Human ageing in Jamaica


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Human ageing in Jamaica

  1. 1. Human Ageing, Health, Health Utilization and Policy Implications: An introduction to Behaviour and Practices Paul Andrew Bourne
  2. 2. Human Ageing, Health, Health Utilization and Policy Implications: An introduction to Behaviour and Practices i
  3. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 21. xx
  22. 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. 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. 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. 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. 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. 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. 28. Dedication This volume is dedicated to Janet Green, Gerald Green, Kervin Smith, Evadney BourneAged people, Jamaicans, Young people xxvii
  29. 29. Human Ageing, Health, Health Utilization and Policy Implications: An introduction to Behaviour and Practices xxviii
  30. 30. Part I: Human Ageing 1
  31. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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