotype in that nation. It was a descriptive cross-sectional study carried out during Septemberand October 2000, of 40 school-aged street children (8-14 years). The sample was substantiallymales (80%), with a mean age of 9 years (± 2 years). The methods of data collection were (i)semi-structured interviews, and (ii) a few focus group discussions. Ali and Muynck (2005)found that the sampled population would seek medical care based on severity of illnesses andfinancial situation. Another finding was that they referred to use home remedy. The reasonbeing that mild ailment is not severity enough to barr them from physical functioning, whichmean that they are okay; and so some morbidities are not for-hospital, which was so the case inNairobi slums (Taff and Chepngeno 2005:421). PIOJ and STATIN (1998) report that “The difference by gender was significant, with10.9 per cent of females reporting illness, compared with 8.5 per cent of males” (PIOJ andSTATIN 1998:45), which is the case even in 2002, that is the rate was 14.6% for females and10.4% for males, and in 2004 it was 13.6% for females and 8.9% for male (PIOJ and STATIN2006; 2003). From statement in the JSLC 2000 “Women have traditionally utilized health careservices more than men and these interactions have allowed closer monitoring and earlierdiagnosis of health conditions among women” (PIOJ and STATIN 2001:58), then this begs the 37
  • 67. question – Are the aggregate data reported reflecting the views of the elderly or more so thefemales? However, what is true is that they [men] will visit health practitioners because thestates of their chronic impairments are severe. This is evident in the higher number of treatedcases in some ailments over that of females – from the hospitalization discharge rate for thepersons 65 years and over, the rate for men is 975.1 per 10, 000 compared to 817.1 per 10, 000females. (Ministry of Health 2004:75, 133). The elderly, on the other hand, are more responsiveto their ill-health and seek medical attention readily, but what about the psychological state ofthis age cohort from things such as – loss of partner, reduction in social support, fear of beingvictimized and so forth. As a result, it should not be surprising that the elderly Jamaicans seekmore medical attention than other age cohorts, which is captured in them indicating more self-reported illnesses and injuries and a higher mean number of days spent in medical care (PIOJ andSTATIN 2006; 2003; 1998). Hence, is the state of the elderly worse than that which is reportedin the JSLC? It should be noted that the data presented in all the official statistics on the healthstatus of Jamaicans are still measuring health using the old biomedical model (using reported andtreated illnesses and/or injuries) - (JSLC; MOH 2004). This approach is single focused as itomits the role environment, social exclusion, fear of crime and victimization as well asdepression, and stress among other factors as determinants of individuals’ wellbeing. Conclusion This paper responds to the underlining concerns of the continuous increase in populationageing in the world. The fast ageing of populations, unless managed in a proactive manner, couldimpose serious challenges for policy makers in the Caribbean and Jamaica. Noteworthy is that aparticular level of economic development is needed in order to deal with the challenges of thisdemographic transition. The demographic composition and structure of future world populationand subpopulation must be understood within policy framework. The challenges that are likelyto arise from an ageing population on public expenditure, on pensions and health care,particularly in the absence of reforms in pensions and health services, could lead to a build-up ofpublic debt in developing countries in specific Caribbean islands In conclusion, the graying of population is not restricted to developed societies such asJapan, Germany, Canada, China, United States and Italy to name a few, but it is a current realityfor nations like Barbados, Trinidad and Tobago and Jamaica. Currently Jamaica does not see the 38
  • 68. demographic transition of ageing as an issue but come 2030 or beyond, it will be a problem formany developing states including that of Jamaica. The yardstick that is used as a symbol of the impending problem in demographic ageingis if a state’s population 60 years or over is between 8 to 10 percent and beyond. The earlysignals of demographic ageing, in Jamaica, began as early as in the 1960s, when the societybegan experiencing mortality and fertility declines. With the introduction of family planning inthe 1970s, the high fertility in the 1960s has been reduced by some 300%. Statistics reveal thatthe aged population of Jamaica is in excess of 10 percent as of 2005, within the context of anincreasing decline in the population 0 to 14 years. This population (age cohort 0-14 years) stoodat 40.3 percent in 1980 and in 25 years (2005), the population has being reduced to 31.2 percent.The conditions of ageing in Jamaica are not only a demographic issue but are disproportionatelybecoming a social, economic and political matter. In keeping with public health measure in theform of better sanitary, food and water security and quality and vaccination, mortality was cut,which is explanation for the high life expectancy of in excess of 75 years since 2004, to the bestof the researcher’s knowledge, no study has sought to examine the likely socioeconomic costs ofageing come 2015 to 2050 and beyond. Despite all the gains of technology, public health, education, lifestyle behaviouralpractices and high life expectancy, non-communicable diseases are on the rise and continue toplague people age 60 years or over. Thus, accompanying population ageing is more ill-wellsenior citizens. Within this general setting, there is a need for medical research on the wayforward in patient care as well as a demand exist for advanced quantitative assessment of themodel, which will evaluate wellbeing of the Jamaican elderly. This will foster a comprehensiveunderstanding of how health should be operationalized, and we then would be able to plan forageing in more informed manner than what presently obtains in our society. One of the socioeconomic and political challenges that the Caribbean in particularJamaica faces is the difficulty with which population ageing will become an economic cost.Population ageing does not simply mean “graying” of population (or proportionately morepersons ages 60 years or older or 65+) but with living longer comes the responsibility of payingsocial security like pension for a longer period of time. Another issue that we have failed toaddress in all of this discussion is the lowered taxes that are going to be collected as a result ofdemographic ageing. Within the same construct is the dwindling of the children population and 39
  • 69. lowered fertility, which means that come 2010 and beyond the elderly dependency ratio will beincreasingly more than in previous years. These developments will mean challenges for publicbudgets, and health care expenditures. The reality is, demographic ageing is here in theCaribbean and equally so in Jamaica. Systems and structures are needed to addressing the newdemand for this age cohort, along with the biopsychosocial state of ageing. 40
  • 70. ReferenceAli, Moazzam, and de Muynck, Aime. 2005. Illness incidence and health seeking behaviour among street children in Pawalpindi and Islamabad, Pakistan – qualitative study. Child: Care, Health and Development 31: 525-32. Academic Search Premier, EBSCOhost (accessed February 13, 2007).Apt, N. 1999. Protection of rights of older persons In Ageing and Health: A global challenge for the twenty-first century. Proceedings of a WHO Symposium at Kobe, Japan 10-13 November 1998. Geneva: World Health Organization.Anthony, Beverley J. 1999. Nutritional Assessment of the elderly. The Caribbean Food and Nutrition Institute Quarterly 32:201-216.Barrett, V. 1987. Analysis of the Jamaica government’s policy (1981 – 1986) on institutional and community programmes for the elderly. Kingston: B.Sc. Public Administration, University of the West Indies, Mona.Bogue, D.J. 1999. Essays in human ecology, 4. The ecological impact of population aging. Chicago: Social Development Center.Brannon, Linda and Jess Feist. 2004. Health psychology. An introduction to behavior and health, 5th ed. Los Angeles: Wadsworth.Buzina, K. 1999. Drug therapy in the elderly. Cajanus 32:194-200.BRW. (1999). ‘Health care, or wealth care?’ Business Review Weekly, Vol. 27, June 11.Callender, J. 2000. Lifestyle management in the hypertensive diabetic. Cajanus, 33:67-70.Caribbean Food and Nutrition Institute. 1999a. Health of the elderly. Cajanus 32:217-240.________. 1999b. Focus on the elderly. Cajanus 32:179-240.Charlesworth, B. 1994. Evolution in Age-structured Populations, 2nd ed. Cambridge: Cambridge University Press.Chevannes, Barry. (2001). Learning to be a man: Culture, socialization and gender identity in five Caribbean communities. Kingston, Jamaica: University of the West Indies Press.Chou, K.L. (2005). “Everyday competence and depressive symptoms: Social support and sense of control as mediators or moderators?” Aging and Mental Health 9, no.2:177-183. Academic Research Premier EbscoHost Research Databases (accessed 6 July 2006).Cowgill, Donald O. (1983). Growing Old in different Societies: Cross Cultural Perspectives. Quoted in Jay Sokolovsky. 1983. Belmont, California: Wadsworth Publishing.Eldemire, Denise (1997). “The Jamaican elderly: A socioeconomic perspective & policy implications”. Social and Economic Studies, 46: 175-193.Eldemire, Denise (1996). Older Women: A situational analysis, Jamaica 1996. New York, USA: United Nations Division for the Advancement of Women.Eldemire, Denise. (1995). A situational analysis of the Jamaican elderly, 1992. Kingston: The Planning Institute of Jamaica.Eldemire, Denise. (1994). The Elderly and the Family: The Jamaican Experience. Bulletin of Eastern Caribbean Affairs, 19:31-46.Eldemire, Denise. (1987a). The Elderly – A Jamaica Perspective. Grell, Gerald A. C. (ed). 1987. The elderly in the Caribbean: Proceedings of continuing medical education symposium. Kingston, Jamaica: University Printers.Eldemire, Denise. (1987b). The Clinical’s Approach to the Elderly Patient. Grell, Gerald A. C. 41
  • 71. (ed). 1987. The elderly in the Caribbean: Proceedings of continuing medical education symposium. Kingston, Jamaica: University Printers.Elo, Irma T. (2001). New African American Life Tables from 1935-1940 to 1985-1990. Demography, 38:97-114.Erber, Joan. (2005). Aging and older adulthood. New York: Waldsworth, Thomson Learning.International Labour Organization. (2000). Ageing in Asia: The growting need for social protection.Gavrilov, L. A., and N. S. Gavrilova. 2001. The reliability theory of aging and longevity. J. theor. Biol 213:527-545.Gavrilov, L. A and Gavrilova, N. S. 1991. The biology of ¸life Span: A Quantitative Approach. New York: Harwood Academic Publisher.Gavrilov, L. A., and P. Heuveline . (2003). Aging of Population. Quoted in the Encyclopedia of Population P. Demeny and G. McNicol, eds. New York: Macmillan.Goulding, M. R., and M.E. Rogers. 2003. Public Health and Aging: Trends in Aging --- United States and Worldwide. Atlanta, Georgia: Morbidity and Mortality Weekly Report 52:101- 106.Grell, Gerald A. C. (ed). (1987). The elderly in the Caribbean: Proceedings of continuing medical education symposium. Kingston, Jamaica: University Printers.Hambleton, Ian, R. Clarke, Kadene, Broome, Hedy, L. Brathwaite, Farley, Hennis, Anslm J. (2005). Historical and current predictors of self-reported health status among elderly persons in Barbados. http://journal.paho.org/?a_ID=138&catID= (accessed March 22, 2006).Jamaica Social Policy Evaluation. (2003). Annual progress report on National Social Policy Goals, 2003. Kingston, Jamaica: Government of Jamaica. Cabinet Office.Lauderdale, Diane S. (2001). Educational survival: Birth cohorts, period, and age effects. Demography 38:551-561.Lawson, Sylvia, C.C. (1996). “Culture and Aging: The case of Jamaican Elderly persons.” Paper presented at the Conference on Caribbean Culture, The University of the West Indies, Mona Campus – Jamaica, March 4-6, 1996.McCarthy, Frances M. (2000). Diagnosing and Treating Psychological problems in Patients with Diabetes and hypertension. CAJANUS 2000, 33:77-83.McEniry, M., Palloni, A., Wong, R., and Pelaez, M. (2005). “The elderly in Latin America and the Caribbean.” United Nations Expert Group Meeting on Social and Economic Implications of changing population Age structure, Population Division. Mexico City, Mexico: United Nations. http://www.un.org/esa/population/publications/EGMPopAge/12_McEniry_rev.pdf (accessed July 21, 2006).Manton, Kenneth G., and Land, Kenneth. (2000). Active Life expectancy estimates for the U.S. Elderly population: A multidimensional continuous-mixture model of functional change applied to completed cohorts, 1982-1996. Demography 37:253-265.Marcoux, Alain. (2001). Population ageing in developing societies: How urgent are the issues? Food and Agriculture Organization Women and Population Division. 42
  • 72. http://www.fao.org/sd/2001/PE0403a_en.htm (accessed February 4, 2007).Ministry of Health. Planning and Evaluation Branch. (2004). Annual Report 2003. Kingston, Jamaica: MOH.Mirkin, Barry and Weinberger, Mary B. (2001). The demography of population ageing. http://www.un.org/esa/population/publications/bulletin42_43/weinbergermirkin.pdf (accessed July 4, 2006). Quoted in United Nations Population Bulletin, Special Issue Nos 42/43, 2001. Population Ageing and Living Arrangements of Older Persons: Critical Issues and Policy Responses.Moore, E.G., Rosenberg, M. W., and McGuinness, D. (1997). Growting old in Canada: Demographic and geographic perspectives. Ontario, Canada: Nelson.Morrison, E. (2000). Diabetes and hypertension: Twin trouble. Cajanus 33:61-63.Pan American Health Organization. (1990). Adult Health in the Americas. Washington, D.C., United States: PAHO.____________ and WHO. 1997. Health of the elderly aging and health: A shift in the paradigm. USA: PAHO and WHO. http://www. paho.org/English/GOV/CE/SPP/doc197.pdf. (accessed December 4, 2006).Peña, Manue. (2000). Opening Remarks and Greetings from the Pan American Health Organization. The Caribbean Food and Nutrition Institute Quarterly 33:64-70.Planning Institute of Jamaica. (2006). Economic and Social Survey Jamaica, 2005. Kingston, Jamaica: PIOJ._____________. (2003). Jamaica Survey of Living Conditions 2002. Kingston, Jamaica: PIOJ and STATIN._____________. (2001). Jamaica Survey of Living Conditions 2000. Kingston, Jamaica: PIOJ and STATIN_____________. (2000). Jamaica Survey of Living Conditions 1999. Kingston, Jamaica: PIOJ and STATIN._____________. (1998). Jamaica Survey of Living Conditions 1997. Kingston, Jamaica: PIOJ and STATIN.Population Reference Bureau. (2007). Cross-national research on aging. Washington D.C.: Population Reference Bureau. http://www.prb.org/pdf07/NIACrossnationalResearch.pdf.Powell, Alfred. P., Bourne, Paul, and Lloyd Waller. (2007). Probing Jamaica’s Political culture, volume 1: Main trends in the July-August 2006 Leadership and Governance Survey. Kingston, Jamaica: Centre for Leadership and Governance, University of the West Indies, Mona.Preston, S.H., I.T. Elo, I. Rosenwaike, and M. Hill. (1996). “African American Mortality at Older Ages: Results of a Matching Study.” Demography, 33:193-209.Randal, J., and German, T. (1999). The ageing and development report: Poverty, independence, and the world’s people. London: HelpAge International. Quoted in World Health Organization. (2002). World report on violence and health. Geneva, Switzerland: WHO.Rowland, Donald T. (2003). Demographic methods and concepts. Oxford: Oxford University Press.Rudkin, Laura. (1993). Gender differences in economic well-being among the elderly of Java. Demography, 30:209-226.Smith, James P. and Raynard Kington. (1997a). Demographic and Economic Correlates of Health in Old Age. Demography, 34:159-170.Smith, K. R., and N. J. Waitzman. 1994. Double jeopardy: Interaction effects of martial and 43
  • 73. poverty status on the risk of mortality. Demography 31:487-507.Statistical Institute of Jamaica (STATIN). (1972 – 2006). Demographic Statistics, various years. Kingston: STATIN.Taff, N., and G. Chepngeno. (2005). Determinants of health care seeking for children illnesses in Nairobi slums. Tropical Medicine and International Health 10:240-45.Thane, Pat . (2000). Old Age In English History Past Experience, Present Issues. Oxford, England: Oxford University Press.Turner, B. S. 1998. Ageing and generational conflicts: A reply to Sarah Irwin. British Journal of Sociology 49:299-320.United Nations. (2007). World Population Ageing 2007. Department of Economic and Social Affairs, Population Division. New York: UN________. (2006). Statistical yearbook, 50th issue. Department of Economic and Social Affairs, Population Division. New York: UN________. (2005c). World population prospect: The 2004 revision. Department of Economic and Social Affairs, Population Division. New York: UN.________. (2003b). World population prospects: The 2002 revision Highlights. Department of Social and Economic Affairs, Population Division. New York: UN.Wise, David A. (1997). Retirement Against the demographic trend: More older people living longer, working less, and saving less. Demography, 34:17-30.World Health Organization. 2006. Elderly people: Improving oral health amongst the elderly. http://www.who.int/oral_health/action/groups/en/index1.html (accessed July 4, 2006).__________. (2005). Healthy life expectancy 2002: 2004 World Health Report. Geneva: WHO. http://www3.who.int/whosis/hale/hale.cfm?path=whosis,hale&language=english (accessed October 20, 2006)__________. (2002). World report on violence and health. Geneva: WHO.__________. (2000). World report on violence and health. Geneva: WHO.__________. (2000b). WHO Issues New Healthy Life Expectancy Rankings: Japan Number One in New ‘Healthy Life’ System. Washington D.C. & Geneva: WHO. http://www.who.int/inf-pr-2000/en/pr2000-life.html (accessed October 21, 2005)._________. (1999). World health report 1999. Geneva: WHO.__________. (1998a). Health promotion glossary. Geneva: World Health Organization.__________. (1998b. Primary prevention of mental, neurological and psychosocial disorder. Geneva: WHO.__________. (1998c). The world health report, 1998: Life in the 21st century a vision of all. Geneva: WHO. 44
  • 74. Table 2.1: Observed & Forecasted Percentage of Elderly 65 years or over in Selected Regions, and the World Countries: 1950, 1975, 2025 and 2050. 1950 1975 2007 2025 2050 % % % % %World 5.2 5.7 7.5 10.5 16.1Africa 3.2 3.1 3.4 4.2 6.7Latin America &the Caribbean 3.7 4.3 6.3 10.1 18.4Caribbean 4.5 5.4 7.8 11.4 18.9China 4.5 4.4 7.9 13.7 23.6India 3.3 3.8 5.4 8.1 14.8Japan 4.9 7.9 27.9 35.2 41.7Europe 8.2 11.4 16.1 21.0 27.6Italy 8.3 12.0 20.4 26.4 35.5Germany 9.7 14.8 19.6 23.9 25.4Sweden 10.3 15.1 17.6 22.1 24.7USA 8.3 10.5 12.4 17.7 20.6Source: United Nations, 2007 45
  • 75. Table 2.2: Observed & Forecasted Percentage of Elderly 60 years or over in Selected Regions, and the World Countries: 1950, 1975, 2025 and 2050. 1950 1975 2007 2025 2050 % % % % %World 8.2 8.6 10.7 15.1 21.7Africa 5.3 5.0 5.3 6.4 10.0Latin America &the Caribbean 6.0 6.5 9.1 14.5 24.1Caribbean 6.9 8.1 11.1 16.4 24.8China 7.5 6.9 11.4 20.1 31.0India 5.6 6.2 8.1 12.0 20.7Japan 7.7 11.4 27.9 35.2 41.7Europe 12.1 16.4 21.1 28.0 34.5Italy 12.2 17.4 26.4 34.4 41.3Germany 14.6 20.4 25.3 32.1 35.0Sweden 14.9 21.0 24.1 28.3 30.9USA 12.5 14.8 17.2 23.8 26.4Source: United Nations, 2007 46
  • 76. Part II: Health: An introduction 47
  • 77. IntroductionThe historiographical view of health currently accounts for its transformation, products,measures and conceptualization. The contemporary conceptual of health dates back to the 1940s.In 1946, in the Preamble to its Constitution, the World Health Organization (WHO) wrote thathealth is more than the absence of diseases to physical, social and psychological wellbeing. Sucha commutative perspective of health was in response to centuries of discourse on theminimization conceptualization and how the definition of health could be widened. Thedefinition of health is important because it is a product, end and a component that is crucial tohuman existence and development. The previous definition of health was a minimized one that was developed around anarrowed perspective, the antithesis of illness. In prehistoric times (10,000 BCE), health wasviewed as endangerment of the body from outside sources, particularly spirits (in Jamaica is isreferred to as “Duppy”). Such a narrowed conceptualization guide and formulate health careservices, treatment and thinking. Simply put health and health response was primarily around thestate of the human body. This belief continued into 1800-700 BCE when it was modified fromthe prehistoric definition to the emergence of endangerment of the gods, who send disease as apunishment for human wrongdoings. During this period, the cosmology of health was aroundreligious interpretations, the epistemology of health was based on this religious cosmology. Throughout the centuries the conceptualization of health has been modified to readdisease, with less reference to god. However, the subculture of health was viewed as a gift fromgod, and that illness was a indicator of punishment. The definition of health, therefore, grew intothe absence of illness, a narrow one but this guided intervention programmes. It was during the 48
  • 78. period of Galenian in Ancient Rome (130 CE – 200 CE) that health was viewed as the absence ofpathogens, such as bad air or body fluids that cause disease. This led to a mechanical approach tothe study of health and restoration of health, by extension the preservation of life. The Ancient Romains believed that health was a positive illness – meaning that the curefor disease could result in healthy bodies (humans). This perspective embodies the biomedicalmodel, the causal link between between disease and ill-health and the absence of illness andwellness. Such a viewpoint exclusively surrounds illness, the biological component, and nothealth, which heralded a mechanistic approach to studying and viewing health. The ushering ofthe biomedical approach to the study of health was a cross over of empiricism, logic,verification, reliability (consistency) and gradual development to health and health. Illness whichwas objectively measured supported a pure science approach, but excluded the other tenets thatconstitute a human. Humans are multidimensional beings, indicating that physical is a singlecomponent of whole person. People are, therefore, mind, body and social beings and anydefinition of health must constitute all these elements before we can state that we are addressingthe concerns of humans. Although the cosmology of humans is that of mind, body and social beings, thebiomedical approach to health, health study and health measurement in still dominant. Duringthe 20th century, while the biomedical model reins supreme, infectious diseases such assmallpox, yellow fever, tuberculosis, cholera and malaria ravished many lives and people wantedcures for those conditions. In response to finding cures, the association between illness anddisease was critical as this enveloped the continuation of life outside of illnesses. The infectiousdiseases accounted for low life expectancy, and providing a cure for those health conditions 49
  • 79. would mean extending life and sharing all forms of development. Following the epidemiological transition from infectious diseases to chronic healthconditions (such as heart disease, hypertension, diabetes, arthritis, respiratory ailments), it begana discussion on the relevance of the biomedical model (Stone, 1987). The biomedical model wasquestioned by scholars as they sought a new paradigm that would be in keeping withmultidimensional aspect of humans. Questionning the relevance of the biomedical model, fuelledplethora of propositions that final yield a biopsychosocial model that developed by Dr. GeorgeEngel. Engel’s explanations of curing mental health was totally in keeping with the broadendefinition offered by the WHO. It was not before the 1800ss (the time of Freud in Austria, late 1800s) that health wasrecognized as being influenced by emotions and the mind. Despite this recognition by Freud,health as a long history of the predominance of a narrowed perspectives, the absence of illness,that drove the pharmacological and medical technology industries. Those industries have spentbillions of dollars on finding cures for particular ailments and health conditions, and in returnhave invested trillions of dollars on medicine, tools and approaches for addressing illness. Thepharmacological and medical technology industries have a dominance of biomedical model thatthey continue to promote as relevant inspite of its one dimensional nature in health and healthcare. This part (Part II) will explore the definitions and operationalizations of health as theywill provide the basis upon which we can understand Jamaicans’ views on health and health caredemand, provisions and allocations. 50
  • 80. ReferenceBourne, P.A. (2010). Health measurement. Health 2(5):465-476.Stone, G.C. (1987). The scope of health psychology. In G.C. Stone, S.M. Weiss, J.D. Matarazzo, N.E. Miller, J. Rodin, C.D. Belar, et al. (Eds), Health psychology: A discipline and professional (pp. 27-40). Chicago: University of Chicago Press. 51
  • 81. Chapter3 Health MeasurementJamaicans are not atypical in how they conceptualize health and/or how they address patientcare as the antithesis of diseases or dysfunctions (health conditions). In the 1900s and earlier,Western Societies were using the biomedical model in the measurement and treatment of health,health attitudes and the utilization of health services. This approach emphasizes sickness,dysfunction, and the identification of symptomology or medical disorders to evaluate health andhealth care. Such an approach places significance on the end (. genetic and physical conditions),instead of the multiplicity of factors that are likely to result in the existing state, or issues outsideof the space of dysfunctions. Notwithstanding the limitations of the biomedical approach, it isstill practiced by many Caribbean societies, and this is fundamentally the case in Jamaica. Thecurrent paper is an examination of health measurement, and provides at the same time arationale for the need to have a more representative model as opposed to the one-dimensionalapproach of using pathogens in measuring health. Owing to the importance of health indevelopment, patient care and its significance for other areas in society, this paper seeks tobroaden more than just the construct, as it goes to the core of modern societies in helping themto understand the constitution of health and how patient care should be treated. Thus, itprovides a platform for the adoption of the biopsychosocial model, which integrates biological,social, cultural, psychological and environmental conditions in the assessment of health and theoutcome of research, by using observational survey data.1. INTRODUCTIONThe construct of health is more than a concept. It is a “leading characteristic of the members of apopulation...” [1] and, ergo, it plays a direct role in the images of health and health care. Amongthe plethora of reasons for the importance of health are not merely the images created by theconstruct, but also its contribution to the production of different tenets of human existence –illness, morbidity, comorbidity, disability, mortality, life expectancy, wellbeing, and so on, aswell as the guide that it affords for health interactions and interventions. In addition to theaforementioned issues, it is of germane significance in aiding us to understand many of thethings that we see. The definition of this single term ‘health’ is important, as a precise use of the 52
  • 82. construct fashions and connects other important applications such as growth and development,productivity, health care and people’s expectations of health care professionals. One scholar, inhelping us to understand the meaning of a construct, says that “without a well-defined construct,it is difficult to write good terms and to derive hypotheses for validation purposes” [2].Embedded in Spector’s argument is the ‘theoretical abstraction’ of the construct, and how wemay use it for outcome research. In this paper, the author will review the existing literature andidentify particular measures of health, examining how these differ from the WHO’s conceptualdefinition of health [3]. At the same time, within the limitations of the biomedical model, thestudy will evaluate the usefulness of the biopsychosocial model in health and how the image ofhealth influences the health care of people. 1.2 Image of Health Health, however, is more than a ‘theoretical abstraction’. There is an ‘objective reality’ tothis construct. It explains life, and life is an objective reality. Furthermore, health is a valuabletool that ‘drives’ health policies and influences the determinants of health care. Then there is theissue of health care and how this is planned for, as well as the role that health plays in thedevelopment of a society. Health, wellbeing and poverty are well documented in developmentaleconomics by scholars such as Amartya Sen, Paul Streeten and Martin Ravallion as havingcritical roles in understanding human development (or the lack of it). The fascination with healthand wellbeing in developmental studies is primarily because of the direct association betweendevelopment and health. Jamaica is not atypical in how its people conceptualize health and/or how they addresspatient care. In the 1900s and earlier, western societies used the biomedical approach in themeasurement and treatment of health [5]. The biomedical approach emphasizes sickness,dysfunction, pathogens, and disability and medical disorders in the construction of health. Thisapproach places importance on the outcome (or the end) instead of the multidimensionalconditions that are likely to result in the existing state. Notwithstanding the limitations of thebiomedical approach, it is still practiced by many Caribbean societies, and this is fundamentallythe case in Jamaica. This is atypical in many Western nations, as contemporary demographersstill use the antithesis of illness and disability to write about health [6-8]. Rowland wrote that“Measures of population health are of general interest to demographers, sociologists,geographers and epidemiologists. Interdisciplinary concerns here include comparing national 53
  • 83. progress through the epidemiologic transition, and identifying social and spatial variations withincountries in patterns of disease and mortality” [5]. The United States has left many Caribbean societies behind in how they conceptualizehealth and treat health care. As early as the commencement of the 20th century [4], the UnitedStates shifted their focus from negative wellbeing (antithesis of diseases) to positive wellbeing.The antithesis of diseases assumes a bipolar opposite between health and diseases. Embedded inthis bipolar thinking is that for one to be healthy, he/she must not be experiencing anysymptomology of dysfunctions. Hence, the health of people is measured by mortality ormorbidity statistics. Health, however, is more than just the antithesis of diseases to positivepsychology, inclusive of socio-cultural conditions and the environment. Positive wellbeingencapsulates the biomedical model in addition to psychological, socio-cultural andenvironmental conditions. The name that Engel gave to this new approach is the biopsychosocialmodel. The current paper is a discourse on the limitation of the biomedical model, which willprovide a rationale for the need to have a more representative model as against this one-dimensional approach to the measurement of health. Traditionally, health was conceptualised as the ‘antithesis of diseases’ [4]. Using theantithesis of diseases, this construct utilizes a minimization approach or a negative perspective,adopted by western societies, which saw health as the absence of dysfunctions, morbidityconditions or comorbidity. “This definition of health has been largely the result of thedomination of the biomedical sciences by a mechanistic conception of man. Man is viewed byphysicians primarily as a physio-chemical system” [9]. With this thinking, health professionals’evaluation of patient care and diagnostic treatments is based primarily on the identification ofany symptomology of dysfunctions. Hence the standard that is used in the evaluation of health isthe established norm of any deviation from diseases. Rather than conceptualizing health andstating its determinants, this approach uses the identification of symptomology to measurehealth. Therefore, life expectancy is used here as a measure of health. This assumes that oncean individual is alive, it is because there are no dysfunctions to cause death. Embedded in thisassociation is the influence of dysfunctions on health, but there are no other determinants ofhealth except the various symptomologies of diseases. Outside of diseases, there are other determinants of health. Based on the biopsychosocialmodel that George Engel [10, 11] developed, he proposed an approach to the treatment of the 54
  • 84. health care of psychiatric patients that included biological, social and psychological conditions.Such a conceptual framework, unlike the biomedical sciences, introduces and identifies factorsthat are responsible for the health, and by extension the wellbeing, of a population. One scholarcites that “the states of health and disease [are] the expressions of the success or failureexperienced by the organism in its efforts to respond adaptively to environmental changes” [12].Again, when health is defined as the antithesis of diseases its determinant is solely biological, butthis is clearly one-dimensional, and many scholars have shown that health is, in fact,multidimensional, and composed of biopsychosocial and environmental conditions. Another aspect to health is the positive association between the determinants of healthand health care policies. Health care policy makers use the determinants of health as thebenchmark that directs their planning. Therefore, when health policies are too narrow, the healthdeterminants which fashion a population’s health care will take a minimal approach, as this isbased on the image of health. One scholar puts it succinctly, “…health policies affect healththrough their effects on health determinants” [13], which speaks to the importance of ‘good’hypotheses in the schema of things. It should be noted that the hypotheses allow us to derive thepossible determinants of health, which would be used to evaluate the effectiveness of the healthpolicy, and so show how they affect health (Figure 3.1). Determinants Health Policy of Health – Health Biological conditionsFigure 3.1: The relation between health policy and health, and the roles of health determinants The goal of the policy is to decrease the incidence of chronic diseases, high risk sexual behaviour/violence and injury through the adaptation of appropriate behaviours by the population and particularly young children, adolescents and young adults [14]. The general conceptualization of health in Jamaica is the “antithesis of diseases”. Thisexplains why many people emphasize health care for morbidity conditions, genetics, or physical 55
  • 85. functioning (their biology). Another indicator of the usage of this perspective can be seen in howdata are collected on health in Jamaica and/or in the wider Caribbean. Such a situation highlightsthe minimization or substantially negative approach in the construct of health. Despite the titleof the Ministry of Health’s ‘National Policy for the Promotion of Healthy Lifestyle in Jamaica’,throughout the paper the MOH [14] emphasizes mortality, diseases, dysfunctions andreproductive health, which highlights Jamaicans’ perspective on health. This is also evident inthe Planning Institute of Jamaica which is responsible for policy, along with the StatisticalInstitute of Jamaica, collecting information on health by way of (1) preventative (behaviourmodification), curative (surgical procedures, visits to health practitioners), restorative (physicalrehabilitation), and palliative (. pain management) measures, and ownership of health insurance.Thus, the hypotheses that arise from the collected data are in keeping with the narroweddefinition for which the data was initially gathered by the research design exercise. Thehypothesis of the presence of pathogens such as poor air being the cause of diseases, orclassification of ill-health, is ancient, within the context that health has been expanding frommere physical functioning for some time. This hypothesis assumes that a person who does nothave an ailment (or disease condition) is healthy, which is categorically false, as healthpsychologists have shown that psychological conditions do influence wellbeing [4]. Thisperspective dates back to Galen in Ancient Rome (. 130 CE – 200 CE). A point is even moreforcefully made in a study by two economists, which found a strong direct relationship betweenhappiness and wellbeing [15]. Other researchers found an association between ‘positive and/ornegative’ mood(s) and wellbeing [16]. This paper is in two parts, designed: (1) to providedetailed evidence that will support the rationale for an expanded concept which looks at healthand wellbeing, and (2) to illustrate the purpose and significance of the expanded model thatEngel termed the biopsychosocial model. This paper however is not arguing for abiopsychosocial hybrid model, which would include biological, economic, social, cultural,psychological and ecological conditions.2. P HYSICAL F UNCTIONING Caring for patients suffering from ill-health has a long history, which dates back to theAgrarian societies. During those earlier periods, man in his quest to address health conditionsdid so primarily from the standpoint of physical functionality. Based on the annals of time, the 56
  • 86. literature showed that people would treat biological dysfunctions and sometimes the ‘spirit’ intheir pursuit of making man healthier. This approach dates back as far as ancient Rome (. 130 CE– 200 CE). Despite the WHO offering us a better way in the pursuit of happiness and wellness,man continues to return to the biomedical model of health. One of the reasons for the continuedacceptance of the use of the biomedical model is the dominance of technology in this process.As technology is still primarily intended to address physical dysfunctions and the absence ofpathogens, many studies conducted in early societies have not only linked the concept of healthto medical conditions and by extension health care, but have served as another importantindicator in determining lifespan. In 1884, an Englishman named Francis Galton who was both a mathematician andmedical doctor researched the ‘physical and mental functioning’ of some 9,000 people betweenthe ages of 5 and 80 years [17]. Galton wanted to measure the human life span in relation to thephysical and mental functioning of people, so he sponsored a health exhibition that would allowhim to collect data for analysis. Health was traditionally defined as the “antithesis of diseases”,which explains the predominance of physical functioning in policy making and health care, andjustifies Galton’s wanting data on the physical functioning of people. The 20th century has brought with it massive changes in the typologies of dysfunctions,where deaths have shifted from infectious diseases such as tuberculosis, pneumonia, yellowfever, Black Death (. Bubonic Plague), smallpox and ‘diphtheria’ to illnesses such as cancer,heart disease and diabetes [14]. Although diseases have shifted from infectious to degenerate,chronic non-communicable illnesses and science, medicine and technology have expanded sincethen, and the image of health in contemporary Jamaica still lags behind many developed nations.Morrison [18] titled an article ‘Diabetes and Hypertension: Twin Trouble’ in which heestablishes that diabetes mellitus and hypertension have now become problems in Jamaicans andin the wider Caribbean. This situation was equally corroborated by Callender [19] and Steingo[20] at the 6th International Diabetes and Hypertension Conference, which was held in Jamaica inMarch 2000. They found that there is a positive association between diabetic and hypertensivepatients - 50% of individuals with diabetes had a history of hypertension [19, 20]. Prior to thosescholars’ work, Eldemire [21] found that 34.8% of new cases of diabetes and 39.6% ofhypertension were associated with senior citizens (. ages 60 and over). Accompanying thisperiod of the ‘age of degenerative and man-made illnesses’ are life expectancies that now exceed 57
  • 87. 50 years. Before the establishment of the American Gerontology Association in the 1930s and theirmany scientific studies on the ageing process [17], many studies were done based on thebiomedical model, . physical functioning or illness and/or disease-causing organisms [4]. Manyofficial publications used either reported illnesses or the prevalence of seeking medical care formeasuring sicknesses. Some scholars have still not moved to the post biomedical predictors ofhealth status. The dominance of this approach is so strong and present within the twenty-firstcentury, that many doctors are still treating illnesses and sicknesses without an understanding ofthe psychosocial and economic conditions of their patients. To illustrate this more vividly, theresearcher will quote a sentiment expressed by a medical doctor in ‘The Caribbean Food andNutrition Institute’s Quarterly [22]. A public health nutritionist, Dr. Kornelia Buzina [23], says,“When used appropriately, drugs may be the single most important intervention in the care of anolder patient … and may even endanger the health of an older patient …” This propositionhighlights the paradox in biomedical sciences as well as showing the need to expand the imageof health beyond this negative approach to it. Within the context of the WHO’s definition and growing numbers of studies that haveconcluded that health should be a multidimensional construct, in 2007 a group of medicalpractitioners used physical functionality and dysfunctions to treat an elderly patient who wassuffering from a particular health condition [24]. The researchers put forward an examination ofa 74-year old man who with “...a long history of ischaemic heart disease, presented withincreasingly prolonged episodes of altered consciousness” [24]. The physicians cite theargument that “many elderly patients may have more than one cause for this symptom” [24],which summarizes their perspective and reliance on understanding medical disorders in thedispensing of patient care. Throughout the study, the scholars and medical practitioners did notseek to evaluate the psychological, social, and environmental conditions and their possibleinfluence on the current state of dysfunction of the elderly patient. Despite the seemingcomplexity of the result of the detailed inquiry into the neurological conditions of the patient,and the keen medical examination of the patient, his medical condition continued for yearsunabated. This emphasises the dominance of the biomedical model, and it goes beyond thissingle study, as a review of publications in the West Indian Medical Journal – a medical journalin Jamaica – from 1960-2009 revealed a few studies that have gone beyond the use of the 58
  • 88. biomedical approach to the examination of patient care. In seeking to treat the 74-year old patient, the medical practitioners examined and re-evaluated various medical problems. Thus, owing to the thinking of this group of researchers,they used ‘multiple medications’ in the treatment of the patient’s condition. It was clear from theperspective of the scholars that what guided their intervention were the biomedical sciences (.physical functionality or dysfunctions). In this case, health is the ‘antithesis of diseases’. It isthe narrow definition of health – negative health (. biomedical approach) – which explains theimage of health and health care for those scholars and researchers. Apart from the reasons for theuse of diagnosed conditions, life expectancy and other physical issues are utilized in examininghealth, because of the precision in using them to evaluate health as against other approaches thatare more holistic and broader in scope. 2.2 Health measurement The narrow definition of health is the “antithesis of diseases” which Longest [13] says isthe “…absence of infection or the shrinking of a tumour” which can be called dysfunctions (see[1, 4]. As we mentioned earlier, the ‘antithesis of diseases’ idea dates back to Galen in AncientRome. It was widespread in the 1900s, and so medical professionals used this operationaldefinition in patient care. Another fact during this time was that technology was fashioned in thisregard, addressing solely physical dysfunctions. This definitional limitation may be a rationalefor the World Health Organization, nearing the mid-1900s, declaring that health is the “state ofcomplete physical, mental, and social wellbeing, and not merely the absence of diseases orinfirmity” [3]. It should be noted that this conceptual definition which is in the Preamble to theconstitution of the WHO which was signed in July 1946 and became functional in 1948,according to one scholar, from the Centre of Population and Development studies at HarvardUniversity, is a mouthful of sweeping generalizations. According to Bok [25], the definitionoffered by the WHO is too broad and difficult to measure, and at best it is a phantom. Otherintelligentsia point to the WHO’s definition as a difficulty for policy formulation, because itsscope is ‘too broad’ [26]. The question is “Is the conceptual definition formulated by WHO sobroad that those policies faced difficulty in formation”, and by extension should we regress to apre-1946 conceptualization of health because a construct is difficult to operationalize today?Undoubtedly, health extends beyond diseases and is tied to cultural and psychological elements, 59
  • 89. personal responsibility, lifestyle, environmental and economic influences as well as qualitynutrition [27-41]. Those conditions are termed determinants of health [26]. The WHO’s perspective must have stimulated Dr. George Engel to pursue a modificationof the narrow approach to the health and health care debate. Dr. Engel was a psychiatrist whoformulated the construct called the biopyschosocial model in the 1950s. He believed that when apatient comes to a doctor, for example for a mental disorder, the problem is a symptom not onlyof actual sickness (biomedical), but also of social and psychological conditions [10, 11]. Hetherefore campaigned for years for physicians to use the biopsychosocial model for the treatmentof patients’ complaints, as there is an interrelationship between the mind, the body and theenvironment. He believed so deeply in the model, convinced that it would help in understandingsickness and providing healing, that he introduced it into the curriculum of Rochester medicalschool [42, 43]. Medical psychology and psychopathology was the course that Engel introducedinto the curriculum for first year medical students at the University of Rochester. This approachto the study and practice of medicine was a paradigm shift from the biomedical model that waspopular in the 1980s and 1990s. The Planning Institute of Jamaica and the Statistical Institute of Jamaica employ thebiomedical model in capturing the health status and/or wellbeing of the populace. This approachwas obsolete by the late 20th century, as in 1939 E.V. Cowdy, a cytologist in the United States;expanded on how ageing and health status should be studied in the future. Cowdy broadened thebiomedical model in the measurement of the health status of older adults by including social,psychological and psychiatric information in his study entitled the “Problem of Ageing” [17].The Ministry of Health [MOH] [14], however, has published a document in which it shows thathealth interfaces with biomedical, social and environmental conditions. One of the reasons putforward by the MOH to help in understanding why they arrived at the aforementioned position,was the rationale behind the explanation for the changes in the typology of diseases – that is,from infectious and communicable diseases to chronic conditions. The institution cites that this issubstantially because of the lifestyle practices of Jamaicans. One of the ironies within thedocument was in the ‘main components of the policy for the promotion of a healthy lifestyle inJamaica’, which cites that the goal of the policy was to reduce the incidence of communicableand infectious diseases, which speaks to society’s subconscious emphasis on the biomedicalmodel in conceptualizing health and its treatment. Embedded within the MOH’s 2004 60
  • 90. publication are repetition and the focus on seeking to reduce physiological conditions that affectthe individual. The MOH admits, however, that health interfaces with body and environment,which is an expansion of the biomedical model, but all indications in their document point to thebiomedical science approach in the application of the policy. The institution recognized thatpsychological factors (for example, self-esteem, and resilience) play a role in influencing health,so much so that it included these within its ‘goal of the strategic approach’, but they were notsupported in the ‘broad objectives of the strategic approach’. Critical to all of this is the acceptance that the definition of health is fundamental to theconstruction of those hypotheses that are used to formulate health policies. According to Longest[13], the conceptualization of health is indeed critical to all the things that rely on its definition.Longest writes: The way in which health is conceptualized or defined in any society is important because it reflects the society’s values regarding health and how far the society might be willing to go in aiding and supporting the pursuit of health among its members [13]. In Jamaica health policies are still driven by physical functioning, which is an obsoleteapproach to addressing health and by extension wellbeing. This limited approach to health andwellbeing means that little consideration is given to other factors such as lifestyle, psychologicalstate, the environment, crime and violence, among others. This of course implies that Jamaica’shealth policy is limited in its orientation, as it is largely driven by hypotheses that supportphysical functioning. 2.3 Biomedical Approach Dr. Buzina admits that wellbeing is fundamentally a biomedical process [23]. Thisconceptual framework derives from the Newtonian approach of basic science as the onlymechanism that could garner information, and empiricism being the only apparatus to establishtruth or fact. It is still a practice and social construction that numerous scholars and medicalpractitioners [24] continue to advocate despite new findings. Simply put, many scholarships stillput forward a perspective that the absence of physical dysfunction is synonymous with wellbeing(or health, or wellness). Such a viewpoint appears to hold some dominance in contemporarysocieties, and this is a widespread image held in Jamaica. Then there are issues such as the deathof an elderly person’s life-long partner; a senior citizen taking care of his/her son/daughter whohas HIV/AIDS; an aged person not being able to afford his/her material needs; someone older 61
  • 91. than 64 years who has been a victim of crime and violence and continues to be a victim; seniorswho reside in volatile areas who live with a fear of the worst happening, the inactive aged, andgenerally those who have retired with no social support, are equally sharing the same healthstatus as the elderly who have not been on medication because they are not suffering frombiomedical conditions to the extent that they need to be given drugs. Two medical doctors writing in Kaplan and Saddock’s Synopsis of Psychiatry noted thatphysicians are frequently caught in theorizing that normality is a state of health [44]. Theyargued that doctors’ definition of normality correlates with a traditional model (biomedical) thatemphasizes observable signs and symptoms. Using psychoanalytic theories, Saddock andSaddock [44] remarked that the absence of symptoms as a single factor is not sufficient for acomprehensive outlook on normality. They stated, “Accordingly, most psychoanalysts view acapacity for work and enjoyment as indicating normality…” [44]. Among the challengesassociated with this method (biomedical model), is its emphasis only on curative care. Such anapproach discounts the importance of lifestyle and preventative care. In that, health is measuredbased on experiences with illnesses and/or ailments, with limited recognition being placed onapproaches that militate against sickness and/or diseases. The biomedical approach is somewhatbiased against an understanding of multi-dimensional man, which is not in keeping with theholistic conceptualization of health as offered by the WHO. 2.4 Biopsychosocial Approach In the 1950s, George Engel, a physician, teamed with John Romano, a young psychiatrist,to develop a biopsychosocial model for inclusion in the curriculum of the University OfCincinnati College Of Medicine, which measured the health status of people. It is referred to asEngel’s biopsychosocial model. Engel’s biopsychosocial model [10, 11, 43], recognized thatpsychological and social factors coexisted along with biological factors. It was a general theoryof illness and healing, a synergy between medicine, psychiatry and the behavioural sciences [42].Therefore, from Engel’s model, wellbeing must include factors such as motivation, depression(or the lack thereof), biological conditions (such as illnesses and diseases), social systems,cultural, environmental and familial influences on the appearance and occurrence of illness. Some scholars may argue that this paper appears to believe that only quantitative studiesmay provide answers to the examination of the determinants of health. This is absolutely not so, 62
  • 92. and we use a qualitative study to show people’s perception of what contributes to a particularmedical condition. In a qualitative study that uses in-depth interviews with some 17 Malaysianmen aged between 40 and 75 years old, some scholars examined the perception of these men inrelation to erectile dysfunction (ED) – the sample was a convenient one of men who weresuffering from ED and who were willing to speak about their condition. When the interviewersasked the participants about the possible causes of ED, many of them outlined biomedicalconditions such as diabetes, hypertension, medications, past injuries, ageing and then camelifestyle practices (. smoking) and psychosocial factors [45]. Embedded in this perception is therespondents’ emphasis on pathophysiological conditions in health measurement and intervention.Although the sampled respondents do believe that psychosocial factors play a role in healthstatus, it should be noted here that they did not itemize those conditions. This speaks to theconceptualization of health that these respondents have come to accept, and the fact that theybelieve that health is not limited to biomedical sciences. Using their definition of health, thestudy shows how culture plays a pivotal role in determining how men will seek health careirrespective of the nature of their condition. According to a number of demographers [46, 47], health has been conceptualized as“functioning ability”. These pundits categorized “functioning ability” as – (i) being able toprovide both personal care and independent living but having some difficulty in performing thesetasks or in getting about outside the home, (ii) having no functioning difficulties, (iii) beingunable to independently provide personal care, and finally (iv) being able to provide personalcare but not able to manage life in the home independently” [46].3.0 EXPANSION OF THE B IOMEDICAL MODEL Studies reveal that positive moods and emotions are associated with wellbeing [48] as theindividual is able to think, feel and act in ways that foster resource building and involvementwith particular goal materialization [49]. This situation is later internalized, causing theindividual to be self-confident, from which follow a series of positive attitudes that guide furtheractions [50]. Positive mood is not limited to active responses by individuals, but a study showedthat “counting one’s blessings,” “committing acts of kindness”, recognizing and using signaturestrengths, “remembering oneself at one’s best”, and “working on personal goals” all positively 63
  • 93. influence wellbeing [50,51]. Happiness is not a mood that does not change with time orsituation; hence, happy people can experience negative moods [52]. Human emotions are the coalescence of not only positive conditions but also negativefactors [53]. Hence, depression, anxiety, neuroticism and pessimism are seen as a measure of thenegative psychological conditions that affect subjective wellbeing [54-56]. From Evans andcolleague [54], Harris et al. [55] and Kashdon’s monographs [56], negative psychologicalconditions affect subjective wellbeing in a negative manner (. guilt, fear, anger, disgust); and thepositive factors influence self-reported wellbeing in a direct way - this was corroborated in astudy conducted by Fromson [57]; and by other scholars [53, 58,59]. Acton and Zodda [60]aptly summarized the negative affective of subjective wellbeing in the sentence that reads“expressed emotion is detrimental to the patients recovery; it has a high correlation with relapseto many psychiatric disorders.” From the theologians’ perspective, spirituality and religiosity are critical components inthe lifespan of people. They believe that man (including woman) cannot be whole withoutreligion. With this fundamental concept, theologians theorize that man cannot be happy, or feelcomfortable without a balance between spirit and body [62]. In order to achieve a state ofpersonal happiness, or self-reported subjective wellbeing, some pundits put forward a constructthat people are fashioned in the image of God, which requires some religiosity before man can behappy or less stressed. Religion is, therefore, association with wellbeing [63-65] as well as lowmortality [66]. Religion is seen as the opiate of the people from Karl Marx’ perspective, buttheologians, on the other hand, hypothesize that religion is a coping mechanism againstunhappiness and stress. According to Kart [67], religious guidelines aid wellbeing throughrestrictive behavioural habits which are health risks, such as smoking, drinking alcohol, and evendiet. The discourse of religiosity and spirituality influencing wellbeing is well-documented[68, 69]. Researchers have sought to concretize this issue by studying the influence of religiosityon quality of life, and they have found that a positive association exists between those twophenomena [70]. They found that the relationship was even stronger for men than for women,and that this association was influenced by denominational affiliation. Graham et al.’s [71] studyfound that blood pressure for highly religious male heads of households in Evans County waslow. The findings of this research did not dissipate when controlled for age, obesity, cigarette 64
  • 94. smoking, and socioeconomic status. A study of the Mormons in Utah revealed that cancer rateswere lower (by 80%) for those who adhered to Church doctrine [72, 73] than those with weakeradherence. In a study of 147 volunteer Australian males between 18 and 83 years old, Jurkovic andWalker [65] found a high stress level in non-religious as compared to religious men. Theresearchers in constructing a contextual literature quoted many studies that have made a linkbetween non-spirituality and “dryness”, which results in suicide. Even though Jurkovic andWalker’s research was primarily on spiritual wellbeing, it provides a platform that can be used inunderstanding the linkages between the psychological status of people and their generalwellbeing. In a study which looked at young adult women, the researchers found that spiritualityaffects the physical wellbeing of a populace [69]. Embedded within that study is the positiveinfluence of spirituality and religion on the health status of women. Edmondson et al.’s workconstituted of 42 female college students of which 78.8 percent were Caucasian, 13.5 percentAfrican-American, 5.8 percent Asian and 92 percent were non-smokers. Health psychologists concurred with theologians and Christians that religion influencespsychological wellbeing [74, 75]. Taylor [74] argued that religious people are more likely tocope with stressors than non-religious individuals, which explains the former’s better healthstatus. She put forward the position that this may be done through avoidance or vigilantstrategies. This response is an aversive coping mechanism in addressing serious monologue orconfrontational and traumatic events. Coping strategies, therefore, are psychological tools usedby individuals to problem-solve issues, without which they are likely to construct stressors andthreaten their own health status. Taylor [74] said that "some religious beliefs also lead to betterhealth practices", producing lower mortality rates from all cancers in Orthodox Christians.4. EVIDENCE OF USE FOR BIOPSYCHOSOCIAL MODEL Even though policy makers are cognizant of the importance of healthy lifestyle practicesand their influence on wellbeing [76], we continue to sideline them in understanding healthstatus, and using this concept in the formulating of hypotheses that will drive a broader policyfocus of health care for the populace. This is evident in our neglect to expand studies for policypurposes that collect data on health using the biopsychological model, meaning that policyformulators are emphasizing physical vulnerability or dysfunction to measure health status. Isthere a study that has sought to use a maximization definition of health that will be able to better 65
  • 95. evaluate and plan for the wellbeing of Jamaicans? A study conducted in Barbados reveals that there is a statistical causal relationshipbetween socioeconomic conditions and health status. The findings revealed that 5.2% of thevariation in reported health status was explained by the traditional determinants of health(disease indicators – Table 1.1.1). Furthermore, when this was controlled for currentexperiences, the percentage fell to 3.2% (falling by 2%). When the current set of socioeconomicconditions were used they accounted for some 4.1% of the variations in health status, while 7.1%were due to lifestyle practices, compared to 33.5% that were as a result of current diseases [34].It holds that the importance placed by medical practitioners on the current illnesses – as anindicator of health status – is not unfounded as people place more value on biomedicalconditions as being responsible for their current health status. Despite this fact, it is obviousfrom the data – using 33.5% - that there are other indicators that explain some 67.5% of thereason why health status should be as it is. Furthermore, with an odds ratio of 0.55 for numberof illnesses, there is a clear suggestion that the more people reporting illnesses, the lower will betheir health status [34]; and this was equally so for more disease symptoms – odds ratio was0.71). Figure 1 above is a depiction of the use of the biopsychosocial model in the study ofhealth status. This research was conducted in Barbados between 1999 and 2000, in which healthstatus was predicted by a composite function of five general typologies of variables. The modelshows that health status is not primarily limited to biomedical conditions – such as diseases andailments – as has been the custom of many scholars. While different indicators as used by theseresearchers may not be possible in this paper because of the limitation of the secondary dataset –for example ‘current lifestyle risk factors’, ‘childhood nutrition’, ‘childhood diseases’,‘environmental factors’, to name a few – despite the data’s shortcomings, the study emphasizesthe use of a multidimensional approach in the study of wellbeing. Bourne [27], using secondary data, encapsulates George Engel’s conceptual idea of amultidimensional model which incorporates biological, social, psychological, environmental andsocial conditions in examining wellbeing. Wellbeing is operationally defined as materialresources, illness and total expenditure of households. The sample is drawn from a nationallyrepresentative survey of 25,018 Jamaicans, some 9.3% of the sample being elderly. From a 66
  • 96. sample of 2,320 elderly Jamaicans (ages 65+ years), Bourne [27] found that 10 of the 14predisposing variables explain 36.8% of the variance in wellbeing. Of the 10 statisticallysignificant variables, the five most important ones, in descending order, are (1) area of residence(β=0.227), (2) cost of medical care (β=0.184), (3) psychological conditions – [total positiveaffective conditions] - (β=0.138), (4) ownership of property (β=0.135), and (5) crime (β=0.111).Among the other factors, which are the 5 least important conditions, are negative affectiveconditions, marital status, educational level, average occupancy per room, age of residents, andthe environment. Thus, whether or not we use Grossman’s model [77], Hambleton et al.’s model[34] or Bourne’s models [27-33] it is clear from them that wellbeing extends beyond biologicalconditions to include psychological, environmental, and social conditions. Another study was conducted by Bourne [30] of some 3,009 elderly Jamaicans (60 yearsand older), with an average age of 71 years and 10 months ± 8 years and 6 months, of which67% (n=2,010) resided in rural areas, 21% (n=634) dwelled in Other Towns and 12% (n=365)lived in the Kingston Metropolitan Area. The mean General Wellbeing of elderly Jamaicans waslow (3.9 out of 14 ± 2.3). Bourne’s model [30] identified 10 explanatory variables which explain40.1% (adjusted R-squared) of the variance in general wellbeing. In this study he deconstructedthe general model into (1) economic wellbeing and (2) physical wellbeing (proxy by healthconditions). Using the same set of explanatory variables, the latter model explains 3.2% of thevariability in wellbeing (proxy by health conditions) compared to 41.3% for the former model (.economic wellbeing using material economic resources). General Wellbeing was operational asmaterial resources and functional limitation (or health conditions). Material economic resourcesconstitute ownership of durable goods (such as motor vehicles, stereo, washing machines, etcetera); income (proxy by income quintile); and financial support (e.g. social security and otherpensions). Hence, it follows that the biopsychosocial model is a better proxy for wellbeing; andthat functional limitation is still not a good proxy for wellbeing as used by Hambleton et al.Grossman and even Smith and Kington [78]. Globally, regionally and especially domestically, the most popular space in researchconcerning wellbeing is the biomedical approach; its popularity is fuelled by the combination ofthe traditional operational definition of health (good physical health) and the dominance of themedical sciences in this field of enquiry. The number of studies on mortality, structuralalterations and functional declines in body systems, genetic alterations induced by exogenous 67
  • 97. and endogenous factors, prevalence and incidence of diseases, and certain diseases asdeterminants of health, clearly justifies establishing leniency towards medical science in thestudy of health and health care. Engel [10, 11] accredited the biomedical model that governshealth care to the practice of pundits over the last 300 years. This model assumes thatpsychosocial processes are independent of the disease process. Engel argued for the bio-psychosocial model that it includes biological, psychological, and social factors, which is a closematch to the multi-dimensional aspect of man. With this as the base, it can be construed fromEngel’s thrust behind the biopsychosocial model that the previous model is a reductionisticmodel. Engel’s biopsychosocial model in analyzing health emphasizes both health and illness,and maintains that health and illnesses are caused by a multiplicity of factors. Engel’stheorizing, therefore, is better fitted for the definition of health coined by the World HealthOrganization. In Jamaica, only a miniscule number of studies have sought to analyze the effect of thedeath of a family member or close friend, violence, joblessness, psychological disorders andsexual abuse, on wellbeing, or social change on health, area of residence on quality of life andthe perception of ageing and its influence on health conditions. Morrison [18] alluded to atransitory shift from infectious communicable diseases to chronic non-communicable diseases asa rationale for the longevity of the Anglophone Caribbean populace. This was equally endorsedby Peña [79], the PAHO/WHO representative in Jamaica. They argued that this was not the onlyreason for the changing life expectancy. Morrison summarized this adequately, when he saidthat: Aiding this transition is not only the increased longevity being enjoyed by our islanders but also the changing lifestyle associated with improved socioeconomic conditions [18] With the post-1994 widened definition of health as put forward by the WHO, people arebecoming increasingly cognizant of the fact that socio-cultural factors such as geographicallocation, income, household size and so on, as well as several psychological factors, explainwellbeing; hence the new definition of health has coalesced biomedical variables and socio-cultural and psychological variables in the new discourse on wellbeing. Stressors may arise from within the individual or outside his/her environment. One suchexternal stressor that may affect the individual is the death of loved ones. Response to themortality of close family members may be more traumatic, depending on expectancy or non- 68
  • 98. expectancy. Bereavement influences the incidence of mortality. This may result in exhaustion ofthe individuals adaptive reserve. The person’s body wears down and becomes highly vulnerableto morbidity and even death. Rice put forward a study that contradicted an association betweenbereavement and mortality. He wrote that "Fathers who lost sons in war had lower mortalityrates than those who lost son in accidents" [75]. Despite that study, Rice quoted other studies[80] that showed the impact of stress on human physiology. He argued that it is suppressionduring and after bereavement that creates the stressors, which become potent devices formortality and morbidity. Lusyne, Page and Lievens’ [81] study finds that there is an associationbetween bereavement and mortality. However, this is more likely to occur in the short-run (.during the first 6 months after the death of the spouse). As there are a number of confoundingsituations which in the long-run could offset the likelihood of mortality, such as remarriage,social support from other family members, grandchildren and so on, bereavement may notnecessarily be a constant in one’s life. Nevertheless, Lusyne, Page and Lievens affirm with otherstudies that the loss of a long-time partner may result in the death of the living spouse. Theexplanations given for this eventuality are – (i) role theory as the surviving partner may find therole played by the other partner too stressful and so (ii) may not be able to adapt to the new rolealone; this is more a male phenomenon [81]. The Planning Institute of Jamaica and Statistical Institute of Jamaica collect data on ill-health, and questions are asked based on visits to health practitioners, healers and pharmacies,injuries, ailments, ownership of health insurance, duration of the disease or illness, cost oftreatment for ailments and injuries, and mental disability. Those questions are clearly derivativesfrom the biomedical model, as they seek to address physical functioning without equallyemphasizing culture, lifestyle behaviour, depression, stress, fatigue, trust for others, perceptionof one’s position in current society and the likelihood of one’s place in the future, religiosity,time periods, HIV/AIDS of family members or the individual and how it is likely to influence thehis/her health and wellbeing, social involvement in various institutions, and issues on positiveaffective conditions. 69
  • 99. 5. CONCLUSION In sum, any definition of the construct of health must be multidimensional in nature.Such a definition must include (1) personal and environmental conditions, (2) social factors, (3)psychological conditions, (4) diagnosed illness, and (5) self-determination of wellbeing. If healthis solely based on illnesses (biomedical model), we would have failed in our bid to operationallydefine a construct that is comprehensive enough to encapsulate all the tenets that would captureman in his complex milieu. Health is not simply a construct. It plays a critical role in theformulation of policy for health care, and in the development of the society. Thus, if weemphasize only the biomedical approach to the study of health, its underpinnings could only besymptomology. This approach fails to capture issues outside of the mechanistic structure ofman’s conception of biomedical sciences. Concurringly if health care professionals were to useas their premise dysfunctions to indicate health, which is the deviation from the norm, this imageof health would affect policy formulation and intervention programmes which are gearedtowards this narrow conceptualization. But this approach lacks are clear characteristics outsideof illnesses that will encapsulate wellness, wellbeing, and healthy life expectancy in amultidimensional human. Thus, the biomedical model relies on illness identification to capturehealth and this fashions the health care system, which also limits health coverage outside of thisnegative view of health. This is undoubtedly suboptimal, and does not account for health. Thehealth services in the Caribbean, and in particular Jamaica, are best described as medicalservices, as they are still fundamentally structured around the biomedical model which isembedded as the image of health, and not psychosocial, economic and ecological wellbeing.Although the WHO as early as the 1940s provides a definition of health that is comprehensiveand complex, some scholars believe that it is elusive and by extension immeasurable. There aremerits to the argument of those academics, but the emphasis should not be the difficulty of howoperationalizing the construct labels it ‘elusive’. Instead the goal should have been forresearchers and academics alike to formulate a working definition of the conceptual frameworkcreated by the WHO. Thus, when Grossman in the 1970s moved away from the difficulty posedby the WHO’s conceptual framework, he developed an econometric framework that laid thefoundation for the measure of this seemingly ‘elusive’ construct. Other scholars have built onthe initial theoretical model introduced by Grossman, and Bourne in particular has added 70
  • 100. psychological and environmental conditions to the already established factors of the healthmodel. The constitution of the World Health Organization (WHO) states that “Health is a stateof complete physical, mental and social well-being and not merely the absence of diseases orinfirmity”, [3]. Hence, any use of morbidity statistics, dysfunctions, sickness, diseases or ill-health to conceptualize health is limited, and by extension is a negative approach to the treatmentof this construct. Health, health care, and patient care are critical components in development, asunhealthy people will not be able to offer to the society their maximum, neither will they be ableto comparatively contribute the same to productivity and production as their healthycounterparts. Therefore, the conceptualization of health is not merely a concept but a workingproduct that affects all aspects of society. 71
  • 101. 6. REFERENCE 1. Lamb, V., and Siegel, J.S. (2005. Health demography. In Siegel, J. S., and Swanson, D. A, (Ed). The Methods and Materials of Demography, 2nd. Elsevier Academic Press, San Diego, pp. 341-363. 2. Spector, P. E. (1992) Summated rating scale construction. An introduction. London: Sage Publication. 3. World Health Organization. (1948) Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, June 19-22, 1946; signed on July 22, 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on April 7, 1948. “Constitution of the World Health Organization, 1948.” In Basic Documents, 15th ed. Geneva, Switzerland 4. Brannon, L., and Feist, J. (2007) Health psychology. An introduction to behavior and health, 6th ed. Wadsworth, Los Angeles. 5. Rowland DT. (2003) Demographic methods and concepts. Oxford University Press, New York. 6. Seigel, J. S., and D. A. Swanson, eds. (2004) The methods and materials of demography, 2nded. Elsevier Academic Press, San Diego. 7. Spiegelman, M. (1980) Introduction to demography, 6th. Harvard University Press, Boston. 8. Shryock, H.S., J. S. Siegel, and Associates. (1976) The methods and materials of demography, (condensed edition by Edward G. Stockwell). Academic Press, San Diego. 9. Smith, J.A. (1983) The idea of health: Implications for the nursing professional. Teachers College, New York. 10. Engel, G. L. (1977) the need for a new medical model: A challenge for biomedicine. Science, 196, 129-136. 11. Engel, G. L. (1980) The clinical application of the biopsychosocial model. American Journal of Psychiatry 137, 535-544. 12. Dubos, R. (1965) Man adopting. Yale University Press, New Haven. 13. Longest, B. B. (2002) Health Policymaking in the United States, 3rd. Foundation of the American College Healthcare, Chicago. 14. Ministry of Health, [MOH]. (2004) National Policy for the Promotion of Health Lifestyle in Jamaica. MOH, Kingston. 15. Stutzer, A., and Frey, B. S. (2003) Reported subjective well-being: A challenge for economic theory and economic policy. http://www.crema-research.ch/papers/2003-07.pdf (accessed August 31, 2006). 16. McConville, C., Simpson, E.E. A., Rae, G., Polito, A., Andriollo-Sanchez, Z., Meunier, N., Stewart-Knox, O’Connor, J.M., Boussel, A.M., Cuzzolaro, M., and Coudray, C. (2005) Positive and negative mood in the elderly: the Zenith study. European Journal of Clinical Nutrition, 59, 22. 17. Erber, J. (2005) Aging and older adulthood. Waldsworth, Thomson Learning, New York. 18. Morrison, E. (2000) Diabetes and hypertension: Twin trouble. Cajanus, 33, 61-63. 19. Callender, J. (2000) Lifestyle management in the hypertensive diabetic. Cajanus, 33, 67- 70. 20. Steingo, B. (2000). Neurological consequences of diabetes and hypertension. Cajanus, 72
  • 102. 33, 71-83.21. Eldemire, D. (1995) A situational analysis of the Jamaican elderly, 1992. Planning Institute of Jamaica, Kingston.22. Caribbean Food and Nutrition Institute [Cajanus]. (1999) Health of the elderly. Cajanus, 32, 217-240.23. Buzina, K. (1999) Drug therapy in the elderly. Cajanus, 32, 194-200.24. Ali, A., Christian, D., and Chung, E. (2007) Funny Turns in an Elderly Man. West Indian Medical Journal, 56, 376-379.25. Bok, S. (2004) Rethinking the WHO definition of health. Working Paper Series, 14. "http://www.golbalhealth.harvard.edu/hcpds/wpweb/Bokwp14073.pdf" http://www.golbalhealth.harvard.edu/hcpds/wpweb/Bokwp14073.pdf (accessed Mary 26, 2007).26. Evans, R.G. and Stoddart, G. L. (1990) Producing health, consuming health care. Social Science and Medicine, 31, 1347-1363.27. Bourne P. (2007) Using the biopsychosocial model to evaluate the wellbeing of the Jamaica Elderly. [Abstract]. West India Medical J, 56(Suppl 3), 39-40.28. Bourne PA. (2009) Determinants of Quality of Life of youths in an English Speaking Caribbean nation. North American J of Med Sci, 1, 365-371.29. Bourne, P, A. (2008) Health Determinants: Using Secondary Data to Model Predictors of Well-being of Jamaicans. West Indian Medical Journal 57, 476-481.30. Bourne, P. (2007) Determinants of Well-Being of the Jamaican Elderly. Unpublished Master of Science Thesis, The University of the West Indies, Mona, Jamaica.31. Bourne, P.A. (2008) Medical Sociology: Modelling Well-being for elderly People in Jamaica. West Indian Medical Journal 57, 596-604.32. B