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    Male and older adulthood in Jamaica   health and sex Male and older adulthood in Jamaica health and sex Document Transcript

    • Male & Older Adulthood in Jamaica:Health and Sex Paul Andrew Bourne
    • Male & Older Adulthood in Jamaica:Health and Sex i
    • Male & Older Adulthood in Jamaica:Health and Sex Paul Andrew Bourne ii
    • ©Paul A. Bourne, 2011First Published in Jamaica, 2011 byPaul Andrew Bourne66 Long Wall DriveStony Hill,Kingston 9,St. AndrewNational Library of Jamaica Cataloguing DataMale and older adulthood in Jamaica: Health and SexIncludes indexISBNBourne, Paul AndrewAll rights reserved. Published , 2011Cover designed by Paul Andrew Bourne iii
    • Brief ContentsPrefacePart One: Health, Health Care Utilisation and Mortality 1Part Two: Sexual Practices 330Part Three: Validity and reliability of surveyed data 492Part Four: Commercial Sex Trade & Multiple Partnership 518Part Five: Retesting and refining theories on the association between illness, chronic illness and poverty 598Part Six: Sex and older adulthood 644Part Seven: The Gender Health Discourse 652Part Eight: Sexual harassment in Jamaica 683Part Nine: Social support in older adulthood 778 iv
    • ContentsPreface viiiAcknowledgement xiiiAbout the author xivPart One: Health, Health Care Utilisation and Mortality 11 Biosocial determinants of health and health seeking behaviour of male youths in Jamaica 22 Self-rated health and health conditions of married and unmarried men in Jamaica 283 Predictors of Good Health Status of Rural Men in Jamaica 554 Good Health Status of Older and Oldest Elderly in Jamaica: Are there differences between rural and urban areas? 795 Gender differences in self-assessed health of young adults in an English-speaking Caribbean nation 1086 Health of males in Jamaica 1397 Modelling social determinants of self-evaluated health of poor older people in a middle-income developing nation 1678 Ill-males in an English-Speaking Caribbean Society 1929 The image of health status and quality of life in a Caribbean society 229 v
    • 10 Socio-demographic determinants of health status of elderly with self-reported diagnosed chronic medical conditions in Jamaica 24911 Decomposing Mortality Rates and Examining Health Status of the Elderly in Jamaica 27912 The validity of using self-reported illness to measure objective health 309Part Two: Sexual Practices 32913 Psychosocial correlates of condom usage in a developing country 33014 Young males who delay first coitus for the statutory age and beyond in Jamaica 35915 Young males whose first coitus began at most 15 years old 38316 Reproductive health matters among Infrequent versus Frequent young adult-male-church attendees 40717 Contraception usage among young adult men in a developing country 437Part Three: Validity and reliability of surveyed data 46118 The quality of sample surveys in a developing nation 46219 Paradoxes in self-evaluated health data in a developing country 493Part Four: Commercial Sex Trade & Multiple Partnership 51720 Males and Prostitution in St. Andrew, Jamaica: Behaviour and Practices 51821 Multiple sexual partnerships among young adults in a tropically developing nation: A public health challenge 566 vi
    • Part Five: Retesting and refining theories on the association between illness, chronic illnessand poverty, and dichotomisation of health 59822 Dichotomising poor self-reported health status: Using secondary cross-sectional survey data for Jamaica 59923 Retesting and refining theories on the association between illness, chronic illness and poverty: Are there other disparities? 619Part Six: Sex and older adulthood 64424 Active ageing: Sex and older adulthood 645Part Seven: The Gender Health Discourse 65325 Gendered health 654Part Eight: Sexual harassment in Jamaica 68426 Jamaica is without a National Sexual Harassment Policy: Challenges, Consequences, Health Problems and the Need for a National Policy Framework 68527 Sexual harassment and sexual harassment policy in Jamaica: The absence of a national sexual harassment policy, and the way forward 730Part Nine: Social support in older adulthood 77828 Social networks among late adult men in Jamaica 779 vii
    • PrefaceThe discourse of men’s health in Jamaica is sparse, inadequate and requires impetus to providepolicy makers with scientific findings to guide their efforts and set a flat form for truth seekingand germane information on various areas and subareas. There are some paradoxes in healthliterature, particularly among males in Jamaica, as they seek less health care, and they are lesslikely to report an illness. Yet, life expectancy for females is about 6 years more than that formales. Clearly, with age specific mortality rates being higher for males than that of females, thenwe cannot simply reply on self-rated (or reported) health data on this sex to formulate healthpolicies and interventions with more investigation of the data and data quality. The Jamaican male is culturalized to hide his feelings as well as suppress illness. Illnessis construed as weakness. The culture is such that males cannot openly speak about illness,sexual malfunctions (including abstinence from sexual intercourse, fathering children, erectiledysfunctions), and premature ejaculations as well as fears. These bar males from openly crying,airing frustrations and weakness, and by extension seeking medical care, particularly utilising theservices of psychiatrists and/or psychologists, “the shrink”. The Jamaica males, like many of hisEnglish-Speaking Caribbean counterparts, is labeled by the society in such a way that createpsychological pressures that are embedded in the psyche, and guide the perception, beliefs andpractices of these people. The cultured standards that are levied on Jamaican males are primarily responsible fortheir absence from health care utilisation, promiscuity, and fears of weakness. The fears ofweakness are so crippling the behaviours, practices and choices of males in regard health, healthcare utilisation, sexuality, power relations, fatherhood, masculinity and survivability. Theinterrelationships among the culture, behaviour, practices, socialization, choices, and specifictasks are fashioning new generations of males embodied in the cosmology of their parents,particularly fathers, inspite of the growing paradigm shifts that have been occurring globally andregionally. The dominance of the cultured standards, therefore, are disbarring any paradigm shift thathealth care administrators and policy makers would like to forge ahead for Jamaican males. TheJamaican male is captured in a maze (or a cobweb scenario) that is continuously perpetrated bythe socialization processes, which hold them hostage and make extremely difficult neededchanges. Based on international standards, the cultured standards in Jamaica are graduallyshifting in some genres, such as sexuality. However, the pace at which these shifts is occurring inthe society are so incremental that expenditure on behavioural modification programmes appearto be ineffective, and a waste of resources. viii
    • The science of society, particularly among males, cannot be advanced with acomprehensively examination of matters surround 1) health, health care utilisation and mortality,2) sexual practices, 3) commercial sex trade multiple partnership, and the 4) quality of data. Thecurrent text is concerned about advancing the science of male and older adulthood in Jamaica.This cannot be framed without scientific enquires on the aforementioned issues. The enquiresmust evaluate issues on youth, adults and older adulthood in regard health, health care utilisation,mortality, sexual practices, and commercial sex trade among males, particularly amongJamaicans, in order to provide the answers to the hidden questions. Science cannot indefinitelywait for history to provide conclusions and a set of propositions. It is the mother of invention,knowledge, theories, guidelines and thought. Therefore, scientists must continuously examine,explore and test hypotheses that will frame law, principles, theories and knowledge about howthings operate in the world. The knowledge gains through research provide the impetus forapplication and solutions of problems in everyday lives of people. My book explains how research studies attempt to provide crucial answers to questions ofimportance on males’ issues in Jamaica. In order to provide answers to questions of importance,I describe studies in details in a way that they can be understood by all readers. However, thereare some statistical technicalities that are embodied in each study that may be difficult tounderstand by some readers, but these can be overcome with a read of the entire section (orstudy). For some of the readers who seek to comprehensively understand the technicalities, I amrecommend reviewing an introductory text in statistics, and particular chapters in an advancedstatistical text such as multiple regressions, logistic regression and the calculations of odds ratio. Because I belief that the information presented in this volume should provide soundknowledge on the various topic, I examine the quality of data in order to assess whether theinformation are of the highest quality that can advance science the science of health, health careutilisation, mortality, and sexuality, particularly among males. The testing of hypotheses arecritical to the formation of knowledge, this thought cannot be so if the quality of data are poorand forms the basis upon which I test the data quality and quality of survey data in Jamaica. Toachieve the highest degree of knowledge, ALL the chapters herein are empirical studies that testdifferent hypotheses, which can now be used to set propositions and theories about Jamaicanmales. Within the context of the complexities of knowledge, a number of the chapters emergedout of discussions with colleagues as I sought to extend coverage of some themes becausedifferent perspective on issues. All the chapters are research studies, with the majority of thembeing published in peered reviewed journals. Thus, some of the chapters were co-authored withother Caribbean and non-Caribbean scholars. These themes, therefore, are embedded in thegreatest degree of scientific rigors, which will provide many truths on the diverse topics. ix
    • The advancement of science is based on the questioning all established truths. Truths arenot continuous flows, indefinitely over time. They are accepted, modified, or refuted over time.It is the continuous questioning of things that result in the testing of hypotheses, theestablishment of new set of propositions, theories and principles on the governing of what is.“What is now? Is based on a set of proposition of what is known on some matters. If thefundamental guiding principles change, then set of understanding will emerge to explain what is.Any discussion on health cannot go without examining the validity and reliability ofconceptualisation of health (absence of illness, mortality). Empirical evidence showed thatillness is related with poverty, making the debate on illness, a poverty one as well as the use ofconceptual frameworks. Poverty is well established as being associated with illness and chronic illness. Studieswhich have examined this phenomenon have done so using objective indices such as lifeexpectancy, infant mortality and general morality. This volume therefore evaluates (1) examinedsubjective indices such as self-reported illness and self-reported health, (2) re-tested the theoriesthat chronic illnesses are more likely to be greater in number among the poor and that illnessesare positively correlated with poverty, and (3) evaluated other social characteristics that accountfor the poverty-illness theory. Conceptual frameworks are not only forwarded in this book, they are tested to providetruths on findings and validity of data used to established facts. There is a longstanding discourseon whether self-reported health is a good measure of objective health. This has never beenempirical examined in Jamaica. Study text 1) examine the relationship between particularsubjective and objective indexes; 2) investigate the validity of a 4-week subjective index inmeasuring objective indexes; 3) evaluate the differences that exist between the measurement ofsubjective and objective indexes by the sexes; and 4) provide policy makers, other researchers,public health practitioners as well as social workers with research information with which can beused to inform their directions. Administrators, policy specialists, medical practitioners,researchers, scholars and the general populace have been using survey data and quoting findingswith testing of the accuracy of the results. In this volume having tested (Chapter 12) subjectiveand objective conceptualisation of health found that self-reported illness in a 4-week referenceperiod (subjective index of health) is a good measure of objective health than self-reportedillness for males and was a better measure for objective health for females. The discourse on the subjective versus the objective indexes of health wascomprehensively examined in chapter 12. The findings revealed that life expectancy at birth ofJamaicans and self-reported illness (assessed based on a 4-week period) are strongly negativelycorrelated with each other (correlation coefficient, r = - 0.731). Fifty-four percent of the variancein life expectancy at birth for the population of Jamaica can be explained by 1% change in self-reported illness. Disaggregating the results by gender revealed some variations in outcomes.There is a strong negative significant statistical correlation between life expectancy at birth of amale and self-reported illness of male (in %) - correlation coefficient, r = - 0.796. Sixty-three x
    • percent of the variance in life expectancy at birth of a male can be explained by self-reportedillness (in %). There is a negative moderate correlation between life expectancy at birth of afemale and self-reported illness of female (in %) – correlation coefficient = 0.683. Forty-sevenpercent of the variance in life expectancy at birth of a female can be accounted for by 1% changein self-reported illness females (in %). Although some finality can be used on subjective versus objective indexes of health inJamaica, there are some paradoxes in self-reported health data. Some of these paradoxes arehighlighted in this text (chapter 19), caution now must be used by researchers in interpreting self-reported health data collected from males, as they are clearly under-reporting illnesses and over-stating their health care-seeking behaviour. In spite of the paradoxes in the data, self-reportedhealth collected on females in Jamaica is of high quality. This denotes that the paradoxes withinthe health data have provided critical answers to males’ reluctance in visiting health carefacilities, their unwillingness to openly speak about illnesses and the fact that they haveconcealed information on their health. The paradox in income can be seen in the fact that while wealthy Jamaicans have moreincome and access to more socio-material and political resources, their health status is notgreater than the under-privileged, poor and poorest 20%. Additionally, the contribution ofincome to health status is minimal, which is not the case in the literature. It was expected thatJamaicans who sought more health care must have been experiencing more ill-health, but thiswas not the case. Having established that health data collected from males indicates a lowvalidity, with 49% of the sample being males, it follows that paradoxes identified in the currentstudy highlight the difficulties in interpreting health data in Jamaica. Therefore, a new approachis needed in soliciting information from males about their health status including who is used tocollect data. Sometimes, researchers and scholars rely on particular agencies (WHO, United Nations,ILO, World Bank, UNESCO, Statistical Agencies and Governmental Planning Agencies) forfindings (including statistical results). Those findings are treated as absolute truths, withouttesting (validation) by scholars. The Statistical agency of Jamaica opined that the population ofSt. Catherine can be used to represent that of the nation. This was used by a former colleague ofmine to examine older men’s health in Jamaica, using St. Catherine as the sample frame. Chapter19 of this work examines the validity of this finding. It is clear from the inconsistencies in thehealth data collected by the relevant agencies that the reliability of self-reported health data frommales will pose a problem in public health planning. Sample surveys are used for teaching healthcare professionals; examining health care staff requirements; community health care; planninghealth care; planning and determining the future care of patients; evaluation of public healthpolicies; health care interventions; the construction of community centres, hospitals and publicclinics; and clinical and health service provisions. Then there are two other issues that emergedfrom the present findings, firstly, as dichotomizing self-evaluated health for males loses some ofthe original information, and secondly, that a sample of St. Catherine is not the same as samplingthe nation, and so a sample from the parish of St. Catherine does not reliably reflect the detailedcharacteristics of the wider Jamaican population. Thus, care should be taken in the usage of sub- xi
    • national samples to generalize about a population and more so when it comes to data collectedfrom males in regards to their health. Even the dichotomisation of health (using illness or self-rated health status) was tested inthis text. One of the purposes of this volume is not to merely provide findings on health,particularly among males in Jamaica, but to validate the results, and if needs be provideclarifications on established truths. Truths can be empirically resulted and validated withexperiences. I wanted to provide truths in men’s health and sexual expressions in Jamaica, so Iopted to verified many of the established set of propositions as well as forward new perspectivesbased on the emerged findings. The findings of the current study show that the choice of cut-offfor the dichotomisation of self-reported health status marginally matters for age, marital status,and area of residence. These findings concur with Finnas et al.’s work [18] (Chapter 23).However, social class matters for males. The odds ratios for males at the different social classes,when moderate heath status is added to poor health status, changed substantially. This suggeststhat the dichotomisation of self-reporting for males will not shift and will produce a differentresult from if only poor or very poor were the cut-offs for self-reported health status. A discourse on men’s health and issues cannot conclude with an examination of sexualharassment, and men’s roles in this phenomenon. Chapters 26 and 27 evaluate sexual harassmentin Jamaica, health problems, consequences and implications.LAYOUT OF THE BOOKThis volume comprises 28 chapters, which is ideal for the general populace, administrators,sociologists, health demographers, public health practitioners, medical practitioners,undergraduate or graduate courses in health, health care utilisation, sexuality, sexual expressions,and health behaviour, particularly among males. Chapter 22 is highly statistical, so beforereading this one I am recommending reviewing the calculations of odds ratio and theirinterpretations. Even without this understanding, some general knowledge can still be had onreading the chapter. By for a comprehensive understanding of the text, undergraduate andgraduate students may require to do some course (or training) in advanced statistics. Paul Andrew Bourne Director Socio-Medical Research Institute 2011 xii
    • AcknowledgementI wish to thank a number of people who directly or indirectly contributed to the final text. Duringpursuing a master of science in Demography, I accidentally can on a work written by ProfessorDenise Eldemire-Shearer (formerly Denise Eldemire) that examined issues on aged Jamaicans. Iwas intrigued by the work, wanted to know more on ageing and so my interest became a passionfor knowledge on the subject. The discourse outlined in Professor Dr. Eldemire-Shearer’spublication lead me to other works. The urged was such that in a week I had read more than 10published works on ageing, particularly in the Caribbean. This began a love affair with ageingstudies. The question emerged was how could a demographer study ageing. In answering thisquestion, I search and extensively read over 20 studies published in journals entitledDemography and Population Studies. During this search, I thought that this could be my thesis to complete a master indemography. Professor C. Uche, tested my readings on the subject before he hesitantly acceptedthe possible of such a study. The passion for the area (ageing) was so strong that even when Iwas asked to select a new area that I opted for another supervisor, Professor Patricia Anderson.Professor Anderson believed that the topic was researched, guided the focus of the paper, andthen set me on my way with some junior academics (Dr. Sharon Priestley and Mr. JulianDevonish). Dr. Priestley (at the time Ms. Priestley) and Mr. Julian Devonish say the completionof the work. From the completed thesis, I was encouraged by Dr. I. Solan (a mathematician in theDepartment of Mathematics and Computer Science, the University of the West Indies, Mona) tothink of submitting an article for publication. This was followed up with two papers sent to theWest Indian Medical Journal. Subsequently, the articles were published after some adjustments.In order to meet the specified requirements of the journal, the papers went through extensivedrafts, redrafts, literature search, focus and reading of latest studies on ageing. The reading onageing deepens my interests in ageing and health, which later followed plethora of publicationsin the areas and related matters. The writing of this book is, therefore, in response to the aforementioned persons, myinterest in ageing and family members. I am undoubtedly indebted to all the named persons, thesuggestions from friends that I am able to collate the materials into a text. Thank you, all. xiii
    • About the AuthorPaul A. Bourne is the Director of Socio-Medical Research Institute, Kingston, Jamaica. He isthe author of Growing Old in Jamaica: Population Ageing and Senior Citizens’ Wellbeing, and ASimple Guide to the Analysis of Quantitative Data. An Introduction with hypotheses,illustrations and references, and coauthored Probing Jamaica’s Political Culture, volume 1: MainTrends in the July – August 2006 Leadership and Governance Survey, and A landscapeAssessment of Political Corruption in Jamaica. Dr. Bourne has taught at different level in theJamaican educational system (Primary, John Mills Junior High (formerly John Mills All Age);Vauxhall High (formerly Vauxhall Comprehensive High); Kingston College; Oberlin High,Gaynstead High; University of the West Indies, Mona Campus; Moneague Teachers’ College;Browns Town Community College, St. Mary’s College, and Young Women’s ChristianAcademy (YWCA). His numerous publications focused on 1) health, 2) health care utilisation,3) ageing, 4) validity and reliability of survey data, 5) sexual behaviour and 6) Trust. Some ofthe publication are shown in scientific journals such as North American Journal of MedicalSciences, International Journal of Collaborative Research on Internal Medicine and PublicHealth, Healthmed, Journal of Men’s Health, West Indian Medical Journal, Rural and RemoteHealth, Journal of Clinical and Diagnostic Research, Patient Related Outcome Measures,Accred Qual Assur: J for Quality, Comparability and Reliability in Chemical Measurement ,African Journal of Primary Health Care and Family Medicine, Research and Reports inTropical Medicine, Journal of Biomedical Sciences and Engineering, Open Access Journal ofContraception and Current Research Journal of Social Sciences. Dr. Bourne has served on manyeditorial boards, and reviews plethora of articles on various subjects.Contact information: Dr. Paul A. Bourne, Director, Socio-Medical Research Institute, 66 LongWall, Stony Hill, Kingston 9, St. Andrew, Jamaica, West Indies.Email: paulbourne1@yahoo.com or paulbourne1@gmail.com. Tel: (876) 457-6990 xiv
    • Part One: Health, Health Care Utilisation and Mortality 1
    • Chapter1 Biosocial determinants of health and health seeking behaviour of male youths in JamaicaThe current study aims to provide an understanding of the health of young males (ages 15-25years) which has been primarily lacking in the Caribbean, and in particular Jamaica. This studyutilised secondary cross-sectional dataset for 2007 taken from the Jamaica Survey of LivingConditions (JSLC). The questionnaire was modelled from the World Bank’s Living StandardsMeasurement Study (LSMS) household survey. The current study extracted 607 respondents (15-25 years) from a sample of 6,783 respondents. SPSS for Windows 16.0 (SPSS Inc; Chicago, IL,USA) was used to store, retrieve and analyse the data. A p-value of < 0.05 (two-tailed) was usedto indicate statistical significance. Four variables emerged as statistical significant correlates ofhealth status: self-reported illness, OR = 16950, 95% CI = 46.4-6187362.9; self-reported injury,OR = 114643.2, 95% CI = 100.2-131124116.9; crowding, OR = 0.2, 95% CI = 0.09-0.59 andhead of household, OR = 0.001, 95% CI = 0.0-0.2. None of the identified variables emerged assignificant correlates of the good self-rated health status of male youths - Model χ2= 16.284(8),P < 0.061. Of the variables identified, 1 emerged as a correlate of poor self-rated health status –self-reported illness – OR = 42.2, 95% CI = 2.6-693.2. Poverty is substantially a ruralphenomenon. Almost 30% of rural respondents were classified as being in the poorest 20%,compared to 17.3% of those in semi-urban and 8.7% in urban areas. At the same time, nostatistical association existed between area of residence and self-reported health status, self-reported injury, self-reported diagnosed health conditions and poor health status. The currentstudy does not concur with the established finding that poverty is more common among thechronically ill than among those who are not chronically ill. However, it supports the literaturethat current illness is primarily a response to males’ willingness to utilize health care. Theimplications for these findings are far-reaching, and public health practitioners now have aplatform upon which they can fashion interventions, health education and future research on thisvulnerable age cohort in Jamaica. 2
    • IntroductionThe Caribbean continues to grapple with an alarming crime problem. Scholars have found thatmuch of it is perpetrated by young males (≤ 30 years of age) [1-8]. Statistics showed that 67.6%of those arrested for major crimes in Jamaica (i.e. murder, shooting, robbery, house-breaking,rape and carnal abuse) were 16-30 years old, and that young males accounted for more than 80%of the numbers (Table 1.1). Bearing this out, for the period 1999-2002, statistics in Jamaicarevealed that more than 50% of those treated for gunshot wounds in the Accident and Emergencydepartments at public hospitals were 10-29 years of age, with the figures being relatively thesame for males and females. A recently conducted study by Powell, Bourne and Waller [9] foundthat 44% of Jamaicans indicated that ‘crime and violence’ was their most pressing problem, aphenomenon which extends to many other Caribbean nations such as Barbados, Trinidad andTobago, and Guyana [1-8]. The social realities of the crime problem in the region justify (1)studies on crime and violence, and (2) an inquiry into the fear of crime and victimization. Understandably, there are many studies on crime, violence and the fear of crime andvictimization in the Caribbean, but there are also other concerns such as substance abuse, sexualpractices, the survivability of young people, and male marginalization. Those issues have beenstudied and re-studied [10-18], sometimes yearly, but in addition to crime which is a narrowedaspect of the broad social issues that continue to challenge Caribbean peoples, there is a need toexpand research into this social problem. Studies continue to examine crimes, violence and thefear of crime and victimization, and rightfully so in the region and little attention if any has beenplaced on men’s health, and in particular young men’s health in the region, except in the area ofreproductive health and sexual practices [19-21]. 3
    • Recently an entire book entitled “Health Issues in the Caribbean” [18] covered topicssuch as child health, reproductive health, the elderly, chronic non-communicable diseases,disability, health care-delivery and health issues in the Caribbean, reinforcing the claim of thelack of research on men’s health and young males’ health. A study by Bourne [21] examined“Demographic shifts in the health conditions of adolescents 10-19 years, Jamaica”, whichprovided pertinent information on this cohort, but again men’s health or young males’ health wasnot the emphasis; neither did it capture most of those who attested for crimes, nor those who areinfluenced by crime and violence. With crime being such a dominant social problem and the factthat it is perpetrated by mostly young males, there is the tendency to become overindulgent inthis discourse. However, research conducted by Powell, Bourne and Waller [9] found that only18% of Jamaicans indicated that they have been victims of crime and violence in the last 12months. Clearly, there is an obvious need to expand the research, from crime, violence, fear andvictimization to health status, health conditions and health care-seeking behaviour among theyouth. Apart from being the perpetrators of crime and violence, how is their (1) health status, (2)health care-seeking behaviour and (3) how are the health conditions among young males (15 –25 years)? The current study aims to provide an understanding of the health of young males (ages15-25 years) which has been primarily lacking in the Caribbean, in particular in Jamaica. What isinfluencing their health care seeking behaviour? Those questions cannot be answered from theperspective of a general study on health or the health care-seeking behaviour of Jamaicans [22],as without disaggregating the results, pertinent information is lost on the this cohort because itwould be general findings on the populace. 4
    • Materials and MethodsStudy populationThis study utilised secondary cross-sectional dataset for 2007 taken from the Jamaica Survey ofLiving Conditions (JSLC). The JSLC is a joint publication from the Planning Institute of Jamaica(PIOJ) and the Statistical Institute of Jamaica (STATIN) for analysis [23-25]. The JSLC began in1988 to collect data on the living conditions of Jamaicans in order to measure governmentpolicies. These cross-sectional surveys were conducted between May and October of each yearacross the 14 parishes of Jamaica. The current study extracted 607 respondents (15-25 years)from a sample of 6,783 respondents [26, 27]. The JSLC used a stratified random probabilitysampling technique to draw the original sample of respondents. The non-response rates were26.2%. The JSLC survey used a complex design with multiple stratifications to ensure that itrepresented the population, marital status, area of residence and social class. The sample wasweighted to reflect the population of Jamaica [23-25].Study instrumentThe JSLC used an administered questionnaire where respondents were asked to recall detailedinformation on particular activities. The questionnaire was modelled using the World Bank’sLiving Standards Measurement Study (LSMS) household survey [23]. There are somemodifications to the LSMS, as JSLC is more focused on policy impacts. The questionnairecovers demographic variables, health, immunization of children 0–59 months, education, dailyexpenses, non-food consumption expenditure, housing conditions, inventory of durable goodsand social assistance. Interviewers are trained to collect the data from household members.Statistical methods 5
    • Descriptive statistics were used to analyse the socio-demographic characteristics of the samples.Chi-square analyses were used to examine the association between non-metric variables for areaof residence, and gender of respondents. T-test statistics and Analysis of Variance were used toevaluate metric and either a dichotomous or non-dichotomous variable respectively. Logisticregression analyses examined 1) the association between good health status and some socio-demographic, economic and biological variables, as well as 2) a correlation between self-reported health conditions (illnesses, dysfunctions or ailments) and some socio-demographic,economic and biological variables. SPSS for Windows 16.0 (SPSS Inc; Chicago, IL, USA) wasused to store, retrieve and analyse the data. A p-value of < 0.05 (two-tailed) was used to indicatestatistical significance. The only selection criterion for this study was based on the males being 15-25 years old.For the model, the selection criteria were based on 1) the literature review; 2) low correlations,and 3) non-response rate. The correlation matrix was examined in order to ascertain ifautocorrelation and/or multicollinearity existed between variables. Based on Cohen & Holliday[28, 29] correlation can be low (weak) - from 0 to 0.39; moderate – 0.4-0.69, and strong – 0.7-1.0. This was used to exclude (or allow) a variable in the model. Where collinearity existed (r >0.7), the variables were entered independently into the model to help determine which oneshould be retained in the final model construction. This was used to exclude or include somevariables, and was based on the variables’ contribution to the predictive power of the model andits goodness of fit. Such an approach was utilised in order to reduce multicollinearity and/orautocorrelation between or among the independent variables [30-36]. Forward stepwise logisticregression technique was used to determine the magnitude (or contribution) of each statisticallysignificant variable in comparison with the others, and the Odds Ratios (OR) aided the 6
    • interpretation of each significant variable. To derive accurate tests of statistical significance, theresearcher used SUDDAN statistical software (Research Triangle Institute, Research TrianglePark, NC), and this adjusted for the survey’s complex sampling design.MeasureAge is a continuous variable which is the number of years alive since birth (using last birthday):from 15 to 25 years.Self-reported illness (or self-reported dysfunction): The question was asked: “Have you had anillness such as influenza, asthma, et cetera in the past 4-week period?”Health conditions (i.e. parent-reported illness or parent-reported dysfunction): The question wasasked: “Is this a diagnosed recurring illness?” The answering options are: Yes, Influenza; Yes,Diarrhoea; Yes, Asthma; Yes, Diabetes; Yes, Hypertension; Yes, Arthritis; Yes, Other; and No.Self-rated health status: “How is your health in general?” And the options were: Very good;Good; Fair; Poor and Very Poor.Medical care-seeking behaviour was taken from the question ‘Has a health care practitioner,healer or pharmacist been visited in the last 4 weeks?’ with there being two options: Yes or No.Self-rated health status: “How is your health in general?” And the options were: Very good;Good; Fair; Poor and Very poor. For this study the construct was categorized into 3 groups – (i)Good; (ii) Fair, and (iii) Poor. A binary variable was later created from this variable (1=good andfair 0=otherwise).Social hierarchy: This variable was measured based on income quintile: The upper classes werethose in the wealthy quintiles (quintiles 4 and 5), the middle class was quintile 3, and the poorwere those in lower quintiles (quintiles 1 and 2). 7
    • Crowding: This is the total number of people in the household divided by the number of rooms,excluding verandah, kitchen and bathroom.Area of residence is a non-binary variable. 1= urban, 0=otherwise 1=semi-urban, 0=otherwise Reference group is rural areaResultsThe sample was 607 respondents (15-25 years): dwelling in urban areas, 33.9%; semi-urban,20.9%; rural, 45.2%; injured in last 4-week period, 2.4%; self-evaluated illness (in last 4-weekperiod), 3.3%; health care-seeking behaviour, 68.0%; primary or below education, 64.5%;tertiary level education, 6.5%; household heads, 8.9%; very good self-rated health status, 49.2%;good self-rated health status, 44.9%; moderate self-rated health status, 4.6%; poor self-ratedhealth status, 1.0%; and very poor health status, 0.3%. Of those who reported an illness, 75.5%stated the typology of health conditions: influenza, 6.7%; diarrhoea, 13.3%; asthma, 6.7%;hypertension, 6.7%; and other (unspecified), 66.7%. The mean age of the sample was 19.6 years(SD = 3.2 years). The median length of illness (in days) was 5 (range = 1, 28) and the number ofvisits to a health care practitioner was 1 time (range = 1, 3). Of the 8.9% of those who were heads of households, 29.6% were 24 years old; 18.5%were 22 years old; 14.8% were 23 years old; 13.0% were 25 years old; 11.1% were 19 years old;3.7% were 21, 20 and 17 years old; and .9% were 16 years old. Furthermore, a statisticaldifference existed between those who were and those who were not heads of households (Fstatistic = 48.6, P < 0.0001): mean age of those who were household heads was 22.4 years (SD =2.3 years) compared to those who were not household heads (19.4 years ± 3.1 years). There is a statistical difference between the mean length of illness (in days) and area ofresidence (F statistic = 5.706, P = 0.011). Those in urban areas recorded the greater length of 8
    • illness, 14.4 days (SD = 10.3 days); semi-urban areas, 6.5 days (SD = 5.8 days) and ruralrespondents, 4.7 days (SD = 2.5 days). Furthermore, a statistical difference was found betweentotal annual household expenditure among the social classes (F-statistic = 64.870, P < 0.0001.The mean annual household expenditure for the sample was USD 8,994.04 (SD = USD6716.46). However, those young males in households of the poorest 20% had an annualhousehold expenditure which was 3.3 times less than those in the households of the wealthiest20% (USD 15,152.73 ± 10,179.74), with the following annual household expenditures beingpoor, USD 6,311.23 ± 2,645.72; middle class households, USD 8,522.97 ± 3,656.07; andwealthy, USD 10,812.74 ± 5,573.11. No statistical difference was found between the annual household expenditure of thosewith illness (USD 11,091.18 ± 13,898.55) and those who did not report an illness (USD 9,001.44± 6,433.52) – t-test = 1.320, P = 0.187. A statistical association existed between household heads and areas of residence (χ2 =6.864, P = 0.032). Almost 7% of those who dwelled in rural areas were household headscompared to 6.3% of those living in semi-urban areas and 13.1% of those who resided in urbanareas. There is no significant statistical association between (1) self-reported illness and socialstanding (χ2 = 1.315, P = 0.859), (2) self-reported injury and social standing (χ2 = 2.640, P =0.620), and (3) self-reported diagnosed health conditions and social standing (χ2 = 12.80, P =0.687). Table 1.2 highlights information on the demographic characteristics of the sample by areaof residence. A significant statistical association was found between social standing and area of 9
    • residence (χ2 = 83.5, P < 0.0001). Almost 30% of rural respondents were in the poorest 20%compared to 17.3% of those in semi-urban areas and 8.7% in urban areas.Multivariate analyses Table 1.3 shows information on factors that are correlated with the health care-seekingbehaviour of the sample. Using stepwise logistic regression, 4 variables emerged as statisticalsignificant correlates of health status: self-reported illness, OR = 16950, 95% CI = 46.4-6187362.9; self-reported injury, OR = 114643.2, 95% CI = 100.2-131124116.9; crowding, OR =0.2, 95% CI = 0.09-0.59 and head of household, OR = 0.001, 95% CI = 0.0-0.2. The modelexplains 86.4% of the variability in the health care-seeking behaviour of respondents, and it is agood fit for the data - Model χ2= 123.91(8), P < 0.0001, Hosmer and Lemeshow goodness of fitχ2=37.781, P = 0.778. Concurrently, 55.1% of the variability in health care-seeking behaviour isaccounted for by self-reported illness, and self-reported injury accounted for 26.2%. Table 1.4 highlights the possible factors of self-rated good health status of the sample.None of the identified variables emerged as significant correlates of good self-rated health statusof male youths - Model χ2= 16.284(8), P < 0.061. Almost 95% of the respondents were used toestablished the model, and it was found that the model is a good fit for the data - Hosmer andLemeshow goodness of fit χ2=5.301 (8), P = 0.725. Table 1.5 examines possible factors that are correlated with poor self-reported healthstatus of respondents. Ninety-three percent of the sample was used to establish the model. Of thevariables identified, 1 emerged as a correlate of poor self-rated health status – self-reportedillness – OR = 42.2, 95% CI = 2.6-693.2. The model was a good fit for the data - Model χ2=123.91(8), P < 0.0001; Hosmer and Lemeshow goodness of fit χ2=1.206 (8), P =0.997. 10
    • DiscussionThe current study found that 94 out of every 100 young males (ages 15-25 years) reported atleast good health status. Only 1.3% of the sample indicated poor health status. However, 3.3%indicated having had an illness in the last 4 weeks and 2.4% were injured in the same period oftime. Almost 1 in every 100 young males had reported an acute condition compared to 2 inevery 100 who reported a chronic condition. Of those who reported an illness (n=15), 66.7%indicated other and 6.7% said hypertension. The prevalence of hypertension among young maleswas 2 in every 1,000 persons. Sixty-eight percent of the sample had visited a health carepractitioner in the last 4 weeks; 83% purchased the prescribed medication; 15% had healthinsurance coverage; 58.8% visited a public hospital for treatment compared to 5.9% who used aprivate hospital, 11.8% who utilised public health care centres and 29.4% who attended a privatehealth care centre. Concurrently, the median length of time in illness was 5 days, with themedian number of visits to a health care practitioner being 1. In addition to the afore-mentionedfindings, 27% of poor health status can be explained by self-reported illness, and 47.6% of thevariability in health care-seeking behaviour can be accounted for by illness and 22.6% by injury.Young males who had indicated that they were heads of household were 99.9% less likely toseek health care, and those respondents with more people per room were 76.5% less likely toseek medical care. It is empirically established that health status is determined by medical, social,environmental and psychological factors [19,20,37-49], but for this study self-reported illnesswas the only factor that emerged as being significant, when correlated with health status. Usingdata for elderly Barbadians, Hambleton et al. [43] found that 88% of the variability in self-reported health status could be explained by current diseases, and the current study found 27% of 11
    • the variability in poor health being explained by current self-reported illness. Hambleton andcolleague’s study [43] did not examine the health care-seeking behaviour of the sample, but thisresearch found that 55.1% of the explanatory power of seeking medical care was accounted forby current self-reported illness. Embedded in this study is the image of health of young malesand when they seek medical care. This is not atypical, as a qualitative study conducted by Ali &de Muynck [50] in Pakistan found that illness and its severity are responsible for male streetchildren being willing to utilize medical care facilities. Clearly, in Jamaica as well as other non-Caribbean nations [51-54], males’ image of illness is fundamentally based on illness, injury orthe severity of illness and injury, and not health from the perspective of wellbeing. It is thisnarrow definition of health that influences the decision of young males to seek medical care, andnot preventative health. The current findings show that there is a very good explanation foryoung males’ health care seeking behaviour in Jamaica (R2 = 86.4%), which suggests that healthis the absence of diseases, and this is what impacts on their demand for health care. Health care-seeking behaviour among the current sample is 68 out of every 100 malescompared to 66 per 100 of the general populace and 68 out of every 100 for females.Concurrently, the rate for young males seeking medical care is 5% more than the rate for malesin the general population and the same as for females in the population. It should also be notedhere that the rate of those with illness in this sample is less than 4% which is 4.7 times less thanthe national average (i.e. 15.5% reported illness). Despite the substantially lowered rate of self-reported illness, young males sought more medical care than males in the wider population. Thisfinding highlights a myth that young males, like their older counterparts, avoid seeking medicalcare, but the issue which emerged from this research is that they seek both curative andpreventative care. Current self-reported illness and injury accounted for 81.3% of the variability 12
    • in the health care-seeking behaviour of young males, supporting the culture which stipulates thatmen are strong and should not show weakness, and that illness is a sign of weakness. Hence, theillnesses which influence health care-seeking behaviour cannot be mild, such as the commoncold or diarrhoea, but more like asthma, hypertension and injuries such as gunshots, knifewounds and other severe conditions that are life-threatening, and therefore require immediatemedical attention. Although only 3.3% of the sample reported an illness and the prevalent rate for each self-reported diagnosed health condition was low (influenza, 0.2%; diarrhoea, 0.3%; asthma, 0.2;hypertension, 0.2%; and other (unspecified), 1.6%), on disaggregating those who reported ahealth condition, it becomes clear that this is a public health problem. Two-thirds of those whoindicated a health condition claimed ‘other’, indicating a preponderance of some healthconditions and sexually transmitted diseases. A recently conducted study of Jamaicans by Wilkset al. [13] found that only 24.3% of young males (ages 15-24 years) claimed that they had nothad sex in the last 12 months; 48.7% had more than one sexual partner; 75.7% had sexualintercourse at least once per week; 0.9% claimed that they have had a STI in the last year; 65.8%used condoms; and 8.4% had not used a contraceptive method in the last 12 months. Based onWilks et al.’s study, there are other health conditions apart from sexually transmitted diseaseswhich are dominant in the unspecified health conditions stated in the current sample. Statisticsfrom the Ministry of Health (Jamaica) showed that 15% of males aged 10-29 years (in 2006) hadAIDS, which rules out AIDS as the explanation of the unspecified conditions of the currentstudy. Furthermore, examination of the statistics from the Ministry of Health (Jamaica) foundthat in 2006 36.0% of young males (ages 10-29 years) utilised public health care facilities forbites, 54.3% for gunshot wounds, and 43.1% for accidental lacerations. Those conditions may 13
    • account for the unspecified health conditions identified by the current study, but there is nofinality of this fact without a study of this cohort’s health, health conditions and injuries. Clearlycrime, violence and victimization are having an influence on the health of young males, and whatabout the fear of crime and victimization on those who are not assaulted, but have witnessed theevents and are fearful from reading and watching the wired media? Concurrently, when the unspecified health conditions were disaggregated by area ofresidence, most of the reported cases were in urban areas, followed by rural and semi-urbanareas. Currently, research cannot account for most of the unspecified health conditions, whichdenotes that public health intervention programmes are designed without consideration beinggiven to this unknown event. But what is known is that almost 71% of the sample utilised publichealth care facilities and they constituted mostly rural respondents, which denotes that publichealth care facilities hold some of the clues to the condition of young males. However, thehypertensive cases were in semi-urban areas, and this offers public health policy makers somepertinent information upon which policies can be framed for young males. Poverty is empirically found as being associated with poor health status and a group ofscholars went as far as to declare that money can buy health [38]. Although Marmot [39] didargue that poverty is associated with poor milieu, nutrition, opportunities and choices, more sothan the affluent, using the United States, he showed that there was a weak relationship betweenGross National Product and overall health. Embedded in Marmot’s finding was the fact thatother factors are more of an explanation of poverty and poor health and/or ill-health such aseducation, material deprivation, social environment, racial inequality and occupational hierarchy.He also pointed out that there was a weak statistical association between average income and lifeexpectancy in rich countries, but that within those nations there is a close association between an 14
    • individual’s income and his life expectancy and mortality. Clearly poverty is an influence onillness, and with ill-health also affecting poverty, this could be influenced more by other socialconditions than money (or income). One of the issues which could make the difference betweenMarmot’s work and this one is how health is measured in each study. Health had a narrowdefinition in Marmot’s study as it was operationalized by life expectancy or mortality. However what emerged from these findings are (1) poverty is not associated with poorhealth status; (2) poor young males do not seek less health care than the affluent; (3) ruralpoverty (i.e. those in the poorest 20%) was 3.4 times more than urban poverty and 1.7 timesmore than semi-urban poverty; (4) there was no significant statistical association between self-reported illness or injury and area of residence; (5) there was no significant statisticalrelationship between health care-seeking behaviour and area of residence; (6) urban young maleswere 5.5 times more educated at the tertiary level than rural young males; (7) urban young maleshad the greatest length of illness (in days); and (8) illness, injury or self-reported diagnosedhealth conditions are not statistically related to social standing. The current work disproves thefindings of Van Agt et al. [56], which showed that chronic illness is more prevalent among thepoor. However, this study concurs with Van Agt et al.’s work [56], in that material deprivationwas highest among the poor, but disproves the finding that the higher prevalence of materialdeprivation was among the chronically ill people. Instead, this study found that those who werechronically ill were more likely to be in the wealthy social hierarchy than in the poor socialhierarchies. According to Barillas et al. [57], there was a paradox in the national survey data collectedon Guatemalans, as the poor reported less illness than the non-poor, and individuals in rural areasreported less illness than those in urban areas. It appears from the current study that no statistical 15
    • association between area of residence and self-reported illness and self-reported diagnosed healthconditions and social class would also be a paradox, but it is not the case as these are the realitiesin those nations and not the empirical findings of international health literature. Hence, it is goodto use international empirical findings from one country and create intervention programmes orpublic health education for another geopolitical area. In the current study 14.6% of rural young males claimed that they had an illness in thelast 4 weeks, but Bourne [58] conducted a study on rural men in Jamaican and found that 17%reported an illness. This finding highlights the deceptive nature of using the national average forpublic health planning, as what holds for men in one geo-political zone is not the same for youngmales within the same area. This is also true as Bourne [58] found that (1) 61.2% of rural menvisited a health care practitioner, (2) 2.4% had tertiary level education, (3) 4.9% had healthcoverage, and (4) good health status is a function of social, economic and biological factors.However, in this research health care utilization was greater for young rural males (73.3%);tertiary level respondents were about the same for rural men and young rural males (2.3%);health coverage was significantly more for young rural males (14.5%) than rural men, and nofactor explains the good health status of young males in Jamaica compared to rural men. Hence,even among people who live in the same geopolitical zones there are inequalities, suggesting thatpublic health practitioners cannot use national average or sub-national areas of one group to planfor another. Crime is substantially concentrated in urban zones, and given that it is perpetrated moreby young males, and the fact that more of them are victims of crime, it follows therefore that thelonger time spent in illness could be due to gunshot wounds and other injuries, more so than inthe case of rural and semi-urban young males. Illness is not only physical but a psychological 16
    • condition. This was established long ago by the WHO, and clearly the psychosocial challengesof life account for the health care-seeking and length of illness. The current findings revealedthat those young males who are household heads are almost 100% more likely to seek health careas they need to provide for a household, which indicates that health care switching is occurringamong this cohort in favour of their families. The health care switching which occurs denotesthat many young males who are heads of households will forego health care treatment inresponse to the demands of providing for a household. Not only do they forego health care butthey also forego preventative care, and this delay could account for premature death. Thesocioeconomic challenge of the household also accounts for other risky lifestyles, and may holdanswers to their involvement in criminality and violence. While this study does not examinewhether there is a statistical association between a household head and crime, it can beextrapolated from the findings that the areas in which young males recorded the most heads ofhousehold status (urban areas, 13.1%; semi-urban, 6.3%; rural, 6.9% - χ2 = 6.86, P = 0.032), areprecisely those areas with the greatest crime and violence. One might ask if this is coincidentalor circumstantial, but it needs to be examined as a possible explanation for high crime as well asthe psychological state of young males in urban areas.ConclusionIt is well established in health research that health is a function of social, psychological,environmental and biological factors. Some studies have gone so far as to state the proportion ofthe explanatory variability of each of the afore-mentioned factors, but the current investigationrevealed that none of the factors that have been identified in previous studies were correlatedwith good health status of young males. However, illness emerged as the single factor thataccounts for poor health. Less than 2% of the sample indicated poor health, less than 8% injury 17
    • or illness, but more young males visited medical practitioners in the last 4-week period thanmales in Jamaica and equally the same as females in the nation. Unlike other studies done onhealth care-seeking behaviour around the world, none found an explanatory power as high as thisresearch (R2 = 86.4%). Furthermore, illness or injury is primarily responsible for young males’health care seeking behaviour (81% of the explanatory power, i.e. R2), suggesting that the imageof health is still the opposite of illness and psychosocial wellbeing. A pertinent finding of thecurrent study is the fact that young males who are heads of households are less likely to seekmedical care, which denotes that this group is practicing health care switching for familysurvivability and protection. In sum, the self-rated health status of young males (ages 15 to 25 years) in Jamaica isgood with a small percentage reporting having had an illness or injury in the last 4-week period.The low percentage of those with illness corresponds to 68% health care utilization in the sameperiod, suggesting that young males are seeking medical care but that illness and injury is theprincipal influence on health care-seeking behaviour. The implications for these findings are farreaching, and public health practitioners now have a platform upon which can be fashionedinterventions, health education and future research on this vulnerable age cohort in Jamaica. 18
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    • 53. Stekelenburg J, Jager B, Kolk P, Westen E, Kwaak A, & Wolffers I: Health care seeking behaviour and utilization of traditional healers in Kalabo, Zambia. Health Policy. 2005; 71: 67-81.54. Case A, Menendex A, Ardington C: Health seeking behaviour in Northern KwaZulu- Natal. Working Paper No. 116. Cape Town: Centre for Social Science Research, University of Cape Town; 2005.55. Policy, Planning and Development Division, Planning and Evaluation Branch, Ministry of Health (Jamaica). Ministry of Health (Jamaica) Annual Report, 2006. Kingston: Ministry of Health (Jamaica); 200756. Van Agt HME, Stronks K, Mackenbach JP. Chronic illness and poverty in the Netherlands. European J of Public Health 2000; 10(3):197-200.57. Barillas E, Valladares R, GSD Consultores Asociados. Health sector inequalities and poverty in Guatemala. In: Pan American Health Organization. Investment in health: Social and economic returns. Washington DC: Scientific and Technical Publication, No. 582; 2001:pp. 175-188.58. Bourne PA. Social determinants of self-evaluated good health status of rural men in Jamaica. Rural and Remote Health 9 (online), 2009: 1280. 22
    • Table 1.1: Arrested for Major Crimes By Age Group, 2005 Age Group of Persons Arrested for Major Crimes for 2005 Murder Shooting Robbery Breaking Rape C/AbuseAge Group Male Female Total Male Female Total Male Female Total Male Female Total Male Male Total12-15 6 1 7 4 0 4 10 0 10 54 0 54 12 11 9816-20 157 6 163 167 1 168 183 0 183 122 3 125 66 43 74821-25 235 8 243 239 1 240 214 1 215 129 3 132 68 52 95026-30 160 2 162 137 0 137 120 1 121 105 3 108 73 27 62831-35 85 1 86 74 0 74 71 1 72 93 2 95 48 26 40136-40 54 3 57 40 1 41 36 1 37 69 0 69 23 19 24641-45 15 0 15 12 0 12 13 0 13 44 1 45 18 12 11546-50 7 1 8 2 0 2 1 0 1 18 0 18 12 5 4651-55 5 1 6 0 0 0 2 0 2 2 0 2 3 2 1556-60 1 0 1 1 0 1 6 0 6 1 1 2 1 1 1261& Over 0 0 0 2 0 2 2 0 2 3 1 4 2 0 10Unknown 40 0 40 86 0 86 23 0 23 11 0 11 10 0 170 Total 765 23 788 764 3 767 681 4 685 651 14 665 336 198 3439Source: Compiled by author from data supplied by the Statistics Unit of the Jamaica Constabulary Force (JCF) 23
    • Table 1.2. Demographic characteristic by area of residence, n = 607 Area of residence PCharacteristic Urban Semi-urban RuralSocial standing χ2 = 83., P < 0.0001 Poorest 20% 18 (8.7) 22 (17.3) 82 (29.9) Poor 28 (13.6) 27 (21.3) 75 (27.4) Middle 42 (20.4) 26 (20.5) 49 (17.9) Wealthy 48 (23.3) 24 (18.9) 48 (17.5) Wealthiest 20% 70 (34.0) 28 (22.0) 20 (7.3)Self-reported Injury χ2 = 0.920, P = 0.631 Yes 4 (2.0) 2 (1.6) 8 (3.1) No 193 (98.0) 122 (98.4) 254 (96.9)Marital status χ2 = 4.345, P = 0.361 Married 1 (0.5) 0 (0.0) 1 (0.4) Never married 194 (99.5) 124 (100.0) 253 (98.4) Divorced 0 (0.0) 0 (0.0) 0 (0.0) Separated 0 (0.0) 0 (0.0) 3 (1.2) Widowed 0 (0.0) 0 (0.0) 0 (0.0)Self-evaluated illness χ2 = 2.689, P = 0.261 Yes 4 (2.0) 3 (2.5) 12 (14.6) No 196 (98.0) 118 (97.5) 250 (95.4)Self-reported diagnosed χ2 = 11.000,P = 0.202illness Influenza 0 (0.0) 1 (33.3) 0 (0.0) Diarrhoea 0 (0.0) 0 (0.0) 2 (22.2) Asthma - - - Diabetes mellitus 0 (0.0) 0 (0.0) 1 (11.1) Hypertension 0 (0.0) 1 (33.4) 0 (0.0) Arthritis - - - Other 3 (100.0) 1 (33.3) 6 (66.7)Health insurance coverage χ2 = 0.156,P = 0.925 Yes 31 (15.8) 18 (14.8) 37 (14.5) No 165 (84.2) 104 (85.2) 218 (85.5)Health care-seeking χ2 = 4.243,P = 0.120behaviour Yes 5 (83.3) 1 (25.0) 11 (73.3) No 1 (16.7) 3 (75.0) 4 (26.7)Self-rated health status χ2 = 7.647, P = 0.467Very good 92 (46.2) 60 (48.4) 134 (51.9)Good 91 (45.7) 61 (49.2) 109 (42.2)Moderate 13 (6.5) 3 (2.4) 11 (4.3)Poor 3 (1.5) 0 (0.0) 3 (1.2)Very poor 0 (0.0) 0 (0.0) 1 (0.4) 24
    • Table 1.3. Stepwise logistic regression: Health care-seeking behaviour by explanatory variables 95.0% C.I. Std. R2 Explanatory variable Coefficient Error P Odds ratio Lower Upper change Self-reported illness 0.476 9.738 3.0 0.001 16950.1 46.4 6187362.9 (1=yes) Self-reported injury 0.226 11.650 3.6 0.001 114643.2 100.2 131124116.9 (1=yes) Crowding -1.448 0.5 0.002 0.2 0.1 0.6 0.093 Head of household 0.069 -7.017 2.9 0.014 0.0 0.0 0.2 (1=yes)Model χ2= 123.91(8), P < 0.0001Hosmer and Lemeshow goodness of fit χ2=37.781, P = 0.778Nagelkerke R2 =0.864-2LL = 1525.53n = 575 (94.7%)†Reference group 25
    • Table 1.4. Stepwise logistic regression: Self-rated good health status by variables Std. Odds 95.0% C.I. Variable Coefficient Error P ratio Lower Upper Self-reported illness (1=yes) -0.656 1.1 0.6 0.5 0.1 4.7 Self-reported injury (1=yes) -0.010 1.1 1.0 1.0 0.1 8.2 Age -0.067 0.1 0.2 0.9 0.8 1.1 Crowding -0.029 0.1 0.7 1.0 0.8 1.1 Consumption per person 0.000 0.0 0.5 1.0 1.0 1.0 Head of household (1=yes) 1.340 1.1 0.2 3.8 0.5 32.4 Urban area -0.590 0.4 0.2 0.6 0.3 1.2 Semi-urban 0.719 0.7 0.3 2.1 0.6 7.4 †Rural 1.0 Health care-seeking (1=yes) -1.301 1.3 0.3 0.3 0.0 3.3Model χ2= 16.284(8), P < 0.061Hosmer and Lemeshow goodness of fit χ2=5.301 (8), P = 0.725n = 575 (94.7%)†Reference group 26
    • Table 1.5. Stepwise logistic regression: Self-rated poor health status by variables Std. Odds 95.0% C.I. Variable Coefficient Error P ratio Lower Upper Self-reported illness (1=yes) 3.744 1.4 0.009 42.2 2.6 693.2 Self-reported injury (1=yes) -18.278 7389.8 0.998 0.0 0.0 0.0 Age 0.250 0.1 0.083 1.3 1.0 1.7 Crowding 0.191 0.1 0.104 1.2 1.0 1.5 Consumption per person 0.000 0.0 0.541 1.0 1.0 1.0 Head of household (1=yes) -16.380 4875.4 0.997 0.0 0.0 0.0 Urban area 0.501 0.9 0.581 1.7 0.3 9.8 Semi-urban -16.497 3274.2 0.996 0.0 0.0 0.0 †Rural 1.0 Health care-seeking (1=yes) -18.849 7842.7 0.998 0.0 0.0 0.0 Health insurance (1=yes) -16.130 3686.1 0.997 0.0 0.0 0.0Model χ2= 123.91(8), P < 0.0001Hosmer and Lemeshow goodness of fit χ2=1.206 (8), P =0.997Nagelkerke R2 =0.271-2LL = 55.913n = 565 (93.1%)†Reference group 27
    • Chapter2 Self-rated health and health conditions of married and unmarried men in JamaicaSince 1988, when Jamaica began collecting data on the living conditions of its people, men havereported seeking less health care than women. Despite this fact, the group has never beenstudied by researchers. The same is true about the health status of married and non-marriedmen. The current study will 1) evaluate the changing epidemiological patterns of diseasesaffecting men in Jamaica; 2) determine factors that correlate with good health status of men; 3)compare and contrast the differences in health status of men, in particular marital status; and 4)determine which marital status has the greater health status. The data for this research weretaken from two secondary cross-sectional surveys. A sample of 8,078 respondents 15 years andolder was extracted from the 2002 survey (n=25,018 respondents) and 2,224 respondents fromthe 2007 sample (n=6,783 respondents). SPSS for Windows 16.0 was used to store, retrieve andanalyse the data. Chi-square, analysis of variance, t-test and logistic regression were used inthis paper. Married men are more likely to report an illness than never married (OR = 1.68,95% CI = 1.45-1.95), separated, divorced or widowed men (OR = 2.62, 95% CI = 2.06-3.33).No significant statistical difference existed between the self-rated health status of married andunmarried men. This study provides a platform upon which future studies can commence as webegin to examine men’s health in Jamaica.IntroductionStudies in the Caribbean, and Jamaica in particular, on male issues have concentrated onmarginalisation [1-4], educational underachievement [5, 6], fatherhood [7], masculinity [8],reproductive health and survivability [9-12], and crime and violence [13-16]. In the English-speaking Caribbean, even among the new and emerging themes, studies have avoided men’shealth status, men’s health conditions, and issues affecting men’s health except statistics onmortality and morbidity [17]. In a recently published text titled “Health Issues in the Caribbean”[18], the coverage of topics included child health, reproductive health, the elderly, chronic non- 28
    • communicable diseases, disability, health care-delivery and health issues in the Caribbean, whichreinforces the claim of the lack of research on men’s health. Another text entitled “Gender in the21st Century: Caribbean Perspectives, Visions and Possibilities” [19] had articles on new andemerging themes, redefining masculinities and femininities, but none that examined gender andhealth in the region, particularly men’s health in the 21st century and the challenges of ill-healthof the sexes. Men’s health is therefore in need of research as it remains relatively unexamined inthe region. A comprehensive search of health literature in the English-speaking Caribbean revealed alack of study regarding men’s health, men’s health care-seeking behaviour, correlates of goodhealth status of men, and the epidemiological shifts in health conditions of men. In Jamaica,statistics for 2007 estimated that 49% of the population was male, yet no study exists on thiscohort. This denotes neglect of men’s health although they have had a greater mortality than theirfemale counterparts. Concurrently, since 1988 when the Planning Institute of Jamaica and theStatistical Institute of Jamaica began collecting data on Jamaicans’ Living Conditions, womenhave been outnumbering men in health care utilisation [20]. Life expectancy for the sexes inJamaica revealed that women continue to outlive men, and this is as much as 6 years in 2004[17]. It can be extrapolated from the aforementioned statistics that the lack of health care-seekingbehaviour is accounting for 1) premature mortality of men, 2) men spending more time gettingcare when becoming ill, and 3) men having poorer health status than women. There is a paradox in the health statistics for the sexes as males in Jamaica report fewerillnesses than females, yet they tend to live 6 fewer years than women. Is it that 1) males areunderreporting their illnesses, and 2) that there are issues surrounding subjective health data?Self-reported health conditions have been widely used to measure the health of people or a 29
    • population [20-22]. Using self-reported illness to measure health status in Jamaica, men’s healthwould be greater than women’s health. Since 1988, females have always reported more healthconditions than males. However, they live longer than their male counterparts. Is there a validityissue with self-reported health to assess health? There are some fundamental challengesassociated with the utilisation of subjective measures in the evaluation of health and theseinclude 1) subjectivity, 2) response bias, 3) recall bias, and 4) validity. Studies have revealed that current illness is strongly correlated with health status [23],self-reported illness and life expectancy [24], self-reported health and mortality [24, 25], andself-reported health and functional ability [26], indicating some validity in subjective measuresin assessing objective health status. One study found that self-rated health status is a highlyreliable measure to proxy health and that this “successfully crosses cultural lines” [27].Concurrently, O’Donnell & Tait [17] found that self-reported health status can be used to assesshealth status as they found that all respondents who had chronic diseases reported very poorhealth. The fact that people are asked to recall and state their health status opens the issue ofsubjectivity and biasness. Subjective indexes as a measure of any phenomenon introduce someelement of biasness. If people are asked to recall and provide their assessment (i.e., perception)of a matter, this subjectivity denotes not only people’s perceptions, but it also includes theirbiases. People’s perceptions are highly biased as they can provide an inflated or deflated accountof their state in an interview or on a self-administered questionnaire. It is for this reason thatempirical researchers have avoided and decried its utilisation in the measurement of health. Eventhough subjective indexes are in keeping with the WHO’s widened definition of health, theirbiasness must be understood as challenges. 30
    • It cannot be denied that the discourse on subjective wellbeing, using survey data, is basedon person’s judgement, and therefore must be prone to systematic and non-systematic biases[29]. Diener [30] argued that the subjective measure seemed to contain substantial amounts ofvalid variance, suggesting that this indicated the validity of subjective indexes. Kahneman [31]devised a procedure of integrating and reducing the subjective biases when he found thatinstantaneous subjective evaluations are more reliable than assessments of recall of experiences.This highlights the biasness, therefore, that remains in cross-sectional surveys asking people toremember over a long time. Embedded in the aforementioned findings are whether particularsubjective indexes that comprised recall over 2-4 weeks is a good measure for objective indexesof health. Embodied in the literature is the need to carry out empirical research on subjective andobjective indexes with emphasis on subjective indexes that are not on instantaneous assessment. The literature has provided some empiricism to the use of self-reported health conditionsor self-reported health in assessing health status of people. Within the context that subjectiveindexes are good in measuring health status, this approach will be used to examine men’s healthin Jamaica. The objectives of the current study are to 1) evaluate the changing epidemiologicalpatterns of diseases affecting men in Jamaica; 2) ascertain factors that correlate with good healthstatus of men; 3) compare and contrast the differences in health status of men, in particularmarital status; and 4) determine which marital status group has the greatest health status.Materials and MethodsStudy populationThis study utilised secondary cross-sectional datasets for 2002 and 2007 taken from the JamaicaSurvey of Living Conditions (JSLC). The JSLC is a joint publication from the Planning Instituteof Jamaica (PIOJ) and the Statistical Institute of Jamaica (STATIN) for analysis [32-34]. The 31
    • JSLC began in 1988 to collect data on the living conditions of Jamaicans in order to measuregovernment policies. These cross-sectional surveys were conducted between May and October ofeach year across the 14 parishes of Jamaica. The current study extracted 8,078 respondents whowere 15 years and older from the 2002 sample (n=25,018 respondents) and 2,224 from the 2007sample of 6,783 respondents [35, 36]. The JSLC used stratified random probability samplingtechnique to draw the original sample of respondents. The non-response rates for 2002 and 2007lie between 23 and 27% respectively. The JSLC survey uses a complex design with multiplestratifications to ensure that it represents the population, marital status, area of residence, andsocial class. The sample was weighted to reflect the population of Jamaica [32-34].Study instrumentThe JSLC used an administered questionnaire where respondents are asked to recall detailedinformation on particular activities. The questionnaire was modelled from the World Bank’sLiving Standards Measurement Study (LSMS) household survey [32]. There are somemodifications to the LSMS, as the JSLC is more focused on policy impacts. The questionnairecovers demographic variables, health, immunisation of children 0–59 months, education, dailyexpenses, non-food consumption expenditure, housing conditions, inventory of durable goodsand social assistance. Interviewers are trained to collect the data from household members.Statistical methodsDescriptive statistics were used to analyse the socio-demographic characteristics of the samples.Chi-square analyses were used to examine the association between non-metric variables for areaof residence, and gender of respondents. T-test statistic and Analysis of Variance were used toevaluate metric and either a dichotomous or non-dichotomous variable respectively. Logisticregression analyses examined the 1) association between good health status and some socio- 32
    • demographic, economic and biological variables; as well as 2) a correlation between self-reported health conditions (illnesses, dysfunctions or ailments) and some socio-demographic,economic and biological variables. SPSS for Windows 16.0 (SPSS Inc; Chicago, IL, USA) wasused to store, retrieve and analyse the data. A 95% confidence interval was used for the analysis,and the final models (i.e., equations) were based on a p-value less than 5%. The only selection criterion for this study was based on the respondents being 15 yearsand older and male. For the model, the selection criteria were based on the 1) literature review,2) low correlations, and 3) non-response rate. The correlation matrix was examined in order toascertain if autocorrelation and/or multicollinearity existed between variables. According toCohen & Holliday [37, 38], correlation can be low (weak) – from 0 to 0.39; moderate – 0.4-0.69,and strong – 0.7-1.0. This was used to exclude (or allow) a variable in the model. Anycorrelation that had at least moderate was excluded from the model in order to reducemulticollinearity and/or autocorrelation between or among the independent variables [39-45].Another approach in addressing and/or reducing autocorrelation is to include in the model allvariables that were identified from the literature review with the exception of those with whichthe percentage of missing cases were in excess of 30%. Forward stepwise logistic regressiontechnique was used to determine the magnitude (or contribution) of each statistically significantvariable in comparison with the others, and the odds ratios (OR) aided the interpretation of eachsignificant variable.ModelsThe current study will employ multivariate analyses in the study of self-reported health statusand self-reported health conditions. The use of this approach is better than bivariate analyses as 33
    • many variables can be tested simultaneously for their impact (if any) on a dependent variable[21-26; 38-45]. The final model for the current study is shown below:H t =f(A i , G i , HH i , AR i , lnC, ED i, MR i , S i , ∑MC t , SRIi , ε i ) [1] Where H t (i.e., self-rated health conditions in time t) is a function of age of respondents A i ; sex of individual i, G i ; household head of individual i, HH i ; area of residence, AR i ; logged consumption per person per household member, lnC; Education level of individual i, ED i ; marital status of person i, MR i ; social class of person i, S i ; summation of medical expenditure of individual i in time period t, MC t ; self-reported illness, SRIi , and an error term (i.e., residual error).MeasuresSelf-reported illness status is a dummy variable, where 1 = reporting an ailment or dysfunction orillness in the last 4 weeks, which was the survey period; 0 if there were no self-reported ailments,injuries or illnesses [21, 22]. While self-reported ill-health is not an ideal indicator of actualhealth conditions because people may underreport, it is still an accurate proxy of ill-health andmortality. Health status is a binary measure where 1 = good to excellent health, 0 = otherwise[24-26, 46], which is determined from “Generally, how do you feel about your health?” Answersfor this question are in a Likert scale matter ranging from excellent to poor. Age is a continuousvariable beginning at 15 years. Medical care-seeking behaviour was taken from the question“Has a health care practitioner, header, or pharmacist being visited in the last 4 weeks?” Answeroptions for this were Yes or No. Medical care-seeking behaviour therefore was coded as a binarymeasure where 1 = Yes and 0 = otherwise. 34
    • ResultsDemographic characteristicsTable 2.1 examines social and health variables of samples for 2002 and 2007. For 2002, a sampleof 8,078 respondents was extracted and this was 2,224 respondents for 2007. Over 2002, thenumber of respondents who reported an illness in 2007 increased by 1.4%. In 2007 over 2002,increases were recorded in number of respondents being diagnosed with cold (+8.4%), asthma(+5.7), diabetes mellitus (+7.5%), and unspecified health conditions (+7.4%). Conversely,reductions were seen in hypertensive (-29.4%) and arthritic cases (-12.0%). Marginally morerespondents sought medical care in 2007 over 2002 (+1.7%). There was a strong significant statistical correlation between self-reported health statusand self-reported health conditions – χ2 (df=4) = 531.7, P < 0.001, correlation coefficient =0.446. The cross-tabulation revealed that respondents who had indicated that they had an illness(dysfunction or health condition) were more likely to report moderate to poor health status. Ninepercent of those with health conditions recorded very good health status compared to 41% ofthose who did not report illness who indicated good health status. A significant statistical association was found between self-reported illness and maritalstatus of respondents for both years – P <0.001. The findings showed that the widowed recordedthe greatest percentage of illness of all the marital statuses. Conversely, those who were nevermarried recorded the lowest illnesses. In 2002, married respondents recorded 2.2 times moreillnesses than men who were never married, and this increased to 2.7 times more illnesses in2007. Concurrently, married respondents recorded more illnesses than divorced respondents.However, this was the reverse in 2007, with the latter group registering 4.3% more illnesses. 35
    • In 2002, a cross-tabulation between self-reported diagnosed health conditions and maritalstatus revealed no significant statistical correlation – P < 0.05. However, significant statisticalassociation was found between the two aforementioned variables in 2007 – P < 0.001 (Table2.2). Hypertension continues to be the most prevalent self-reported diagnosed health conditionsexperienced by the marital statuses in this sample except for never married respondents in 2007(Table 2.2). A significant statistical correlation existed between medical care-seeking behaviour andmarital status of respondents in 2002 – P < 0.5. Conversely, there was no statistical associationbetween the two aforementioned variables for 2007 – P > 0.5 (Table 2.3). In 2002, marriedrespondents were the second most to visit medical care institution.Multivariate analysesTable 2.4 represents information on social and biological determinants of good health status ofthe sample. Three determinants accounted for 29.2% of the variability in self-reported healthstatus. The model is a good fit for the data: Hosmer and Lemeshow χ2= 3.88, P = 0.87: 76.8% ofthe data were correctly classified, with 56.1% of those classified in good self-reported health and88.5% in poor health status. Table 2.5 highlights information on social determinants of self-reported healthconditions. Seven social determinants accounted for 7.6% of the variability in self-reportedhealth conditions. The model is a good fit for the data: Hosmer and Lemeshow χ2= 5.6, P = 0.69:83.4% of the data were correctly classified, with 99.7% of those classified in health and 76.5% inpoor health status. 36
    • DiscussionThere are many empirical studies which have established that married people have a better self-reported health status (or self-reported health, subjective wellbeing) and/or a lower mortalitythan non-married people [47-55]. The current study disagrees with the literature as it revealedthat there was no significant statistical difference between the self-reported good health status ofmarried and unmarried men. However, married men have a greater probability of reporting anillness than those who were never married, with those who were separated, divorced andwidowed having a greater probability of reporting illness compared to married and never marriedmen. Concurrently, this study went further than the other research that examined health status ofmarried and unmarried men by examining the shift in self-reported illnesses. It was revealed thathypertension continues to be the leading cause of illness among men except for men who werenever married and divorced men. Hypertension was greater among separated men followed bymarried men. Another critical finding which emerged from this study is the dissipation ofstatistical difference among the different marital statuses and medical care-seeking behaviour ofmen. Even when there were significant differences among the marital statuses, separated menutilised medical care facilities more than married men, and unmarried men visited the least. Halfa decade later (2007), there is equality among men of different marital statuses and medical care-seeking behaviour. Education is one of the socio-demographic correlates of health, and this is wellestablished in health literature. There is a paradox which emerged from this study as educationalattainment is not significantly associated with good health status; however, it is correlated withhealth conditions. The current research found that as men become more educated, they are lesslikely to report health conditions. Embedded in this finding is the role of education in better 37
    • lifestyle practices and choices. However, greater educational attainment is not translated intobetter “good” health status, as typologies of reported dysfunctions are lifestyle causing,suggesting that the while education is aiding in reducing poor health status, it is not translatinginto better health for men as they still not adhering to healthy lifestyle practices. Grossman [56], Smith & Kington [57], Marmot [58], and other scholars have found thatincome is strongly correlated with good health. The current study found that income is notcorrelated with good health status, but rather with health conditions. Men with more income are0.21 times less likely to report poor health status. Concurrently, medical care-seeking behaviouris based on 1) one’s ability to afford it, 2) perception of the illness and its effect on life, 3)severity of illness, and 4) other factors [21]. Although income does not directly influence goodhealth status for men, it indirectly affects it through medical care-seeking behaviour. Men whoseek medical care are 0.60 times less likely to report health conditions, suggesting that medicalcare-seeking behaviour is a preventative measure against poor health. Hence, being able to affordit is critical to medical care utilisation. Income affords people the ability to visit medical carefacilities, and it should be noted here that Jamaican men are more likely to visit private healthcare centres. Income, therefore, cannot buy good health as Smith & Kington [57] opined, as thegroup with the wealthy men in Jamaica were 1.32 times more likely to report more healthconditions in reference to those in the two poorest quintiles. Embedded in this finding is erosionof good health by having income beyond a certain amount, as wealthy men in Jamaica areinvolved in unhealthy lifestyle practices which accounted for their health status being lower thanthat of poor men. While income is able to afford particular things, including better medical care,the wealthy involvement in unhealthy lifestyle behaviour is reducing the gains of income onhealth for men. 38
    • The literature has shown that area of residence is correlated to health status, and thisconcurs with that finding. However, area of residence was not significantly associated with goodhealth but rather with health status. Unlike other studies that found urban dwellers had thegreatest health status [59, 60], the current research found no significant statistical differencebetween self-reported health conditions experienced by urban and rural men. On the other hand,men who resided in other town areas were less likely to report illness than rural men. The number of people living in a household is well established as being associated withhealth [59, 60] and this study concurs with that finding. The current work however found thatcrowding is associated with health conditions but not related to good health status. The morepeople dwelling in a household denotes that men will be 0.15 times less likely to report ailments,suggesting that family and relatives positively contribute to men’s health. The contributioncomes in the form of assistance in seeking medical care, financial assistance to seeking care,advice on seeking care, and provision of care. However, men who have social support are morelikely to report illnesses. Separated, divorced and widowed men are the most likely to record illness than men ofother marital status. The current findings also revealed that separated men were more likely torecord having had hypertension, diarrhoea and arthritis compared to other marital statuses. Thissuggests that separation increases health conditions in men, and higher rates in theaforementioned chronic illnesses indicates the poor lifestyle choices made by this group ofindividuals. A study by Ben-Shlomo et al. [61] highlights the unhealthy lifestyle choices ofunmarried men, when they found that “heavy alcohol consumption” was greatest amongdivorced/separated men and that alcoholic beverages accounted for between 21 to 30% ofmortality resulting from respiratory and non-cardiovascular/neo-plastic diseases. Concurrently, 39
    • current smokers were highest among separated and divorced men, and mortality caused by lungcancer was 1.83 times more for the former than for married men which was the highest amongthe different marital statuses [61]. Ben-Shlomo et al.’s work provides some explanation for thehighest levels of self-reported illness, in particular chronic dysfunctions, affecting separated menin Jamaica, as separation results in a change towards unhealthy lifestyle practices among thesemen. It can be extrapolated from the current findings that separation of men from their spousesresults in unhealthy practices. The unhealthy choices that are made by these men increase theirrisk of coronary heart disease, stroke and diabetes mellitus [62] and this reinforces the diseaserisk for separated, divorced, and widowed men in Jamaica as they become indulgent (or increaseindulgence) in unhealthy lifestyle practices. Unhealthy life choices of divorced, widowed orseparated men including tobacco use, physical inactivity, alcohol consumption, and unhealthydietary intake further erode life expectancy of these individuals. These lifestyle practices maybegin in early adulthood and with the new marital status begin to be practiced increasingly bysome men. Hence, separated and divorced men who remain in these categorisations for a longtime are more likely to experience premature death caused by suicide or other issues such as lungcancer, resulting from their increased unhealthy lifestyle choices. They are also more likely torelapse into depression [63] and commit suicide [64]—divorced and separated men are 2.4 timesmore likely to commit suicide than married men. A recently conducted research by Abel et al.[65] found that the suicide rates among men was 9 times more than among women and whilethey do not disaggregate this by marital status, a part of this is owing to the choices they makeand their inability to live with these choices. An important question that needs to be addressed is 40
    • whether there are differences in suicide rates among marital statuses in Jamaica, as this willprovide some answers to the cost of separation and divorce on men. Those unhealthy choices are problematic not only for men but their families, includingtheir children and particularly the young children [66-69]. This disruption in the family iscorrelated with increased suicide, greater risk of illnesses such as asthma, headaches,delinquency [70] and poverty for the children who are now a part of the separation process.Separation and divorce not only affects young children. A study on children 18 to 22 year s oldwhose parents separated or divorced were more likely to have poor relationships with theirparents as well as reported psychosocial behaviour problems [71]. Separation and divorceextends to the wider society as the general society will be required to pay the medical costs forcare of those who visit public health care facilities as well as the uninsured, including elderlyseparated and divorced men.ConclusionIn sum, the current study revealed that married men do not have greater health status thanunmarried men in Jamaica, and that there are epidemiological shifts in illness from hypertensionto unspecified conditions for widowed men and those who were never married. While incomecorrelates with health conditions, it does not directly influence good health status of men. Incomehas an indirect correlation with good health status through its relationship with illness andmedical care-seeking behaviour. Marriage is beneficial for men, and once they becomeseparated, divorced or widowed, the separation from their spouses positively correlates withincreased health conditions. This study therefore provides a platform upon which future studiescan commence as we begin to examine men’s health in Jamaica, and this will be critical to publichealth practitioners in effectively carrying out their mandate as well as for future research. 41
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    • Table 2.1. Demographic characteristics of sample, 2002 and 2007Characteristic 2002 2007 n % n %Marital statusMarried 2007 25.7 522 24.3Never married 5417 69.4 1528 71.1Divorced 64 0.8 34 1.6Separated 85 1.1 16 0.7Widowed 234 3.0 50 2.3Medical care-seeking behaviourYes 540 62.1 176 63.8No 330 37.9 100 36.2Health care utilisationPublic, Hospitals 41.9 35.9Private, Hospitals 7.9 7.0Public, Health care centres 13.4 15.8Private, Health care centres 44.1 49.7Other 2.5 2.4Self-reported illnessYes 834 10.7 261 12.1No 6996 89.3 1898 87.9Self-reported diagnosed illnessCold 0 0 23 8.4Diarrhoea 2 2.6 7 2.6Asthma 1 1.3 19 7.0Diabetes mellitus 3 3.9 31 11.4Hypertension 39 50.6 58 21.2Arthritis 16 20.8 24 8.8Other (unspecified) 16 20.8 77 28.2Not diagnosed 0 0 34 12.5Self-reported health statusVery good 794 36.9Good 977 45.4Moderate (fair) 266 12.4Poor 92 4.3Very poor 21 1.0Age Median (range) 36 years (84 years) 37 years (84 years)Length of illness Median (range) 7 days (90 days) 7 daysNumber of visits made to health practitioner(s) 1 (19 visits) 1 (12 visits)Median (range) 50
    • Table 2.2. Self-reported diagnosed health conditions by marital statusCharacteristic Marital status P Married Never Divorced Separated Widowed married % % % % %2002Self-reported < 0.05diagnosed illnessCold 0.0 0.0 DNR 0.0 0.0Diarrhoea 2.3 4.3 DNR 0.0 0.0Asthma 2.3 0.0 DNR 0.0 0.0Diabetes mellitus 2.3 8.7 DNR 0.0 0.0Hypertension 54.5 34.8 DNR 100.0 66.7Arthritis 22.7 17.4 DNR 0.0 22.2Unspecified 15.9 34.8 DNR 0.0 11.0Not diagnosed 0.0 0.0 DNR 0.0 0.0Total 44 23 1 92007Self-reported <0.001diagnosed illnessCold 9.0 7.1 9.1 0.0 15.8Diarrhoea 0.0 4.0 9.1 25.0 0.0Asthma 4.5 10.3 9.1 0.0 0.0Diabetes mellitus 15.3 7.1 27.3 0.0 10.5Hypertension 31.5 11.9 9.1 50.0 26.3Arthritis 12.6 4.8 9.1 25.0 10.5Unspecified 18.0 38.1 27.3 0.0 26.3Not diagnosed 9.9 16.7 0.0 0.0 10.5Total 111 126 11 4 19DNR – Did not report 51
    • Table 2.3. Self-reported health conditions by marital statusCharacteristic Marital status P Married Never Divorced Separated Widowed married % % % % %2002Medical care-seeking < 0.05behaviourYes 68.3 56.5 57.1 69.2 64.2No 31.7 43.5 42.9 30.8 35.8Total 331 428 14 13 812007Medical care-seeking > 0.05behaviourYes 64.9 63.1 63.6 50.0 61.1No 35.1 36.9 36.4 50.0 38.9Total 111 130 11 4 18 52
    • Table 2.4. Stepwise Logistic regression: Correlates of self-reported good health status, n=1,952 Odds 95.0% C.I. Variable S.E. P ratios Lower Upper R2 Age 0.01 0.000 0.95 0.93 0.96 0.292 Self-reported illness 0.64 0.045 0.29 0.08 1.00 0.016 Medical care-seeking behaviour 0.30 0.002 0.40 0.22 0.72 0.034 53
    • Table 2.5. Stepwise Logistic regression: Correlates of self-reported health conditions Variables Odds 95.0% C.I. S.E. P ratio Lower Upper R2 Two wealthy quintiles 0.09 0.002 1.32 1.11 1.56 0.002 †Two poor quintiles 1.00 Log income 0.05 0.000 0.79 0.72 0.87 0.005 Separated, divorced or 0.015 0.12 0.000 2.62 2.06 3.33 widowed Married 0.08 0.000 1.68 1.45 1.95 0.008 †Never married 1.00 Other towns 0.08 0.032 0.84 0.72 0.99 0.001 †Rural areas 1.00 Secondary 0.08 0.000 0.58 0.49 0.67 0.030 Tertiary 0.17 0.018 0.66 0.47 0.93 0.002 †Primary and below 1.00 Social support 0.07 0.000 1.37 1.20 1.56 0.005 Log crowding 0.06 0.003 0.85 0.76 0.95 0.008 54
    • Chapter3 Predictors of Good Health Status of Rural Men in JamaicaA comprehensive review of literature revealed that there was a gap in health research literaturein Jamaica on determinants of good health of rural men. This study seeks to fill this void byexamining cross-sectional survey data to model predictors of self-reported good health status ofrural men in Jamaica. A sample of 5,041 respondents was extracted from a national cross-sectional survey of 25,018 respondents. Stratified random probability sampling technique wasused to draw the sample. Data were stored, retrieved and analyzed using SPSS for Windows16.0. Descriptive statistics were used to provide pertinent socio-demographic characteristics ofthe sample and logistic regression was used to establish a predictive model of good self-reportedhealth status of rural Jamaicans. Seventeen percent of rural men claimed that they had poorhealth, 4.9% had health insurance, 61.6% visited a health care practitioner, 96.0% purchasedprescribed medications and 45.3% completed taking the prescribed medications. The predictorsof good health status of rural men in Jamaica are cost of medical care (OR=0.916, 95%CI=0.841-0.997), retirement income (OR=0.0.382, 95% CI=0.206-0.707), marital status –separated, divorced or widowed with reference to those never married (OR=0.270, 95%CI=0.178-0.410), and married with reference to never married men (OR=0.465, 95% CI=0.356-0.609)- health insurance coverage (OR=0.041, 95% CI=0.027-0.063), number of children inhousehold (OR=1.200, 95% CI=1.069-1.347), and the number of durable goods owned by theman (OR=1.107, 95% CI=1.050-1.166). Children continue to be not only futuristic assets toparents, but that they currently improve the health status of rural men.IntroductionCulturally and traditionally in Jamaica, health is viewed on the other side of the sicknesspendulum. This is not atypical to Jamaica as it is the case in many Western Societies that healthis the ‘absence of diseases’ 1-4. This approach is both narrow and negative in scope. According tosome scholars, the aforementioned conceptualization of health emphasizes the absence of somedisease causing pathogens, and not really health1-3. Such a perspective is in keeping with 55
    • traditional biomedical model that views the exposure to specific pathogen as the cause ofdiseases in organisms. This began during 130ce to 200ce in Ancient Rome 2, 5, and despite theefforts of the WHO as early as in 1946 4 and Engel 6-10 to expand this image of health, it is stillwidespread in contemporary Jamaica. Owing to the image of health which is sickness, health care utilization for men can beinterpreted as weakness and not preventative care. This cultural bias is such that ‘sicky sicky’ isused to explain men who frequently visit health care facilities or claim that they are sufferingfrom dysfunctions. Men who must protect their machoism (or masculinity) will then infrequentlyvisit health care utilization as they must display strength and so sickness which is the opposite ofthis viewpoint must be distant from their social survivability. Continuing, task specialization forCaribbean males’ means that some functions are labeled based on gender specification. This 11explains why Caribbean men in particular Jamaican males will not publicly execute some 12-14functions ; because your gender defines particular roles and general function in the society.Masculinity for the Caribbean man is synonymous with power, strength, ‘toughness’, and in theprocess he must shut any appearance of ‘softness’, fragility, as these are associated withfeministic behaviour. It is within the aforementioned context that Jamaican males are not loversof reading, literature, english language, home management, child-care, nursing, cosmetology andcannot display being “sicky sicky” (ie. sickly). Sickness is synonymous with health explains therationale for the health-gender differential in seeking medical care in Jamaica. Over the last 2 decades (1988-2007), Statistics from the Planning Institute of Jamaica andthe Statistical Institute of Jamaica (in Jamaica Survey of Living Conditions - JSLC) (15) showedthat the greatest percentage of Jamaican men report illness or ailment (16.3% in 1990) and of 56
    • that amount 37.9% of them sought medical care (Table 3.1). Women, on the other hand, reportedmore dysfunctions compared to men and sought more health care than men except in 1991, 1995and 1997. The last available data on Jamaica in regard to health is for 2007; this showed that13.1% of men reported illness and 62.8% of them sought health care for this health conditions.The irony is 17.8% of women reported ailments and 68.1% of them visited health care facilitiesfor medical care and spent less time suffering from those illnesses (9.3 days) compared to men(10.6 days). This health gender-differential accounts for the disparity in life expectancy betweenthe sexes as statistics for Jamaica showed that women outlive men by 6 years 5. Globally, thisdifference in life expectancy is 8 years more for women than men 16, 17; emphasizing the role thatculture plays in denying men of better health compared to their female counterparts. In both developing and developed countries, urbanization is substantially as a result ofdevelopment of those zones compared to rural geopolitical areas. Although we cannot establishin Jamaica that urbanization is result in more illness experienced by rural residents, the JSLCrevealed that over the last two decades (1988-2007) there are more self-reported illness/injury byrural Jamaicans than urban dwellers. In 2007, 17.3% of rural Jamaicans reported illnesscompared to 13.9% of those who dwelled in Other Towns and 14.1% of those in urban areas. Ofthose who reported illnesses, 59.9% of them indicated a chronic recurring ailment. The typologyof chronic ailments suffered by rural residents was asthma (8.2%), diabetes (10.8%),hypertension (22.6%) and arthritis (9.3%); and more of them had arthritis and less diabetes thanthose who resided in other geopolitical zones. Statistics from the Statistical Institute of Jamaica 18 indicated that the 5 leading cause formortality of men in Jamaica were cerebrovascular diseases, diabetes mellitus, ischaemic heart 57
    • disease, malignant neoplasm of prostate and hypertensive diseases. A group of scholar cited thatthe rate of cancer for Jamaican men was even greater than that of men in the United States 19. Ifthe culture is such that men are less likely to visit health care facilities and that more of them livein rural zones, within the context of the aforementioned morality and particular dysfunctions inrural areas, what determine good health for rural men? A comprehensive review of healthliterature in the Caribbean and Jamaica revealed that dearth of studies exist on this phenomenon.Studies that have examined health in the region have not yet ventured into this aspect of health. Itis well documented that since 1880 in Jamaica 5, 18, women have been outliving men and that lessmen have been reporting illness; then, there is undoubtedly a need to understand those factorsthat determine good health status of rural men in order to effectively plan health programmesthat are geared towards improving health in those with poor health. This study examines predictors of good health status of rural men, as it offers anopportunity to understand men and how their health can be planned for. Given that more peoplelive in rural zones in Jamaica, it follows that understanding health status of rural men is tocomprehend much about this group of people than mortality to habits, beliefs and practices. Asthe health of men is not the same as that of women and so we cannot apply the solutions thedifferent sexes, or even geopolitical zones as they are different from each other. Given that menused less of the health care facilities than women, to comprehend those with good health as ininsight into the life of those with poor health. 58
    • Method and DataParticipants and questionnaireThe current research extracted a sample of 5,041 respondents (20.2% of the survey) based onthose who indicated residing in rural parishes in Jamaica and being men. The sample of all ruralmen was taken from a nationally cross-sectional survey’s dataset of 25,018 respondents. Thesurvey used stratified random probability sampling technique to drawn the 25,018 respondents.The non-response rate for the survey was 29.7% with 20.5% who did not response to particularquestions, 9.0% did not participated in the survey and another 0.2% was rejected due to datacleaning. The study used secondary cross-sectional data from the Jamaica Survey of LivingConditions 20. The JSLC was commissioned by the Planning Institute of Jamaica (PIOJ) and theStatistical Institute of Jamaica (STATIN). These two organizations are responsible for planning,data collection and policy guideline for Jamaica. The JSLC is a self-administered questionnaire where respondents are asked to recalldetailed information on particular activities. The questionnaire covers demographic variables,health, immunization of children 0 to 59 months, education, daily expenses, non-foodconsumption expenditure, housing conditions, inventory of durable goods, and social assistance.Interviewers are trained to collect the data, which is in preparation of the household members.The survey is conducted between April and July annually. Model 21 The multivariate model used in this study is a modification of those of Grossman ,Smith & Kington 22, and Bourne 5, 23 which captures the multi-dimensional concept of health, andhealth status. The current research further refine the aforementioned studies and in the process 59
    • add some new factors such crowding, and consumption per person in household. Anotherfundamental difference of the current research and those of Grossman 21, Smith and Kington 22, 5, 23and Bourne is that it is area specific as it focused on rural residence primarily which hasmajority of the poor in Jamaica, and for any effective health education and private care to takeplace, this cohort’s health status must be explained by way of scientific inquiry. The proposedmodel that this research seeks to evaluate is displayed below [Eqn. (1)]:H t = f (P mc , ED, R t , A t , Q t , HH t , C, E n , MS, HI, HT, SS, LL, X, CR, DI, O, (ΣNP i , PPi), M, N, FS, Ai , ε i )…….....(1) The variables were identified from the literature [Equation 1], and using the using theprinciple of parsimony only those explanatory variables that are statistically significant (ie. p<0.05) were used in the final model as only those factors can be used to predict current goodhealth status of men in rural Jamaica. Hence the final model that speaks to self-reported goodhealth of rural men Jamaicans is displayed in Eq. [2].H t = f (lnP mc , Rt , MS, HI i , N i , O, ε i ) …….....(4) The current good health status of a rural resident, H t , is a function of 12 explanationvariables, where H t is current good health status of person i, if good or above (i.e. no reportedhealth conditions four week leading up to the survey period), 0 if poor (i.e. reported at least onehealth condition); lnPmc is logged cost of medical care of person i; Rt is retirement income ofperson i, 1 if receiving private and/or government pension, 0 if otherwise; marital status, MS; HI iis health insurance coverage of person i, 1 if have a health insurance policy, 0 if otherwise; andN i is number of children in household of person i; and ownership of durable goods (includingland and property) Measure Some of the variables in the model are explained. Health status is a dummy variable,where 1 (good health) = not reporting an ailment or dysfunction or illness in the last four weeks, 60
    • which was the survey period; 0 (poor health) if, there were no self-reported ailment, injury orillness. While self-reported ill-health is not an ideal indicator actual health conditions as peoplemay underreport their health condition, it is still an accurate proxy of ill-health and mortality (24,25). Social support (or network) denote different social networks with which the individual hasor is involved (1= membership of and/or visits to civic organizations or having friends that visitones home or with whom one is able to network, 0=otherwise). Age group was classified intothree groups. These were young adults (ages 15 to 30 years), other adults (31 to 59 years) andelderly (60+ years). Statistical analysis Statistical analyses were performed using Statistical Packages for the Social Sciences(SPSS) 16.0 software for Widows. Descriptive statistics include frequency, mean and standarddeviation that were used to provide background information on the sample. A single hypothesiswas tested, which was ‘health status of rural men is a function of demographic, social,psychological and economic variables.’ The enter method in logistic regression was used to testthe hypothesis in order to determine those factors that influence health status of rural residents.The logistic regression used as dependent variable is a binary one. The final model wasestablished based on those variables that are statistically significant (ie. P < 0.05), and all othervariables were removed from the final model (P > 0.05). Continuing, categorical variables werecoded using the ‘dummy coding’ scheme. The predictive power of the model was tested using Omnibus Test of Model and Hosmerand Lemeshow 26 was used to examine goodness of fit of the model. The correlation matrix wasexamined in order to ascertain whether autocorrelation (or multi-collinearity) existed between 27variables. Cohen & Holliday stated that correlation can be low/weak [0 to 0.39]; moderate 61
    • [0.4-0.69], or strong [0.7-1.0]. This was used in this study to exclude (or allow) a variable in themodel, and the correlation matrix was used to examine these. Any variable that had a correlationthat was moderate to strong was excluded from the model. Another criterion for exclusion (orinclusion) was response rate of a rate. A variable that had a non-response rate in excess of 20%was excluded from the model. Finally, Wald statistics was used to determine the magnitude (orcontribution) of each statistically significant variables in comparison with the others, and theodds ratio (OR) for the interpreting each significant variables.Results: Demographic Characteristic of SampleOf the sampled respondents (n=5,041), 98.2% of them reported an age. Of those who reported anage, 39.0% were young adults (ages 15 to 30 years), 41.8% other adults (ages 31 to 59 years) and19.2% elderly (ages 60+ years). Some 83.0% (n=4,087) of sample reported good healthcompared to 17.0% (n=838) with poor self-reported health. Only 61.6% (n=371) of those whohad indicated poor health visited a health practitioner in the last 4 weeks of the survey period;and 96.0% of those with self-reported health conditions claimed they had purchase medicationwith only 45.3% mentioned that they completed ‘taking the prescribed medication’. Continuing,of those who responded to the health insurance question, 4.9% (n=241) had private coverage. Result: Multivariate Regression Of the 15 identified variables that were tested in this study, 6 of them were found to bestatistically significant (P < 0.05) for the final model (Equation 2). These determine good self-reported health status of rural men in Jamaica. Using logistic regression analyses, the predictors of good health status of rural men inJamaica are cost of medical care (OR=0.916, 95% CI=0.841-0.997), retirement income 62
    • (OR=0.0.382, 95% CI=0.206-0.707), marital status – separated, divorced or widowed withreference to those never married (OR=0.270, 95% CI=0.178-0.410), and married with referenceto never married men (OR=0.465, 95% CI=0.356-0.609)- health insurance coverage (OR=0.041,95% CI=0.027-0.063), number of children in household (OR=1.200, 95% CI=1.069-1.347), andthe number of durable goods owned by the man (OR=1.107, 95% CI=1.050-1.166) (Table 3.3). The model had statistically significant predictive power (Omnibus Test χ2 (18) =507.07,P < 0.001; n = 2824; Hosmer and Lemeshow goodness of fit χ2=5.321 (8), P = 0.72) andcorrectly classified 87.6% of the sample (Correct classification of cases of good or beyond healthstatus =98.4% (N=2,339) and correct classification of cases of with dysfunctions 30.4%(N=136). The logistic regression model can be written as: Log (probability of good health ofrural men in Jamaica) = 2.673 – 0.963 R t (retirement income) – 0.088lnP m (logged medicalexpenditure) – 1.309 MS1(marital status if divorced, separated or widowed) – 0.765 MS2(marital status if married) – 3.187 HI i (health insurance) + 0.182 N i (number of children inhousehold) + 0.101 O (ownership of durable assets excluding property and land) (Table 3.3).DiscussionJamaica is among Caribbean societies and developing countries in which men’s view health issickness. Their image of sickness is synonymous with health and weakness; and in keeping withthe machoism of these men, they are less likely to attend health care facilities for preventativecare as this is an indicator of weakness. Health which is broader than disease (or sickness) is stillcase in many developing nations. Oftentimes, they become active participants in addressing theirhealth conditions when the problems have become chronic and leading to death, incapacitationfrom employability, livelihood or sexuality. This explains why men in the Caribbean and in 63
    • particular Jamaica are less likely to take prostate examination as the process is carried outthrough inserting in the anus, and why sexual dysfunctions are kept in silence. This is notlimited to Caribbean men, as Viagra is the leading sold medicine in world, suggesting that sexualdysfunction is not only weakness for men but that it indicates how manhood is defined anduphold in many societies. Many men are only willing to visit health practitioners in an event that the ailment ordisability is severe and extensive and may result in death. Their first point of contact in case ofdysfunctions or that they perceive that ill-health is occurring is to use self-care or ‘self-medication compared to women who are eager and willing to seek health-care on the smallest ofperceived symptom of ill-health and even for preventive care. A group of researchers found thatmen are only willing to report life threatening diseases like heart diseases; this is also reiterated 28by Low et al. who argue that even when men suffer from erectile dysfunction only 10.5% ofthem sought help. These barriers to health-seeking behaviour are all embedded in one’s beliefs, 29which could be as a result of perceived personal control of the situation, level of optimism ,ethnic background and level of risk taking. These cultural happenings are not limited to Jamaicaand the Caribbean as a study conducted in Malaysia shows a similar health-seeking behaviour asin Jamaica and in Pakistan. Low and colleague 28 cite that: Erectile dysfunction (ED) is a common sexual disorder affecting men. [1-3]. Although new treatments for ED have emerged for many years, this does not directly translate into men actively seeking treatment for their ED problem 28 A substantial aspect to this is the emphasis that is placed on biomedical treatment, andperception of people as issues that are classified as health related. This is even evident in howinformation is collected on health; how health is measured in many studies, and how peopleinternalize those symbols. This explains how the society deals with particular health-related 64
    • matters. Low et al. state that “some men did not see ED as a medical problem, while othersaccepted it as a normal sequence of aging” 28. But still the reality lingers, health is substantiallyseen as a biomedical phenomenon – that is, communicable diseases, maternal and prenatalconditions, and nutritional deficiencies and non-communicable diseases as the causes of changesto health status and/or death. Now, what constitute good health of rural men in Jamaica? In this study, self-reportedhealth status was used to examine health of rural men. Is this a good measure? Self-rated healthis a complex variable that captures multiple dimensions of the relation between physical healthand other personal and social characteristics. It is very consistent in its capacity to predict 30 31 32mortality . It has also been strongly associated with successful aging . Ringen in a papertitled ‘Wellbeing, measurement, and Preferences’ argued that non-welfarist approaches tomeasuring wellbeing are possible despite its subjectivity. The direct approach for wellbeingcomputation through the utility function according to Ringen is not a better quantification asagainst the indirect method (i.e. using social indicators). The stance taken was purely from thevantage point that utility is a function ‘not of goods and preferences’ but of products and ‘taste’.The constitution of wellbeing is based on choices. Choices are a function of individual assetsand options. With this premise, Ringen forwarded arguments which show that people’s choicesare sometimes ‘irrational’, which is the make for the departure from empiricism. Hence, self-reported health status (or subjective wellbeing) is good to use to evaluate health of people. The current study revealed that 83.0% of Jamaicans claimed good health. Whatdetermines this good self-reported health? Good self-reported health of rural men in Jamaica aredetermined by cost of medical expenditure, retirement income, marital status, health insurance,number of children in household and ownership of durable goods (excluding property and land). 65
    • Of the 6 predictors of good self-reported health of rural men, only 2 of them positively influencegood health. These are number of children in household and ownership of durable goods.Continuing, the current study revealed that young children (ages less than 14 years) not onlypositively determine good health of rural men but that for each additional children that is in thehousehold, good self-reported is likely to increase by 1.2 times and that good health will increaseby 1.1 times for more durable goods owned by the rural man. Other studies have shown that 32-35wellbeing is increased by material resources , which this study concurs with; and thatchildren positively determine good health (or wellbeing). This explains why rural residents havemore children than urban families in Jamaica. In 1997, the prevalence of poverty in the nation was 19.9%. Of the prevalence of povertyin the island, rural poverty was 2.95 times more than that of urban poverty (9.3%) and 1.85 timesmore than that of poverty in Other towns (14.8%). One decade after 1997 (ie 2007), the nations’poverty fell by 50.3% (to 9.9%) and although rural poverty fell by 44.2% (to 15.3%), it was 3.83times more than poverty in Other Towns and 2.47 times more than urban poverty. Despite thereduction in prevalence of poverty in Jamaica and rural areas, it is approximately 4 times in 2007than in 1997. It is this reality that encourages increased fertility and more children in rural area,and contribution that they make to the future economic livelihood of households in rural areas. 36Keister study finds a strong association between family size and wellbeing in adult years,which means that for each additional child that a family has, this increase the future economicwellbeing of the family which is concurred by this study; and this was also the finding of anotherstudy 37. In the case in Jamaica, children who are less than 15 years old are unable to work, andso their positive influence on rural men’s good health is of a psychosocial nature. Some peopleconceptualize childbearing as a vehicle of social mobility, and some consider their offspring as 66
    • material resources in their old age. Within the psyche of the poor, poverty alleviation is seenthrough the investment in child/ren, and this some people see as investing in stocks, bonds,shares or other physical assets; which speaks to the current psychosocial benefits of children. Health insurance coverage is a product people use for futuristic health conditions. Here inthis study, a rural man is 0.041 times less likely to have good health. This finding reveals thathealth insurance is a precautious measure instead of a preventative one. Rural men buy privatehealth insurance in Jamaica owing to the high likeliness of ill-health. Hence, health insurancecoverage is not a good indicator of preventative health but of curative health; as rural men’s goodhealth is not improved with the purchase of this product. Similarly, the current research revealedthat those who spend more on medical care are 0.916 times less likely to have good health, andthat expenditure on medical care is to restore good health and that is not a preventative approach 5, 23to health care for rural men. This is contrary to studies done by Bourne which found thatspending on medical care to be positively associated with wellbeing. It is well established in research literature that married men have a greater wellbeing thannon-married ones. In Smith & Waitzman’s work 38, they added that men’s gains from marriagewere greater than that of women. This, then, explain why the some scholars made the statementthat “many observers have theorized that married individuals have access to more informal socialsupport than do non-married individuals” 39, which explains a social reality of higher quality oflife of married couples than ‘non-married’ individuals. Some studies have shown that marriedpeople have a lower mortality risk in the healthy category than the ‘non-married’ (39), and thisjustifies why they take less life-threatening risks 38, 40. Using a sample of 1049 Austrians from ages 14 years and over, Prause et al. 41 found thatmarried individuals reported better subjective health-related quality of life index (8.3 ) than 67
    • divorced persons (7.6) or singles (7.7). Smock and colleagues 42 concurred with Prause et al andother studies there is a direct relationship between married women and economic wellbeing.Drawing a longitudinal data from the National Survey of Families and Households for 1987-1988 (NSHH1) and a follow-up survey (NSFH2) of some 13, 008, a sample size of 2665 femalesfrom 60 years and older were used. Each study had a response rate of approximately 74 percentfor NSFH1 and 82 percent for NSFH2. The research revealed that married women had a highereconomic wellbeing than divorced females. It was found that females who were remarriedexperienced an equally high wellbeing as their married counterparts, which was higher than thatexperienced by single females. Smock, Manning and Gupta reported that divorced women liketheir married counterparts; it was found that educational attainment and work experience werepositively associated with wellbeing. Notwithstanding the plethora of studies that have shown correlation between marriedpeople being healthier, Lillard & Panis 43 contradicted all those traditional findings. Firstly, theyfound that healthier men are less likely to be married; and secondly, that healthier married menenter into this union later in life and that they do postpone remarriage. Conversely, Lillard andPanis revealed that it is unhealthy men that enter marriage at an early age, which suggest thatthese men do so because of health reasons 43. Their survey was in itself a contradiction of worksthat establish the positive correlation between marriage and wellbeing. This study concurs withLillard and Panis as it found that rural men who were never married were more likely to reportgood health compared to married or divorced men. Another important finding that emerged from this research is the negative statisticalcorrelation between those who received retirement income and good self-reported health status 44, 45of rural men. This may appear paradoxical as more income should mean greater wellbeing 68
    • Keister 36. According to Keister [in an article titled Sharing the Wealth: The effect of sibling onadult’s wealth ownership, forwarded that] there is “…little doubt that material resources canimprove quality of life and well...” 36. Wellbeing, therefore, can be improved with time through 46, 47material resources. Easterlin argued that material resources have the capacity to improveone’s choices, comfort level, state of happiness and leisure, which militates against staticwellbeing. Retirement is indeed income, but it is receive primarily by those who have reachedthe age of 65+ years for men, and so presents a cohort of men who are less likely to be in goodself-reported health compared to younger men. Continuing, rural men who received retirementincome were 0.382 less likely to report good health in comparison to those who have notreceived this benefit; and that this was the least predictor of good health status of the study. One of the approaches that must be forwarded from here onwards is the need to re-culturized health practitioners and health researchers on their views and image of health, healthcare, and wellness of rural men. A group of Caribbean scholars cited that “wellness involves thedifferent measures that we use to maintain good health and is geared towards preventing illnessand diseases”…This is definitely a positive approach to health care rather than focusing only ontreating and curing diseases 48. The authors gave a conceptual framework of the approach to takefor good health in Jamaica, but this lacks specificities for rural residents or rural men. LikeDavidson, Wright and Lowe 48 and the WHO4 in this study the researcher provides the predictorsof good health of rural men in Jamaica; and equally show the role of social determinants indetermining good health. It is well established in health literature that social determinants are 1-3, 5, 21-23, 49-51significant in predicting health (or wellbeing) of a populace or a sub-population ,and that these factors account for health improvements as reduction in disease causingpathogens. 69
    • ConclusionIn summary, good self-reported health status of rural men is function of health insurancecoverage, marital status, number of children in household, retirement income and ownership ofdurable goods (excluding property and land). This study has provided invaluable insights intofactors that determine good health status of rural men, and within this reality health carepractitioners can forge programmes that will address health concerns of this cohort now thatresearch is available on the group. One of the means of raising the health of a population is toaddress the health concerns of the poor, and in Jamaica this is rural residence. Moreover, mencontinue to seek less care than women, and when this is added to space of rural people, on anaverage rural men would be both poor a seek less health care. Within these realities, this studyhas provided the platform for addressing the health gaps that current exists in narrowing healthgaps in the population of Jamaica. This must be an important policy goal as effective policieswhich seek to address improvements in health must address the health inequalities that exist inrural Jamaica in particular rural men. 70
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    • Table 3.1: Seeking Medical Care, Self-reported illness, and Gender composition of those whoreport illness and Seek Medical Care in Jamaica (in percentage), 1988-2007 Reporting Reporting Mean Mean Seeking Seeking Illness- Illness- Days Days Seeking Health Medical Medical Men Women Of Of Medical Insurance Care - Care - Illness Illness Year Care Coverage Men Women Men Women 1988 NI NI NI NI NI NI NI NI 1989 54.6 8.2 44.7 52.8 15.0 18.5 10.6 11.1 1990 38.6 9.0 37.9 39.2 16.3 20.3 10.2 10.2 1991 47.7 8.6 48.5 47.4 12.1 15.0 10.0 10.3 1992 50.9 9.0 49.0 52.5 9.9 11.3 10.7 10.9 1993 51.8 10.1 48.0 54.7 10.4 13.5 10.7 10.1 1994 51.4 8.8 49.0 53.4 11.6 14.3 10.3 10.4 1995 58.9 9.7 59.0 58.9 8.3 11.3 10.6 10.7 1996 54.9 9.8 50.5 58.5 9.7 11.8 10.0 11.0 1997 59.6 12.6 60.0 59.3 8.5 10.9 11.0 10.0 1998 60.8 12.1 57.8 62.8 7.4 10.1 11.0 11.0 1999 68.4 12.1 64.2 71.1 8.1 12.2 11.0 11.0 2000 60.7 14.0 57.4 63.2 12.4 16.8 9.0 9.0 2001 63.5 13.9 56.3 68.2 10.8 15.9 9 10 2002 64.1 13.5 62.1 65.3 10.4 14.6 10.0 10.0 2003 NI NI NI NI NI NI NI NI 2004 65.1 19.2 64.2 65.7 8.9 13.6 11.0 10.0 2005 NI NI NI NI NI NI NI NI 2006 70.0 18.4 71.7 68.8 10.3 14.1 9.7 10.0 2007 66.0 21.2 62.8 68.1 13.1 17.8 10.6 9.3 Source: Jamaica Survey of Living Conditions, various issues NI - No Information was available 76
    • Table 3.2: Demographic characteristics of sampled population – Rural residence in Jamaica Variable n (%) Age group Young Adults 1968 (39.0) Other Adults 2015 (41.8) Elderly 968 (19.2) Retirement income No 4922 (98.0) Yes 103 (2.0) Health status Poor 838 (17.0) Good 4087 (83.0) Health insurance coverage No 4658 (95.1) Yes 241 (4.9) Per capita income quintile Poorest 1012 (20.1) Poor 1034 (20.5) Middle 1071 (21.2) Wealthy 1006 (20.0) Wealthiest 918 (18.2) Social support No 2370 (54.2) Yes 2371 (45.8) Educational level Primary and below 1032 (23.3) Secondary 3287 (74.2) Tertiary 108 (2.4) Marital status Married 1228 (25.5) Never married 3401(66.6) Divorced, separated or widowed 241 (4.9) Physical Environment No 3970 (79.8) Yes 1003 (20.2) Visited Health practitioner Yes 371 (61.6) No 231 (38.4) Purchase Prescribed Medication Yes 339 (96.0) No 14 (4.0) Completed the Medication Yes 167 (45.3) No 202 (54.7) 77
    • Table 3.3: Logistic regression of rural health of Jamaican Men by Some explanatory variables Std. Variables Error Wald 95.0% C.I Coefficient statistic P Odds Lowe Uppe Ratio r r Retirement Income -0.963 0.314 9.394 0.002 0.382 0.206 0.707 Middle Quintile 0.172 0.172 1.007 0.316 1.188 0.848 1.664 Two Wealthy Quintiles -0.138 0.173 0.637 0.425 0.871 0.621 1.222 Poor quintile* Household Head -0.020 0.595 0.001 0.973 0.980 0.305 3.145 Logged Medical Expenditure -0.088 0.043 4.153 0.042 0.916 0.841 0.997 Separated or Divorced or Widowed -1.309 0.213 37.938 0.000 0.270 0.178 0.410 Married -0.765 0.137 31.069 0.000 0.465 0.356 0.609 Never Married* Health Insurance -3.187 0.213 224.844 0.000 0.041 0.027 0.063 Physical environment 0.023 0.131 0.031 0.861 1.023 0.792 1.323 Secondary 0.040 0.140 0.082 0.775 1.041 0.791 1.370 Tertiary 0.317 0.438 0.522 0.470 1.373 0.581 3.240 Primary and below* Social support -0.213 0.119 3.198 0.074 0.808 0.640 1.021 Crowding -0.003 0.084 0.001 0.970 0.997 0.846 1.175 Land ownership -0.247 0.134 3.405 0.065 0.781 0.601 1.015 Number of female in -0.023 0.070 0.106 0.745 0.978 0.853 1.121 household Number of child in household 0.182 0.059 9.532 0.002 1.200 1.069 1.347 Ownership of durables 0.101 0.027 14.420 0.000 1.107 1.050 1.166 Average Consumption 0.000 0.000 1.851 0.174 1.000 1.000 1.000 Constant 2.673 0.712 14.096 0.000 14.488Omnibus Test χ2 (18) =507.07, p < 0.001; n = 2824-2 Log likelihood = 1963.42Hosmer and Lemeshow goodness of fit χ2=5.321 (8), p = 0.72.Nagelkerke R2 =0.282Overall correct classification = 87.6% (N=2,475)Correct classification of cases of good or beyond health status =98.4% (N=2,339)Correct classification of cases of with dysfunctions =30.4% (N=136);*Reference group 78
    • Chapter4 Good Health Status of Older and Oldest Elderly in Jamaica: Are there differences between rural and urban areas?The aim of the current study was to examine the good health status of older and oldest elderlyJamaicans as well as to determine predictors of this health status. A sub-sample of 1,069respondents (42.4 percent men and 57.6 percent women) who indicated being 75 years and olderwere used for this study. This is extracted from a larger nationally cross-sectional survey of25,018 respondents in 2002. The stratified multistage probability sampling technique was usedto draw the survey respondents, which reflects the socio-demographic characteristic of theJamaican population, and makes the sample generalizable on the population. A self-administered questionnaire was used to collect the data from the sample; and the interviewerswere trained to collect data. The data were entered, stored and retrieved in SPSS 16.0.Descriptive statistics were used to examine the demographic characteristics of the sample; chi-square was used to investigate non-metric variables, and logistic regression was the multivariatetechnique chosen to determine predictors of good health status. Two factors were found to bestatistically significant predictors of good health status of older and oldest elderly respondents.These were area of residence and sex of respondents. Older and oldest elderly men reported agreater good health status than old and oldest elderly women (OR=1.410; 95% CI: 1.048-1.897). On the other hand, there was no statistical difference between the self-reporteddiagnosed (chronic) recurring illness and age cohort of the sample. Rural older and oldestelderly respondents indicated the lowest good health status (OR=1.00) compared to otherresidents (urban: OR=1.670; 95% CI: 1.071-2.606; and other town dwellers: OR=1.847; 95%CI: 1.327-2.572). Good health of this age cohort is not influenced by income or social standing,and there is a need to examine lifestyle risk factors; disease indicators and psychologicalconditions, as this may provide more answers to the good health of Jamaicans 75 years andolder. A quantitative assessment has provided us with answers, but it is clear from the findingsthat more information is needed on this age cohort. The researcher recommends the use ofqualitative methodologies to provide in-depth understanding of those factors that determinegood health of this age cohort. 79
    • I NTRODUCTIONGlobally, statistics revealed that the growth rate for people 80 years and older was 3.9 percent(2000-2005) and that this was twice more than that for elderly 60 years and over. Comparatively,the average annual rate of growth for the population 80 years and older was 4.0 percent for LatinAmerica and the Caribbean, which was 1.4 times more than that for the population 60+ years [1].For the Caribbean, the average annual growth rate for the population 80+ years was 0.7 timesless than the younger elderly. Moreover, the annual rate of growth for the population of Jamaicasince 2003 is between 0.50 and 0.45, which is less than the rate of growth for the population 60 +years (1.2 percent) and 80+ years (2.0 percent). People are not only living longer in theCaribbean, but traditional health indicators such as total fertility rate, crude birth and death rates,infant and maternal mortality have been relatively stable since 1996. For some time now, Caribbean nations such as Barbados, Cuba, Dominica, Guadeloupe,Jamaica, Martinique and Trinidad and Tobago have been experiencing demographic transition[1-5]. This is a shifting of the population from younger ages to older ones (ages 60 years andolder or elderly) owing to reduced child and adult mortality, better public health andenvironmental conditions, higher standard of living and a reduction in the population under 15years. Those countries have in excess of 8 percent (2007) of their population 60 years and older[1-5]. Some demographers argue that population ageing occurs when 8 percent and more of acountry’s population are elderly [6]. Population ageing in the Caribbean is similar to theexperiences of the rest of the world, but it is more rapid, with a high degree of poverty andsignificant gender differences and inequalities. Another noticeable aspect of the ageing process isthe average annual rate of growth of the population 80 years and older in comparison with 60+years. 80
    • Undoubtedly ageing is a biological process, and continues throughout one’s lifetime.Over the lifespan of an individual he/she shifts from one birthday to the next, and equally so isthe case for morbidity, health status and quality of life. Health literature has shown thatbiological ageing is correlated with increased morbidity, mortality and poor health status [7, 8],which explains the health disparity (including functional and working capacity) between youngerand older ages (60+ years). This justifies the rationale for the WHO’s disability adjusted lifeexpectancy (DALE or healthy life expectancy) [9]. Life expectancy that has been widely usedby demographers to assess the health status of a population is computed from mortality data, anda critical assumption is that all people subscribe to the same mortality patterns. Embedded in thisconstruct is the fact that living means good health status. This, however, is not the case, aspeople can be alive but not enjoying their lived years, because of ailments which are not life-threatening but debilitating health conditions. This gave rise to the WHO’s recognition that theemphasis should not be on life expectancy but on healthy life expectancy. Here, it argued for thediscounting of life expectancy for the number of years lived with disabilities or illnesses. The elderly have a greater probability of facing health conditions compared to people ofyoung ages owing to their biological composition, which implies that the older an elderly personbecomes, the less likely it is that he/she will have good health. The WHO [1] calculated thatdeveloping countries’ life expectancy should be discounted by 9 years, and this should be 8.4years for men and 9.5 years for women in Jamaica. Although life expectancy has doubled formen and women in Jamaica over the last 100 years [2, 10], people are living longer with moredisabilities and health conditions. According to WHO [11], “In developing countries, their(elderly – ages 60 years and older) situation is generally much less widely-known and their needsand contributions have been largely invisible.” This is not the case in Jamaica, as Bourne [3, 10, 81
    • 12], Eldemire [13-20], and others have [21-27] extensively reviewed different aspects of the lifeof people and/or elderly women and men. Although those studies have been done, an extensivereview of health literature in Jamaica found no study that has investigated determinants of goodhealth status of the older and oldest elderly Jamaicans. Hence, the aim of this study is to examinefactors that explain good health status of the older elderly (ages 75 to 84 years) and the oldestelderly (ages 85+ years) in Jamaica.M ETHODSThe sub-sample for the current study was 1,069 older and oldest elderly respondents (ages of 75years and older) extracted from a nationally representative cross-sectional survey of 25,018Jamaicans (Jamaica Survey of Living Status, JSLC). The survey was drawn using stratifiedrandom sampling. This design was a two-stage stratified random sampling design where therewas a Primary Sampling Unit (PSU) and a selection of dwellings from the primary units. ThePSU is an Enumeration District (ED), which constitutes of a minimum of 100 dwellings in ruralareas and 150 in urban areas. An ED is an independent geographic unit that shares a commonboundary. This means that the country was grouped into strata of equal size based on dwellings(EDs). Based on the PSUs, a listing of all the dwellings was made, and this became the samplingframe from which a Master Sample of dwelling was compiled, which in turn provided thesampling frame for the labour force. Ten percent was selected for the survey (JSLC). This study used JSLC 2002 which was conducted by the Statistical Institute of Jamaica(STATIN) and the Planning Institute of Jamaica (PIOJ) between June and October 2002. Theresearchers chose this survey based on the fact that it was the second largest sample size for thesurvey in its history (since 1988 to 1998), and in that year the survey contained questions oncrime and victimization and the physical environment, unlike previous years. A self- 82
    • administered questionnaire was used to collect the data, which were stored and analyzed usingSPSS for Windows 16.0. The questionnaire was modelled from the World Bank’s LivingStandards Measurement Study (LSMS) household survey. There are some modifications to theLSMS, as JSLC is more focused on policy impacts. The questionnaire covered areas such associo-demographic, economic and wealth variables, crime and victimization, social welfare,health status, health services, nutrition, housing, immunization of infants and physicalenvironment. The non-response rate for the survey was 27.7%. Descriptive statistics such as mean, standard deviation (SD), frequency and percentagewere used to analyze the socio-demographic characteristics of the sample. Chi-square was usedto examine the association between non-metric variables, and an Analysis of Variance(ANOVA) was used to test the relationships between metric and non-dichotomous categoricalvariables. Logistic regression examined the relationship between the dependent variable andsome predisposed independent (explanatory) variables, because the dependent variable was abinary one (self-reported health status: 1 if reported good health status and 0 if poor health). The results were presented using unstandardized B-coefficients, Wald statistics, Oddsratio and confidence interval (95% CI). The predictive power of the model was tested using theOmnibus Test of Model, and Hosmer and Lemeshow (28) was used to examine goodness of fitof the model. The correlation matrix was examined in order to ascertain whether autocorrelation(or multicollinearity) existed between variables. Based on Cohen and Holliday (29) correlationcan be low (weak) - from 0 to 0.39; moderate – 0.4-0.69, and strong – 0.7-1.0. This was used toexclude (or allow) a variable in the model. Wald statistics were used to determine the magnitude(or contribution) of each statistically significant variable in comparison with the others, and theOdds Ratio (OR) for the interpreting of each significant variable. 83
    • Multivariate regression framework [10,12] was utilized to assess the relative importanceof various demographic, socio-economic characteristics, physical environment and psychologicalcharacteristics, in determining the health status of Jamaicans; and this has also been employedoutside of Jamaica [30,31]. This approach allowed for the analysis of a number of variablessimultaneously. Secondly, the dependent variable is a binary dichotomous one and this statistictechnique has been utilized in the past to do similar studies. Having identified the determinantsof health status from previous studies, using logistic regression techniques, final models werebuilt for women in general as well as for each of the geographical sub-regions (rural, peri-urbanand urban areas) using only those predictors that independently predict the outcome. A p-valueof 0.05 was used to for all tests of significance. The proposed model which this study seeks to evaluate is the health status of Bourne [10,12] which was used previously to model health status of Jamaican.Hi = ƒ(W i , HH i, Pmc i, C i, MR i, AR i, ED i, SS i, CR i, (∑NAi, PAi ), Mi , F i, CHi, At , Xi, A i, HI i, LL i, En i, Y i, Vi ,ε i)(1) Health status of person i H i , is a function of W i is the two wealthiest quintiles ofperson i. 1 if yes, 0 if two poorest quintiles; HH i is household head of person i. 1 if yes, 0 ifotherwise; Pmc i is cost of medical care of person i, in US dollars; C i is average consumptionper person in household, in Jamaican dollars; MR i is marital status of person i; AR i is area ofresidence of person i; ED i is educational level of person i; SS i is having social support ofperson i. 1 if, yes; and 0 if no; CR i is crowding of person i, in numbers; (∑NA i , PA i ) is apsychological status which is the summation of negative affective status of person i, NA i wherevalues are in continuous numbers; and, PA i is positive affective psychological status of person i,where values are in continuous numbers; M i is number of men in household of person i; F i is 84
    • number of women in household of person i; CH i is number of children below the age of 14 yearsof person i; A t is asset owned of person i, in continuous numbers; X i is gender of respondent i;Ai is age of person i, in continuous numbers; HIi is ownership of private health insurance ; LLiis living arrangement where 1= living with family members or relative, and 0=otherwise; En i isphysical environment of person i. 1 if affected by flood, landslides, soil erosion, 0 if no; Yi isaverage income per person in household (this variable is measured by total expenditure, and V i iscrime of person i, where values are continuous numbers, and ε i is the residual error.Using data on older and oldest elderly Jamaicans, this study found that self-reported health statuscan be predicted by two variables [Eqn. (2)]Hi = ƒ(AR i, X i, ε i) (2)MeasuresSelf-reported Health Status is self-assessed illness (cold, diarrhoea, asthma attack, hypertension,diabetes mellitus or any other illnesses) reported by respondents in the last 4 weeks of thesurvey period. Good Health Status is a dummy variable, where 1=good health (not reporting anailment, injury or dysfunction) and 0=poor health (self-reported illness, injury or ailment).Household crowding is the average number of persons living in a room excluding kitchen,bathroom and verandah. Physical Environment is the summation of responses as reported byrespondents on suffering the effects of landsides, property damage due to rains, flooding; or soilerosion in the last 4 weeks of the survey period. Psychological Conditions are the psychologicalstate of an individual, and this is sub-divided into positive and negative affective psychologicalstatus. Positive Affective Psychological Status refers to the number of responses that are hopefuland optimistic about the future and life generally. Negative Affective Psychological Status refersto the number of respondents having lost a breadwinner and/or family member, experienced loss 85
    • of property, been made redundant, or failed to meet household and other obligations. Age is thenumber of years lived, which is also referred to as age at last birthday. This is a continuousvariable, ranging from 15 to 100 years. Age is classified into three groups: young respondentsaged 15 to 30 years, older adults 31 to 59 years, and elderly 60 years and older. Crime andVictimization Index (Crime Index) measures the number of cases and severity of crimescommitted against a person or his/her family members, but not against property. Using Cohenand Holliday’s [29] correlation guideline, low crime was from 0 to 34; moderate from 35 to 61,and high from 62 to 88. Older elderly is defined as the chronological age of 75 years to 84 years.Oldest elderly is the chronological age of 85 years and older. Social support (or network) denotesdifferent social networks in which the individual is involved (1= membership of and/or visits tocivic organizations or having friends that visit one’s home or with whom one is able to network,0=otherwise).R ESULTS: Demographic Characteristic of SampleThe sample was 1,069 respondents (42.5 percent men and 57.6 percent women), of which therewere 74.2 percent older elderly and 25.8 percent oldest elderly. Forty-three percent wereclassified as either poor or poorest; 71 percent were never married (included common-law),separated, divorced or widowed; 5 percent had private health insurance coverage; 8 percentreceived some form of retirement; 68 percent lived in rural areas compared to 32 dwelling inurban areas (of this 21 percent lived in other towns and 11 in cities); 67 percent had at mostprimary level education, of which 2 percent reported tertiary level education; 48.3 percentindicated that they had good health compared to 51.7 percent with poor health status; 41 percentreported having suffered the effects of soil erosion, landslide or some other form of naturaldisaster. Crimes affecting the sample were very low (1.12 ± 0.84); 52.1 percent reported visits to 86
    • private health care facilities compared to 47.9 percent public health care facilities, meanconsumption per person in household was US$699.13 ± US$627.64; 55.7 percent of respondentsindicated that they had social support; 20.7 percent lived alone; 35.5 percent were living withgrandchildren, and 29.2 percent of the sample was married. On further examination of some of the aforementioned variables by age cohort,interesting results came to light (Table 4.1). The findings revealed that there was no statisticaldifference between the reported good health status of older elderly respondents (48.7%)compared to that of the oldest elderly respondents (45.5%), p = 0.385. The same thing wasfound with private health insurance coverage for older elderly respondents compared to oldestelderly respondents (p = 0.184). However, a statistical correlation was found between sex ofrespondents and age cohort (p = 0.003). Fifty-five and one tenth percent of older elderlyrespondents were females compared to 44.9 percent of the oldest elderly. More of therespondents dwelled in rural areas, with there being no statistical difference between olderelderly and oldest elderly respondents (p = 0.121). A high percentage of the sample owned theirown home (87.2 percent), and there was no statistical difference between the older elderly (87.7percent) and oldest elderly (85.5 percent) (Table 4.1). The crime index showed that this affected more urban than rural elderly respondents(urban 1.61 ± 7.53; rural 0.74 ± 3.02) (p = 0.007) (Table 4.2). The findings revealed that povertywas 2.2 times greater in rural than in urban areas (12.4 percent of urban residents were below thepoverty line); higher level education was greater in urban than rural areas; private healthinsurance coverage was 5.2 times greater for urban residents compared to rural residents (2.0percent); self-reported good health was greater for urban (58.9 percent) than rural respondents 87
    • (43.5 percent) (Table 4.2). Also retirement income was 2.4 times more for urban respondentsthan for rural respondents (5.7 percent). Table 4.3 revealed that there was a statistical correlation between health insurancecoverage and retirement income (p = 0.001). Respondents who reported receiving retirementincome were 5.8 times more likely to have reported private health insurance coverage than theelderly who had not reported having received retirement income (Table 4.3). Of the sample (N=1,069), 41.3 percent answered the question of “Is your illnessdiagnosed as (chronic) recurring illness?” Of this number, 97.1 percent indicated a diagnosed(chronic) recurring ailment. A cross tabulation of diagnosed (chronic) recurring illness and agecohort of respondents showed no statistical correlation (p = 0.509). Notwithstanding theaforementioned p value, 75.5 percent of those who responded to this question reported diabetesmellitus, hypertension and arthritis, with 37.3 percent having hypertension and 21.9 percentdiabetes mellitus (Table 4.4). The number of respondents who indicated hypertension, diabetesand arthritis of the sample was 31.3 percent (n=335); with 15.4 percent hypertension, 9.1 percentdiabetes mellitus and 6.8 percent arthritis. With respect to those who indicated being diagnosed (chronic) recurring ailment, 42.2percent of women reported hypertension compared to 29.9 percent of men; 5.7 percent of menhad asthma compared to 1.9 percent of women; 24.6 percent of women reported diabetesmellitus compared to 17.8 percent of men; and 21.3 percent of men reported arthritis comparedto 13.4 percent of women (Table 4.5).R ESULTS: Multivariate AnalysisPredicting Good Health Status of Older and Oldest Elderly Jamaicans. Two factors were foundto be statistically significant predictors of good health status of older and oldest elderly 88
    • respondents. These were area of residence and sex of respondents. The model had a statisticallysignificant predictive power (chi-square = 37.258, p=0.001; Hosmer and Lemeshow goodness offit chi-square=5.785, p= 0.671). In addition, it was revealed that overall 58.39% of the data werecorrectly classified: 69.6% of those who indicated poor health status and 45.7% of those whoindicated good health status (Table 4.6). Based on Table 4.6, older and oldest elderly men reported a greater good health statusthan older and oldest elderly women (OR=1.410; 95% CI: 1.048-1.897). Rural older and oldestelderly respondents indicated the lowest good health status (OR=1.00) compared to otherresidents (urban: OR=1.670; 95% CI: 1.071-2.606; and other town dwellers: OR=1.847; 95% CI:1.327-2.572). None of the other factors such as consumption, social support, crowding, healthinsurance coverage, cost of medical care, education, age of respondents, and the physicalenvironment predicted good health status of older and oldest elderly respondents (p > 0.05).D ISCUSSIONThe current study has shown that the health status of older and oldest elderly in Jamaica isrelatively moderate, as 48 out of every 100 older and oldest elderly reported good health status.It was found that there was no statistical difference between the self-reported good health statusof older people (ages 75 – 84 years) and oldest elderly (ages 85 years and older). Nine of every100 older-to-oldest elderly had diabetes mellitus; 15 out of every 100 hypertension and 7 out ofevery 100 had arthritis. In addition, there was a statistical correlation between good health statusand area of residence, or self-reported (chronic) recurring illness and age cohort. Furthermore,the data showed that older and oldest elderly Jamaicans who dwelled in rural area had the lowestself-reported good health compared to those who resided in other towns and urban areas.Continuing, those who resided in other towns reported the greatest good health status. 89
    • Approximately, twice more women reported being diagnosed with (chronic) recurring illnesscompared to men. Eldemire [32] opined that ageing population is associated with increased disability, and ifthis is so then there should be more illness with ageing. The current study does not concur withEldemire findings, that as people age (older to oldest elderly) they would report more disabilities.This approach emphasizes the longevity of the cells, in relation to the number of years theorganism can live. Thus, in this construction the human body (an organism) is valued based onphysical appearance and/or state of the cells. Embedded in this apparatus is the geneticcomposition of the survivor. Gompertz’s law in Gavriolov and Gavrilova [7] demonstrates the fundamentalquantitative theory of ageing and mortality of certain species (the examples here are as follows –humans, human lice, rats, mice, fruit flies, and flour beetles). Gompertz’s law went further toestablish that human mortality increases twofold with every 8 years of an adult life, which meansthat ageing increases in geometric progression. This phenomenon means that human mortalityincreases with the age of the human adult, but that this becomes less progressive in advancedageing. Thus, biological ageing is a process where the human cells degenerate with years (i.e.the cells die with increasing age), which is explored in evolutionary biology [33, 34]. Butstudies have shown that using the evolutionary theory for “late-life mortality plateaus” failedbecause of the unrealistic set of assumptions on which the theory is based [35-38]. The reliability theory, on the other hand, is a better fitted explanation for the ageing ofhumans than that argued by Gompertz’s law, as the ‘failing law’ speaks to the deterioration ofhuman organisms with age [7] as well as the non-ageing term. The latter, based on Gavrilov andGavrilova [7], can occur because of accidents and acute infection, which are called “extrinsic 90
    • causes of death. While Gompertz’s law speaks to mortality in the ageing organism due to age-related degenerative illnesses such as heart diseases and cancers, a part of the reliability functionis Gompertz’s function as well as the non-ageing component. The current study did not find astatistical difference between self-reported diagnosed (chronic) recurring illness and older andoldest elderly elderly; this can be as a result of the data. Despite the fact that people are the bestjudge of what affects them, there is a clear disparity here between biological ageing theorists’findings and the self-reported results of older and oldest elderly Jamaicans. The World Health Organization [39, 40] put forward a position that there is a disparitybetween contracting many diseases and the gender constitution of an individual. One healthpsychologist, Rice [41], in concurring with WHO, argued that differences in death and illnessesare the result of differential risks acquired from functions, stress, life styles and ‘preventativehealth practices’. Rice believed that this health difference between the sexes is due to social support.Other scholars explained that it is owing to epidemiological trends [42], i.e. lifestyle practicesjustify the advantages that women enjoy compared to men concerning health status. The currentstudy found that older and oldest elderly men had superior good health status to that of women,with men being 1.4 times more likely to report good health than women. A survey done byRudkin found that women have lower levels of economic wellbeing than men [43], and this isone of the justifications for the latter group reporting superior good health status. This finding isfurther sanctioned by Havenman et al [44] whose study revealed that retired men’s wellbeingwas higher than that of their female counterparts, because men usually received more materialresources, and more retirement benefits compared to women ages 65 years and older. Thus,with men receiving more than women and having more durable possessions than women, their 91
    • general satisfaction with life (including health) will be better than their women counterparts.There is a paradox here, as Bourne showed from statistics [3, 10] that the life expectancy ofwomen in Jamaica has been at least 3 years (1880-1882) to 6 years (2002-2004) longer, yet theyhave a lower good health status. A part of the gender health disparity that was put forward is owing to the culture. Amongthe gender roles ascribed to Caribbean males are the protection of the family, children, wife orgirlfriend, and parents. The man is expected to handle the laborious tasks such as lifting heavyitems, pruning trees and hedges and taking out the garbage, while maintaining a specialprotective role for his parents, in particular his mother. A Caribbean male finds it impossible totolerate someone criticizing his mother or belittling her, without becoming abusive or evenconfrontational. It is not that Caribbean males take a minimalistic role in regard to the family,but it is primarily the gender specification of these societies along with task specialization.Another cultural bias that emerged from the laborious tasks they are expected to undertake isillness. Illness is an indicator of weakness and lowered masculinity, which explains men’sunwillingness to seek preventative care, visit health facilities and report illness. This thenaccounts for the lowered good health status of women and the greater one reported by men.Despite this reality, let us examine particular health conditions. Women have a higher propensity than men to contract particular conditions such asdepression, osteoporosis and osteoarthritis [39, 45]. Herzog [45] noted that “… it appears thatolder women are more likely to be impaired by their health problems, while older men are morelikely to die from them.” A study by Schoen et al. [46] found that a group of adolescentsrevealed something different from that which was reported by WHO. The researchers found that 92
    • males are more likely than females to feel stressed; ‘overwhelmed’ or ‘depressed’, and theyattributed this to men’s limited social networks. Other researchers have agreed with Schoen et althat men in general tend to be more stressed and less healthy than females, and further arguedthat men can use denial, distraction, alcoholism and other social strategies to conceal their illnessor disabilities [47-50]. On the other hand, Herzog [45] in Physical and Mental Health in OlderWomen, using studies from a number of experts, wrote that females had higher rates ofdepression than their male counterparts. Data for the Caribbean showed that hypertension and arthritis are morbidities thatsignificantly plague both men and women [26]. The current study revealed that diabetes mellituswas the leading cause of illness among older and oldest elderly in Jamaica, followed byhypertension and arthritis, which differs from a past study [17] that had hypertension as theleading cause of morbidity of the elderly (43.4 percent), followed by arthritis (39.8 percent) anddiabetes mellitus (10.2 percent). When reported illness was cross tabulated by sex of older andoldest elderly respondents, the findings showed that 1.4 percent more women had diabetesmellitus than men and this was the same for hypertensive older and oldest elderly Jamaicans. Onthe other hand, there were 1.6 times more old and oldest elderly Jamaican men with self-reportedarthritis than women. These chronic non-communicable diseases continue to interface within thefunctional lives of the elderly, which means that they are indeed living longer but are faced withlower levels of good health than young adults (ages 15 to 29 years) and middle-aged adults (ages30 to 59 years). However, there was no statistical difference between self-reported ill and olderand oldest elderly age cohorts in this study, suggesting that health disparity is not between olderelderly and oldest elderly Jamaicans, but rather between older and oldest elderly and other agecohorts, such as young adults and middle-aged adults. Bourne’s study [10] of 3,009 elderly 93
    • Jamaicans (ages 60 years and older) found a low general wellbeing of respondents (3.9 out of 14± 2.3) which concurs with the current study. This study has refined the aforementioned one, byshowing that there is no statistical difference between the self-reported health status of older andoldest elderly Jamaicans; but it did not examine the young old (ages 60 to 74 years) and so it isunable to state whether there was a difference between young old and old and oldest elderlyrespondents. The old and oldest elderly are less likely to be productively employed in the labour forcethan middle-aged adults. This does not mean that they cannot be actively engaged in many otheractivities. Old and oldest elderly Jamaicans are involved in social work, home gardening, andactively engaged in extended family functions such as the rearing of grand-children. In this study36 out of every 100 old and oldest elderly reported that their grandchildren lived with them. InJamaica, the extended family is still cohesive [20] and the current study showed that this has notchanged, as approximately 54 out of every 100 persons were either married or in common-lawunions; but 8 out of every 10 old and oldest elderly were not living alone, suggesting that theextended family is still alive in 2002. In 1997, Statistics from the Planning Institute of Jamaica and the Statistical Institute ofJamaica [51] revealed that 54.3 percent of elderly (ages 60 years and over) lived in rural areas,and the current study showed that approximately 7 out of every 10 old and oldest elderly lived inrural areas, compared to 6 out of 10 for those 60 years and older of the population. In addition,20 out of every 100 Jamaicans were below the poverty line, compared to 25 out of every 100 inrural Jamaica. Given that the elderly substantially lived in rural areas and that poverty for thisgroup was 10.2 percent (in 2007), it is not surprising that the old and oldest elderly in this area ofresidence had a lower level of good health status than the urban old and oldest elderly in 94
    • Jamaica. It should be noted here that studies have shown that income was related to good health(52, 53), but this is not the case for the current study (old and oldest elderly Jamaicans). Poverty leads to ill-health, suggesting that the poor are less likely to have superior ‘goodhealth status’ to those in middle to upper classes [54]. Murray [54] opined that the interrelationbetween poverty and health is expressed in poor nutrition, improper sanitation and water qualityand inadequate housing, and these contribute to a lower health status. Other studies [55-57] haverefined this relationship by showing that persistent poverty affects health and even mortality, aswell as accounting for much of the malnutrition in developing countries [58]. Poverty and poorhealth is not only outside of the Caribbean as a study conducted in Jamaica [59] revealed that theleast health was reported by those in the lower class. This is not the case for the old and oldestelderly Jamaicans, as there was no statistical difference between the various social standings (i.e.lower, middle and upper classes) and good health status. The rationale for this is embedded in thedefinition of health, which means that health is tied to the living by more than difficulties ofhypertension, diabetes mellitus and arthritis. Those conditions are not viewed as poor health, asthey are permanent conditions, and therefore may not be construed as such. In studies done on elderly Jamaicans (ages 60+ years), physical environment, age, thenumber of males, females and children in a household, education, consumption, health insuranceand cost of medical care were significantly related to good health [3,4,10], as is also the case inBarbados [30], Canada [60] and the United States [61]. However, those variables are not relatedto good health for the old and oldest elderly population in Jamaica, suggesting that variables arenot what account for good health in old and oldest elderly respondents. In Bourne studies onelderly Jamaicans generally [3, 4, 10], it was revealed that crowding, marital status, area ofresidence, physical environment and gender accounted for the majority of the explanatory power 95
    • of good health, and that only crowding and marital status were not included in the current study,indicating that good health for ages 75 years and older was not due to identified variables orthose affecting 60+ years and older. Embedded in this figure is that most of the variables thatwere predictors of good health of elderly were more explanations of young elderly (60 to 74years) than the older and oldest elderly elderly. The validity of using people’s assessment of their life satisfaction and health is old and hasalready been resolved. Nevertheless, it will be succinctly put forward here for those who are notcognizant of this discourse. Scholars have established that there is a statistical associationbetween subjective wellbeing (self-reported wellbeing) and objective wellbeing [62-68], andDiener went further when he found a strong correlation between the two variables [68]. Gaspart[63] opined on the difficulty of objective quality of life (GDP per capita) and the need to useself-reported wellbeing in assessing the wellbeing of people. He wrote, “So its objectivism isalready contaminated by post-welfarism, opening the door to a mixed approach, in whichpreferences matter as well as objective wellbeing” [63], which speaks to the necessity of using ameasure that approximates more to this multidimensional construct, rather than continuing withthe traditional income per capita approach. Another group of scholars emphasized theimportance of measuring wellbeing outside of welfarism and/or pure objectification, when theysaid that “Although GDP per capita is usually used as a proxy for the quality of life in differentcountries, material gain is obviously only one of many aspects of life that enhance economicwellbeing” [69] and that wellbeing depends on both the quality and the quantity of life lived bythe individual [70]. Another study found that self-rated health was a strong predictor ofmortality, and remained the same even when controlled for physical health [64]. As such, self-rated health encompasses a more extensive coverage of health (such as physical status; cognitive, 96
    • emotional and social health) that are in keeping with old age than the objective health, which aresubtle and difficult to measure objectively using physical health assessment. CONCLUSIONS In summary, we now have a better understanding of those factors that account for olderand oldest elderly good health. While the data were well fitted for the model, the explanatorypower was low for those identified predictive factors. This means that the good health of this agecohort is not influenced by income, social standing and many other factors that predict healthstatus for the general populace, and that there is a need to examine lifestyle risk factors, cultureand the meaning system of this group, as those variables may provide more answers to the goodhealth of Jamaicans 75 years and older. This quantitative assessment has provided us withpertinent answers, but it is clear from the findings that more information is needed on this agecohort and that this can be had by qualitative methodology. The researcher recommends the useof qualitative methodologies to provide in-depth understanding of the culture and meaningsystem of this cohort as they can provide valuable insight into some of the determinants of goodhealth.ACKNOWLEDGEMENTThe author would like to thank the Data Bank in the Sir Arthur Lewis Institute of Social andEconomic Studies, the University of the West Indies, Mona, Jamaica for making the dataset(Jamaica Survey of Living Conditions, 2002) available. It was used for the current study. 97
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    • Table 4.1. Sociodemographic Characteristics of Sample by Old and Oldest Elderly CohortsVariable Older Elderly Oldest Elderly P value n (%) n (%)Sex 0.003 Male 356 (44.9) 97 (35.1) Female 437 (55.1) 179 (64.9)Health Insurance No 742 (95.0) 256 (96.6) 0.184 Yes 39 (5.0) 9 (3.4)Good Health Status 0.385 No 403 (51.3) 140 (52.6) Yes 382 (48.7) 126 (47.4)Education 0.170 Primary and below 491 (65.2) 171 (70.7) Secondary 241 (32.0) 68 (28.1) Tertiary 21 (2.8) 3 (1.2)Area of residence 0.121 Urban 259 (32.7) 79 (28.6) Rural 534 (67.3) 197 (71.4)House Tenure 0.613 Rent free 61 (7.7) 25 (9.1) Rented 36 (4.5) 15 (5.5) Owned 696 (87.8) 235 (85.5) 102
    • Table 4.2. Sociodemographic Characteristics of Sample by Urban-rural AreasVariable Urban Rural p value n (%) n (%)Good Health Status 0.001 No 137 (41.1) 406 (56.5) Yes 196 (58.9) 312 (43.5)Retirement Income 0.001 No 292 (86.4) 689 (94.3) Yes 46 (13.6) 42 (5.7)Gender 0.185 Male 136 (40.2) 317 (43.4) Female 202 (59.8) 414 (56.6)Marital status 0.282 Married 97 (29.4) 207 (29.1) Never married (include common law) 80 (24.2) 175 (24.6) Divorced 10 (3.0) 8 (1.1) Separated 6 (1.8) 18 (2.3) Widowed 135 (41.5) 305 (42.9)Age group 0.214 Older Elderly 259 (76.6) 534 (73.1) Oldest Elderly 79 (23.4) 197 (26.9)Utilization of Health Facilities 0.293 Private 39 (55.7) 119 (51.1) Public 31 (44.3) 114 (48.9)Private Health Insurance coverage 0.001 No 296 (89.7) 702 (98.0) Yes 34 (10.3) 14 (2.0)Education 0.001 Primary and below 196 (61.4) 466 (68.9) Secondary 105 (32.9) 204 (30.2) Tertiary 18 (5.6) 6 (0.9)Social class 0.001 Poorest 42 (12.4) 197 (26.9) Poor 45 (13.3) 171 (23.4) Low Middle 59 (17.5) 136 (18.6) Upper Middle 77 (22.8) 117 (16.0) Wealthiest 115 (34.0) 110 (15.0)Per capita consumption* Mean (SD) US$1,820.23 US$1,263.21 0.001 ($1,399.19) ($1,187.49)Crowding Mean (SD) 1.05 (0.85) 1.15 (0.83) 0.071Crime Index Mean (SD) 1.61 (7.53) 0.74 (3.02) 0.007Living Alone 75 (22.2) 146 (20.0) 0.405*US$1= Ja.$50.97 103
    • Table 4.3. Health Insurance by Retirement Income Retirement Income No Yes TotalHealth Insurance Coverage No 96.7 81.0 100.0 Yes 3.3 19.0 4.6Total 962 84 1,046χ 2 (1) =4.610, p value = 0.001 104
    • Table 4.4. Chronic (recurring) Illness by Age Cohort Age Cohort Older Elderly Oldest elderly TotalChronic Illness Cold 3.9 2.8 3.6 Diarrhoea 1.2 2.8 1.6 Asthma 3.9 1.9 3.4 Hypertension 23.4 17.6 21.9 Diabetes 37.1 38.0 37.3 Arthritis 16.5 16.7 16.5 Other 11.7 15.7 12.7 No 2.4 4.6 2.9Total 334 108 442χ 2 (7) =6.269, p value = 0.509 105
    • Table 4.5. Chronic (recurring) Illness by Gender Gender Male Female TotalChronic Illness Cold 4.6 3.0 3.6 Diarrhoea 1.7 1.5 1.6 Asthma 5.7 1.9 3.4 Hypertension 17.8 24.6 21.9 Diabetes 29.9 42.2 37.3 Arthritis 21.3 13.4 16.5 Other 16.7 10.1 12.7 No 2.3 3.4 2.9Total 174 268 442χ 2 (7) =19.908, p value = 0.006 106
    • Table 4.6. Logistic Regression on Good Health of Old and Oldest Elderly Jamaicans andSome Explanatory Variables, N=958 Coefficien Std Wald Odds 95.0% C.I. Variables t Error Statistics p value Ratio Lower Upper Average Consumption 0.000 0.000 0.334 0.563 1.000 1.000 1.000 Environment 0.103 0.143 0.517 0.472 1.108 0.837 1.468 Other Towns 0.614 0.169 13.213 0.000 1.847 1.327 2.572 Urban 0.513 0.227 5.115 0.024 1.670 1.071 2.606 †Rural area 1.000 Social support -0.165 0.134 1.513 0.219 0.848 0.652 1.103 Sex 0.343 0.151 5.145 0.023 1.410 1.048 1.897 Number of male 0.008 0.074 0.012 0.914 1.008 0.872 1.165 Number of female 0.084 0.076 1.227 0.268 1.088 0.937 1.262 Number of children 0.050 0.062 0.644 0.422 1.051 0.930 1.188 Age -0.019 0.012 2.501 0.114 0.981 0.957 1.005 Middle Quintile 0.023 0.188 0.015 0.901 1.024 0.709 1.478 Wealthiest Quintiles 0.088 0.205 0.185 0.668 1.092 0.731 1.631 †Poorest-poor quintiles 1.000 Health Insurance 0.241 0.326 0.549 0.459 1.273 0.672 2.411 Cost of medical care 0.000 0.000 0.203 0.652 1.000 1.000 1.000 Primary Education 0.180 0.142 1.592 0.207 1.197 0.905 1.582 - Constant 0.774 1.024 0.572 0.450 2.168Nagelkerke R-square=5.0%-2 Log likelihood = 1325.803Hosmer and Lemeshow chi-square=5.785; P=0.671Model: Omnibus Test - chi-square=37.258, p=0.001Overall correct classification = 58.3%Correct classification of cases of poor health status =69.6%Correct classification of cases of good health status = 45.7%†Reference group 107
    • Chapter5 Gender differences in self-assessed health of young adults in an English- speaking Caribbean nationGender differences in self-assessed health in young adults (i.e. ages 15 – 44 years) are under-studied in the English-speaking Caribbean. The aims of the current research are to (1) providedemographic characteristics of young adults; (2) examine self-assessed health of young adults;(3) identify social determinants that explain good health status for young adults; (4) determinethe magnitude of each social determinant, and (5) gender differences in self-assessed health. Thecurrent study extracted a sub-sample of 3,024 respondents from a larger nationally cross-sectional survey of 6,782 Jamaicans. Statistical analyses were performed using the StatisticalPackages for the Social Sciences v 16.0. Descriptive statistics were used to provide demographicinformation on sample. Chi-square was used to examine the association between non-metricvariables, and an Analysis of Variance was used to test the relationships between metric andnon-dichotomous categorical variables. Logistic regression examined the relationship betweenthe dependent variable and some predisposed independent variables. One percent of sampleclaimed injury and 8% illness. Self-reported diagnosed illnesses were influenza (12.7%);diarrhoea (2.9%); respiratory disease (14.1%); diabetes mellitus (7.8%); hypertension (7.8%);arthritis (2.9%) and unspecified conditions (41.2%). The mean length of illness was 26.0 days(SD = 98.9. Nine social determinants and biological condition explained 19.2% of the variabilityof self-assessed health. The biological condition accounted for 78.1% of the explanatory model.Injury accounts for a miniscule percentage of illness and so using it to formulate interventionpolicies would lack depth to effectively address health of this cohort.IntroductionGender differences in self-assessed health in young adults (i.e. ages 15 – 44 years) are under-studied in the English-speaking Caribbean. Previous studies that have examined young adultshave focused on reproductive health; survivability; teenage pregnancy; substance use and abuse;HIV/AIDS; injuries and impact of injuries on health [1-7]. While studies on injuries have shownthat young males 15 to 44 years are mostly affected by violent-injuries [6, 7], in Jamaica 108
    • statistics [8] revealed that many of the deaths occurred in this age group can be accounted for byinjuries. Injuries are among reasons for ill-health and by extension do not constitute a significantpercentage of illness. Injuries accounted for most morbidities and/or mortalities in the world [7],but this is not typical to Jamaica, making studies on injuries germane but lacks extensivecoverage on health. Statistics on Jamaica showed that of the 10 leading causes of mortality, in2002 [8-10], homicides and injuries were the 5th and 10th causes of deaths respectively [10]. In2004, statistics from the World Health Organization (WHO) showed that injuries were the 4thleading cause of morality in Jamaica [11] and in 2006, statistics from the Jamaica Ministry ofHealth [9] indicated that injuries was not among the 5 leading cases of hospital utilisation inJamaica. Policies therefore in Jamaica would not have been formulated using general health statusresearch, but more so from data on injuries, reproductive health, survivability and mortalities.Policy intervention on those issues are pertinent and cannot be neglected from the general pursuitof health, using general health status and health conditions would provide invaluable insightsfrom the individual’s perspective on those issues; which would add value to addressing healthconcerns that waiting for particular outcomes such as pregnancies, mortality, injuries or crime,violence and victimization by young adults. A study by Hambleton et al. [12] identified thatillness constituted significant percentage of the explanatory power of self-assessed health ofolder Barbadians (ages 60+ years) and while this provides some understanding of the role ofillness on general health status of which may be caused by injuries, the research identified otherfactors (i.e. social determinants) that played roles in health status determination. Injuries therefore do account for a percentage of ill-health, indicating that a study of theirtypologies is imperative but this cannot abate or replace a study on general health of young 109
    • adults. An extensive reveal of health literature in the English-speaking Caribbean nations found alack of studies on the general health status of young adults. Empirical literature showed that anystudy of health must coalesce biological and social determinants [13- 25], which is also lackingfor young adults. Recently a study by Bourne [26] provided invaluable insights into the typologyof health conditions and the demographic shifts in these between 2002 and 2007. Tables 5.1-5.3highlight hospital utilisation for gunshot wounds and suicides, and victim prolife of individualsin Jamaica for 2005. The data highlights the crime and hospital utilisation profile, whichindicates that health care utilisation and victims of crimes are substantially between 14 and 45years. Age 15 – 45 years does not only represent most of the victims of crime (Table 5.3-5.4),mortality and hospital utilization in Jamaica, it also denotes the group which constitutes arrest formajor crimes. Some of the issues are social and do affect mortality, but what about those personsof this group who are alive and fear being a victim of violence as well as those who reside inthose communities in which such incidences are perpetuated each day. In addition what abouttheir general health as well as those members of this age group who are not likely victims owingto other social conditions such as social hierarchy, area of residence or those who do not reside ininner-cities communities. It is within this context that the current study chose to examine self-reported health of this group in order to provide insights into the health of young adults and thesocial determinants that explain their health status. The aims of the current research are to (1) provide demographic characteristics of youngadults; (2) examine self-assessed health of young adults; (3) identify social determinants thatexplain good health status for young adults; (4) determine the magnitude of each socialdeterminant, and (5) gender differences in self-assessed health. 110
    • Materials and MethodsThe Jamaica Survey of Living Conditions (JSLC) was commissioned by the Planning Institute ofJamaica (PIOJ) and the Statistical Institute of Jamaica (STATIN) in 1988 [27]. These twoorganizations are responsible for planning, data collection and policy guidelines for Jamaica, andhave been conducting the JSLC annually since 1989 [28]. The JSLC is an administeredquestionnaire where respondents are asked to recall detailed information on particular activities.The questionnaire was modelled from the World Bank’s Living Standards Measurement Study(LSMS) household survey [28]. There are some modifications to the LSMS, as JSLC is morefocused on policy impacts. The questionnaire covers demographic variables, health,immunization of children 0–59 months, education, daily expenses, non-food consumptionexpenditure, housing conditions, inventory of durable goods and social assistance. Interviewersare trained to collect the data from household members. The survey is conducted between Apriland July annually. The current study extracted a sub-sample of 3,024 respondents (i.e. ages15 -44 years) from a larger nationally cross-sectional survey of 6,782 Jamaicans. This study used thedataset of the JSLC for 2007 [29].MeasuresAn explanation of some of the variables in the model is provided here. Self-reported is a dummyvariable, where 1 (good health) = not reporting an ailment or dysfunction or illness in the last4 weeks, which was the survey period; 0 (poor health) if there were no self-reported ailments,injuries or illnesses. While self-reported ill-health is not an ideal indicator of actual healthconditions because people may underreport, it is still an accurate proxy of ill-health andmortality. Social supports (or networks) denote different social networks with which the 111
    • individual is involved (1 = membership of and/or visits to civic organizations or having friendswho visit one’s home or with whom one is able to network, 0 = otherwise). Psychologicalconditions are the psychological state of an individual, and this is subdivided into positive andnegative affective psychological conditions. Positive affective psychological condition is thenumber of responses with regard to being hopeful, optimistic about the future and life generally.Negative affective psychological condition is number of responses from a person on having losta breadwinner and/or family member, having lost property, being made redundant or failing tomeet household and other obligations. Health status is a binary measure (1=good to excellenthealth; 0= otherwise) which is determined from “Generally, how do you feel about your health”?Answers for this question are in a Likert scale matter ranging from excellent to poor. Healthcare-seeking behaviour is derived from the question: Have you visited a health care practitioner,pharmacist or healer in the past four 4 weeks, with an option of yes or no. For the purpose of theregression the responses were coded as 1=yes, 0=otherwise. Crowding is the total number ofindividuals in the household divided by the number of rooms (excluding kitchen, verandah andbathroom). Age is a continuous variable in years.Statistical analysisStatistical analyses were performed using the Statistical Packages for the Social Sciences v 16.0(SPSS Inc; Chicago, IL, USA) for Widows. Descriptive statistics such as mean, standarddeviation (SD), frequency and percentage were used to analyze the socio-demographiccharacteristics of the sample. Chi-square was used to examine the association between non-metric variables, and an Analysis of Variance (ANOVA) was used to test the relationshipsbetween metric and non-dichotomous categorical variables. Logistic regression examined the 112
    • relationship between the dependent variable and some predisposed independent (explanatory)variables, because the dependent variable was a binary one (self-reported health status: 1 ifreported good health status and 0 if reported poor health status). The final model was based onthose variables that were statistically significant (p <0.05), and all other variables were removedfrom the final model (p >0.05). Categorical variables were coded using the ‘dummy coding’scheme or a reference category. The predictive power of the model was tested using the ‘omnibus test of model’ andHosmer & Lemeshow’s [30] 3 technique was used to examine the model’s goodness of fit. Thecorrelation matrix was examined in order to ascertain whether autocorrelation (or multi-collinearity) existed between variables. Cohen & Holliday [31] stated that correlation can below/weak (0–0.39); moderate (0.4–0.69), or strong (0.7–1). This was used in the present study toexclude (or allow) a variable. Finally, forward stepwise technique in logistic regression was usedto determine the magnitude (or contribution) of each statistically significant variable incomparison with the others, and the odds ratio (OR) for interpreting each of the significantvariables.ModelTo study the relationship between self-assessed health status and social determinants, biologicalconditions and welfare, and logistic regression was used to estimate the following regressionmodel. Equation [1] denotes the 20 social, SDHij, 3 welfare variables, Wij, and biologicalcondition, B i , of self-assessed health status (Hi ) and some standard error: 113
    • , [1]Table 5.6 presents the results from the econometric exercise, which is captured in Equation [2].Equation [2] therefore presents only those variables which are significantly correlated with self-assessed health status of young adults: , [2] where: Hi is the level of self-assessed health status of person i. SDH ij denotes the 9 statistically significant social determinants of person i.ResultsThe sample was 3,024 respondents: 47.6% males and 52.4% males. The mean age of the samplewas 28.5 years (SD = 8.8 years). Thirty percent of the sample was single; 20.4% common-law;13% married; and 27.1% in visiting unions. Thirty-six and three-tenth percent of the sample waspoor with 17.1% in the poorest 20% compared to 44.1% in the wealthy social hierarchies, ofwhich 23.2% was in the wealthiest 20%. Forty-five and nine tenth percent of the sample dwelledin rural area, 22% in peri-urban and 32.1% in urban areas. Of the sample population, with respectto the questions on injury and illness 97.1% and 97% responded respectively. Of thoserespondents, 1% claimed injury and 8% mentioned illness. When respondents were askedwhether the illness was diagnosed and the typologies of conditions, 100% stated that the healthcondition was diagnosed by a medical practitioner. The self-reported diagnosed health conditionswere influenza (12.7%); diarrhoea (2.9%); respiratory disease (14.1%); diabetes mellitus (7.8%);hypertension (7.8%); arthritis (2.9%) and unspecified conditions (41.2%). The mean length ofillness was 26.0 days (SD = 98.9), with 1 visit made to a health care practitioner in the last 4- 114
    • weeks. When respondents were asked if they had visited a health care practitioner (includinghealer, pharmacist, nurse, and wife) in the last 4-weeks, 64.2% said yes. The health careinstitutions were public hospitals (34.8%); private hospitals (7.0%); public health care centres(14%); and private health care centre (51.6%). Twenty percent of the sample had healthinsurance coverage; 89.6% claimed at least good health (including 42.2% very good self-assessed health) compared to 1.9% who stated at least poor health (including 0.3% very poorhealth). A cross-tabulation of health care-seeking behaviour and illness shows no significantstatistical association. Ninety-seven percent of those who seek medical care were ill compared to94% of those who sought medical care in the last 4-weeks.A cross-tabulation between illness and age group revealed a significant statistical association – χ2= 39.4, P < 0.0001. Figure 5.1 provides the information on the age group and percentage ofyoung adults who indicated that they had an illness in the last 4-weeks. No significant statistical association was found between health care-seeking and agegroup (P = 0.608): age 15 – 19 years, 60%; age 20 – 24 years, 53.1%; age 25 – 29, 60.0%; age 30– 34 years, 67.7%; age 35 – 39 years, 68.0% and age 40 – 44 years, 69.%. No significant statistical relationship was found between health care-seeking behaviourand social hierarchy (P = 0.339): poorest 20%, 51.1%; poor, 69.2%; middle class, 67.4%;wealthy, 65.5%, and wealthiest 20%, 67.7%. There is a statistical difference between age of respondents who reported havingparticular health conditions – F-test = 4.5, P < 0.001. The mean ages of particular healthconditions were influenza, 29.3 years (SD = 9.2); diarrhea, 32.2 years (SD = 8.7); respiratory, 115
    • 30.3 years (SD = 9.6); diabetes mellitus, 37.3 years (SD = 5.9); hypertension, 36.8 years (SD =7.1) and other, 29.9 years (SD = 9.3). Figure 5.2 highlights young adult who reported injury (%) and illness (%) that dwelled inparticular area of residence controlled for sex of respondents. Figure 5.2 showed that over 50%of those with illness and injury dwelled in rural areas. However, there was no significantstatistical relationship when illness and injury by area of residence was controlled for by sex ofrespondents (illness – male χ2 = 2.6, P < 0.271 and female χ2 = 2.3, P < 0.323; injury – male χ2 =2.5, P < 0.292 and female χ2 = 0.93, P < 0.628). Figure 5.3 shows sex composition of those who utilised health care facilities in Jamaica.Most young adult males utilised private hospitals (36.4%) compare to females who visited publichealth care (72.7%). The least percentage of females visited private hospitals (63.6%) comparedto public health care centres for males (27.3%).Multivariate analysisTables 6 represent the results from the econometric exercise: Of the 24 variables that were testedin an initial model, 9 were social determinants and 1 a biological variable. Biological variable(i.e. self-reported illness) accounted for 78.1% of the explanatory power of the model (i.e.15.3%), indicating that the social determinants accounted for 21.9% of the self-assessed healthstatus of young adults.Limitations of studyHealth is a function of social, psychological, economic, biological and ecological factors. Basedon the multi-dimensional nature of health determinants, the present study used secondary survey 116
    • data and variables such as psychological, ecological and some social issues; such as childhoodhealth history, culture, belief and value system were omitted from the model. Those omissionsreduced the explanatory power of the current study, but provide a platform with which futurestudies can be launched.DiscussionIn the present study, the prevalence of injury in Jamaica for young adults was 1% compared to8% in illness. A cross-tabulation between self-reported injury and self-reported illness showed asignificant statistical relationship. The association was a very weak one, correlation coefficient =0.12 (or 12%). Forty-one of every 100 young adults who reported having an injury stated thatthey had an illness in the last four-weeks, indicating that less than one- half percent of those withan injury had an illness. Concurrently, 2 times more young adult-females sought medical caremore than males. On the other hand, males were 2.3 times likely to record injury while femaleswere 2 times more likely to have an illness in the last 4-weeks. Furthermore, the odds ratio ofrecording better good self-assessed health status for males was 1.5 times more than that offemales. Outside of the gender differences in self-assessed health status, medical care-seekingbehaviour, and injuries, the odds ratio of recording good health married young adults was 1.6times more than their single counterparts and this was similar for peri-urban respondents withreference to rural young adults. On the other hand, a young adult who sought medical care was65% less likely to record good health; young adults with tertiary level education were 47% morelikely to record good health and those who spent more on medical care (i.e. medical care-expenditure) were 1% less likely to have good self-assessed health status. 117
    • Empirically, research has established that any investigation of health must coalescesocial, psychological, economic and biological variables [12-25, 32-37]. Hambleton et al. [12]went further when he disaggregated the contribution of biological and non-medical conditions ofself-assessed health status. They found that 87.7% of the explanatory power of good health statusof elderly Barbadians could be accounted for by current illness. The present study found thatcurrent illness accounted for 78.1%, which suggests that illness accounted for less of youngadults’ health status than for elderly people. One of the challenges in effectively comparing theaforementioned issues (which is embedded in the data) is that the perception of people acrossdifferent nations are not the same, and this as well as the age component could account for someaspects of the disparity.. The present study has not only highlighted the role that socialdeterminants play in health status but also that they play a greater role in the health of youngeradults than old people. Statistics seemingly show a large percent of young adults being victims ofinjuries but the current findings indicate that these represent a small part of ill-health of youngadults. The small percent of injuries experienced by young adults denote that using injuries as aguide in health policy intervention would be addressing an even smaller percent of health statusthan illnesses. From the aforementioned results which show that illness contributes more tohealth status than social determinants, along with injuries. It is clear that despite the cultural andbiological differences rooted in both figures, current illness is a strong determinant of self-assessed health status in each region and if health must combine social, biological, psychologicaland ecological determinants, public health interventions that are using any one determinant inparticular injuries would not be addressing the health concerns of young adults. This empiricalevidence concretizes the rationale for social determinants in the discussion and research onhealth status as well as ill-health. 118
    • The finding in the present paper showed that social determinants of young adultsconstituted more explanation than for elderly. Therefore the usage of injuries and/or illness tomeasure and guide public intervention denotes that1 in 5 of the health status of young adultswould have been unaddressed in this effort and as much as 9 out of 10 of injury statistics areused in public policy interventions. Current social determinants of health for elderly Barbadiansaccounted for 4.1% of health and historical determinants, suggesting the increased role ofbiological determinant in the health process with ageing. Historical determinants which includededucation, occupation, children, economic situation, childhood nutrition, childhood health anddiseases theoretically is apart of social determinants. Disaggregating social determinants toascertain a value for historical determinants to compare with Hambleton et al.’s finding in thisstudy found that education was the only factor of those identified in the Barbadian health status,and that education accounted for only 0.3% of the explanatory model in this study. Thereforewithin the limitations of the current study, meaningful comparison using disaggregated socialdeterminants would be close to impossible as the components are not necessarily the same. Inspite of the limitations of the current work, the study can effective compare self-assessed health status as both studies collected this from its population. The current study whichuses data for 2007 and Hambleton et al’s work used data for December 1999 to June 2000showed that young adults’ health was between 1.5 to 1.9 times more than that for elderlyBarbadians. Although there are time differences which cannot be discounted for in this study,there is emerging information in the reduction of health status with ageing. Ageing is a natureevent. Imagine purchasing a new car, taking this car home and locking it away in the car porchunder cover for 20 years; and on removing the covers although the item was not used, it wouldhave aged. On using the car however increases the deterioration or depreciation on the human 119
    • structure, and therefore account for illness, health care utilisation and lowered health status Theissue of the car symbolizes the natural ageing and progressive depleted state of things and this issimilarly the case for humans. The current study revealed that as young people age, the oddsratio (OR = 0.97) of indicating good health falls by 3% and using the aforementioned statisticswould mean that odds ratio of good health for elderly people should fall. A study by Bourne,McGrowder and Crawford [38] showed that illness affecting elderly Jamaicans was more chronicthan acute compared to the converse in this study. With the changes in the typology of illnessesfrom acute to chronic conditions, the elderly’s health status must be lower than that for youngadults. Hence although homicides accounted for more deaths of young adults that elderly people,the health status of the former is still greater and this is due largely to lower risk of biologicalconditions. Again the biology of an individual accounts for greater percentage of self-assessedhealth than external factors such as injuries from accidents. Injuries from accident affect 1 inevery 100 young adults, making its effect on health smaller than illnesses which accounts for 8 inevery 100 young adults.With biological conditions accounting for more of self-assessed health ofolder people, this supports lower health status than young adults and greater health careparticipation for the former as they seek to address the ageing of the organism and the increaseddepreciation owing to old age. Gompertz’s law in Gavriolov and Gavrilova [39] shows that there is a fundamentalquantitative theory of ageing and mortality of certain species (the examples here are as follows –humans, human lice, mice, fruit flies, and flour beetles. Gompertz’s law went further to establishthat human mortality increases twofold with every 8 years of an adult life, which means thatageing increases in geometric progression. This phenomenon means that human mortalityincreases with age of the human adult, but that this becomes less progress in advance ageing. 120
    • Thus, biological ageing is a process where the human cells degenerate with years (i.e. the cellsdie with increasing in age), which is explored in evolutionary biology [40-43]. But studies haveshown that using evolutionary theory for “late-life mortality plateaus”, fail because of thearguable unrealistic set of assumptions that the theory uses to establish itself [44-46]. Ageing therefore denotes gradual deterioration in living organisms as well other non-living items, which accounts for demand in medical care. Medical seeking-behaviour couldindicate either preventative or curative care. The present study revealed that the odds ratio ofgood health of young adults in Jamaica decline by 65% for those who seek medical care.Medical care for young adults therefore is a good measure of curative than preventative care.This also speaks of the cultural impact on health through people’s conceptual perceptions ofhealth; that health is illness and so care is sought for ill-health as against preventative care. Thecurrent work revealed that 94 out of every 100 young adults who sought medical care were ill;reinforcing the cultural perception of illness and the reason why young adults seek health-care iscurative than preventative for this group. Illness in the current work is substantially a female phenomenon. Young adult femaleswere 2 times more likely to report an illness, and this justifies their greater probability to utilizemedical care seeking in order to address ill-health. These findings have a high degree of validityas statistics from the Ministry of Health (Jamaica) showed that females attended health careinstitutions twice as much as men for curative care since 2000-2007 [9]. Since 1988, statisticsobtained from Jamaicans in national cross-sectional surveys revealed that females wereapproximately more likely to report an illness and utilize medical care than males. Thisreinforced the cultural biasness of illness and health care facilities. Health care facilities areprimarily governed by females for females and this adds to cultural handicap of males afford 121
    • attending public health care institution on experiencing ill-health. , The feminization of healthcare facilities and the large percent of people in particular females who utilise public health careinstitution is another rationale for males use of private health care facilities. Males on the otherhand will attend medical care facilities when ill-health interfaces with their economic livelihoodand the severity is such that this is the only avenue. This is not atypical to Jamaica as aqualitative study in Pakistan on street children found that boys would attend formal health care ifit affects their economic livelihood and health conditions were severe [47]. Another studyconducted in Anyigba, North-Central, Nigeria found that [48] found that 85 out of every 100respondents waited for less than a week after the onset of illness to seek medical, and that 57 outof every 100 indicated that they would recover without treatment. A Caribbean anthropologist [49] stated that the macho socialisation of the Caribbeanmale accounts for his unwillingness to seek medical care. Caribbean males including Jamaicansare socialised to be strong, do not show weakness, and be involved in particular tasks to exhibittheir masculinity as a result illness is a signal of weakness, therefore accounting for the reasonswhy they are skeptical to visit medical institutions and often times wait for severity. On visitingmedical practitioners, it is sometimes so difficult for traditional medical practioner to offer cure.This then offers an explanation for females living longing than males. Although the currentfindings showed that the odds of recording good health is 1.5 times greater for young adultmales, apart of this is owing to the reality that often times males do not see themselves as ill,visit medical practitioner less and justifies the higher mortality among them than females. Thesocial determinants are therefore offering explanation for the biological issues as well,challenges to implement health interventions to improve health of young adults in particularmales are great as definition of illness and severity of symptoms reduce the quality of life of 122
    • people and this finding concurs with a previous study by Williams et al. [50]. Unlike this study,Williams et al. [50] found that medical care-seeking behaviour did not differ significant betweenthe sexes, with this study finding the opposite. Like this paper, Dunlop et al [51] found thatAfrican American men had few physician contacts than minority and non-Hispanic whitewomen. The irresponsiveness of young adult males in seeking health care comparable to theirfemale counterparts in Jamaican extends to even older African American men. With the advancement in literacy and numeracy in the world since the 19th century,specifically in Jamaicans since 1960 (i.e. educational levels), empirical findings showededucation is among the social determinants that influence health status [12-26]. Education affectshealth directly and indirectly. A study on twins in USA found that more years in schooling (i.e.education) was associated with healthier patterns of behaviour. [52], which is an example of thedirect impact of education on health. In the Fujiwara & Kawachi [52] work on increasedschooling was associated with reducing smoking habit and other such healthier practices. Thecurrent study concurs with the literature as the odds ratio of good health status of young adultswith tertiary level education are 1.5 times more than those with primary or below education. Theindirect way that education affects health can be measured using social hierarchy. The presentfindings revealed that the middle class who are the educated ones were 1.5 times more likely toreport good health status and that wealth or income was not correlated with good health status orfor that matter the self-assessed health status of wealthy social hierarchies did not differ fromthose in the poor social hierarchies. Empirical evidence existed that among the social determinants of health is marital status.Some research showed that married people are healthier than non-married people [12-25, 53-58].Koo, Rie and Park [54] findings revealed that being married was a ‘good’ cause for an increase 123
    • in psychological and subjective wellbeing in old age. Smith and Waitzman [55] offered theexplanation that wives found dissuade their husband from particular risky behaviours such as theuse of alcohol and drugs, and would ensure that they maintain a strict medical regimen coupledwith proper eating habit [53, 56]. In an effort to contextualize the psychosocial and biomedicalhealth status of particular marital status, one demography cited that the death of a spouse meant aclosure to daily communicate and shared activities, which sometimes translate into depressionthat affect the wellbeing more of the elderly who would have had investment must in a partner[57]. They pointed to a paradox within this discourse as “…this is not observed among men”.To provide a holistic base to the argument, the researcher will quote a sentence from the findingsof Delbés and Gaymu [57] study that reads “The widowed have a less positive attitude towardslife than married people, which is not an unexpected result [57]. The present study concurs withthe literature that the health status of married young adults is greater than those who are single,but that this was only explained by females. Those findings highlight the value of marriage tofemales which commences at an early age, and seemingly that the benefits of marriage are notfor males. This is clearly not the case as study by Bourne [58], using data on Jamaicans, foundthat the odds ratio of reported good health was 1.6 times more for married males than theirfemale counterparts.Conclusion and policy recommendationsIn sum, statistics for 2007 revealed one in every two Jamaicans was 15-44 years old. This speaksto the importance of a research on this age group. With the demographic reality of young adultsin the country, using injury to examine health is grossly inadequate, narrow and fails tounderstand the matter of health. Health is more that illness as it incorporates social, economic, 124
    • psychological, ecological and biological determinants. While the biological determinant of self-assessed health of young adult predominates health determinants, injury accounts for a minisculepercentage of illness and so using injury to formulate intervention policies would be lacking indepth to effectively address health of this cohort. Although the health of young adult Jamaicansis very good, there are many health disparities between the sexes which are justifying inequitiesin health outcomes between males and females. The present study highlights some of the health disparities between the sexes and affordsresearch findings that can be used to refashion health policies and research focus in the future.Health policies must utilize the wide spectrum of health determinants in order to address themulti-dimensional nature of health. The use of injuries to measure and guide policies andprogrammes because seemingly there are many young adults who are affected is a misnomer anddoes not capture the gamut of illness or even health of this group of people. The identified health disparities are among reasons for health inequities in healthoutcome, and should justify a call for a research and policy direction that include avoidabilitiessuch as technical, financial and moral as these would provide additional explanations for healthdisparities, choices, inequity and/or inequalities in health outcomes among young adults. 125
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    • 54. Koo, J., J. Rie, and K. Park. 2004. Age and gender differences in affect and subjective wellbeing. Geriatrics and Gerontology International, 4:S268-S270.55. Smith KR, Waitzman NJ. Double jeopardy: interaction effects of marital and poverty status on risk of mortality. Demography 1994; 31:487-507.56. Ross, C. E., J. Mirowsky, and K. Goldsteen. 1990. The impact of the family on health. Journal of Marriage and the Family 52:1059-1078.57. Delbés, C., and J. Gaymu. 2002. The shock of widowed on the eve of old age: Male and female experience. Demography 3: 885-914.58. Bourne PA. Self-evaluation of health of married people in Jamaica. (in review) 129
    • Figure 5.1: Illness (%) by age group 130
    • Figure 5.2: Area of residence of those with Injury (%) and Illness (%) controlled for by sex 131
    • Figure 5.3. Sex composition of those who attend health care facilities 132
    • Table 5.1: Treatment for Gunshot wounds at the Accident and Emergency Depts. Of PublicHospitals by Gender and Age cohort (in %): 1999-2002Age cohort Year 1999 2000 2001 2002 Male Female Male Female Male Female Male Female< 5 years 0.8 1.3 0.2 3.1 0.2 0.0 0.0 0.05-9 years 0.3 3.0 0.7 1.9 0.3 1.1 0.3 0.610-19 years 17.9 24.5 16.2 18.5 10.2 17.0 13.9 17.020-29 years 39.0 32.5 40.5 30.2 35.8 19.4 36.6 35.230-44 years 30.6 23.6 31.1 11.1 32.3 26.9 29.3 32.145-64 years 6.6 12.2 6.7 28.4 10.7 22.3 8.9 11.365+ years 3.5 3.0 2.3 11.1 6.7 12.7 8.8 3.6Not unknown 1.4 0.0 2.2 1.2 3.8 0.7 2.3 0.6Total % 100 100 100 100 100 100 100 100Calculated by Paul A. Bourne from Annual Report, 2002 published by the Policy, Planning andDevelopment Division, Ministry of Health, Jamaica 133
    • Table 5.2: Visitation to the Accident and Emergency Depts. Of Public Hospitals for attemptedsuicide by Gender and Age cohort (in %): 2000-2002Age cohort Year 2000 2001 2002 Male Female Male Female Male Female< 5 years 0.0 0.0 1.0 0.0 1.0 0.95-9 years 0.0 3.4 2.0 0.0 2.0 3.510-19 years 19.0 39.3 13.0 49.4 13.0 38.320-29 years 24.1 36.0 20.0 34.8 20.0 36.530-44 years 34.5 13.5 13.0 6.7 13.0 17.445-64 years 12.1 2.2 4.0 3.4 4.0 0.965+ years 6.9 3.4 4.0 2.2 4.0 0.0Not unknown 3.4 2.2 0.0 3.4 1.7 2.6Total % 100 100 100 100 100 100Calculated by Paul A. Bourne from Annual Report, 2002 published by the Policy, Planning andDevelopment Division, Ministry of Health, Jamaica 134
    • Table 5.3: Victims of Major Crimes by Age Cohorts, 2005 Age Group Carnal Murder Shooting Robbery Breaking Rape Abuse Age Group Male Female Total Male Female Total Male Female Total Male Female Total Female Female0-4 2 4 6 3 1 4 0 0 0 0 0 0 3 35-9 3 5 8 0 5 5 1 0 1 0 0 0 27 1510-14 10 8 18 4 11 15 16 11 27 0 6 6 212 22315-19 122 18 140 107 13 120 59 49 108 8 17 25 223 10320-24 268 23 291 212 30 242 162 115 277 52 75 127 122 025-29 252 33 285 192 22 214 233 130 363 81 106 187 48 030-34 223 22 245 161 16 177 198 112 310 114 115 229 28 035-39 177 17 194 138 15 153 199 102 301 140 104 244 23 040-44 139 12 151 107 15 122 171 77 248 116 107 223 17 045-49 72 16 88 68 5 73 146 44 190 98 75 173 12 050-54 46 9 55 46 8 54 98 32 130 75 47 122 7 055 & Over 81 16 97 50 6 56 152 66 218 171 100 271 16 0Unknown 91 5 96 408 3 411 28 9 37 32 14 46 8 2Total 1486 188 1674 1496 150 1646 1463 747 2210 887 766 1653 746 346Total Reported 1674 1646 2210 1653 746 346Source: Statistics department, Jamaica Constabulary Force 135
    • Table 5.4: Age Group of Persons Arrested for Major Crimes for 2005 Age Group Murder Shooting Robbery Breaking Rape C/AbuseAge Group Male Female Total Male Female Total Male Female Total Male Female Total Male Male Total12-15 6 1 7 4 0 4 10 0 10 54 0 54 12 11 9816-20 157 6 163 167 1 168 183 0 183 122 3 125 66 43 74821-25 235 8 243 239 1 240 214 1 215 129 3 132 68 52 95026-30 160 2 162 137 0 137 120 1 121 105 3 108 73 27 62831-35 85 1 86 74 0 74 71 1 72 93 2 95 48 26 40136-40 54 3 57 40 1 41 36 1 37 69 0 69 23 19 24641-45 15 0 15 12 0 12 13 0 13 44 1 45 18 12 11546-50 7 1 8 2 0 2 1 0 1 18 0 18 12 5 4651-55 5 1 6 0 0 0 2 0 2 2 0 2 3 2 1556-60 1 0 1 1 0 1 6 0 6 1 1 2 1 1 1261& Over 0 0 0 2 0 2 2 0 2 3 1 4 2 0 10Unknown 40 0 40 86 0 86 23 0 23 11 0 11 10 0 170Total 765 23 788 764 3 767 681 4 685 651 14 665 336 198 3439Source: Statistics department, Jamaica Constabulary Force 136
    • Table 5.5. Particular variables by sex of respondents Sex PVariable Male (%) Female (%) n = 1,439 n = 1,585Injury 0.037 Yes 1.4 0.6 No 98.6 99.6Illness Yes 5.3 10.5 < 0.0001 No 94.7 89.5Self-assessed health status < 0.0001 Very good 44.8 39.8 Good 47.5 47.4 Moderate 6.3 10.4 Poor 1.1 2.2 Very poor 0.4 0.2Health care-seeking behaviour < 0.0001 Yes 3.5 6.8 No 96.5 93.2Household head < 0.0001 Yes 34.1 73.0 No 65.9 27.0Union status 0.103 Married 12.1 15.1 Common-law 19.7 21.0 Visiting 28.1 26.2 Single 30.8 28.9 Not stated 9.3 8.7Self-reported diagnosed health condition 0.289 Acute: Influenza 12.9 12.7 Diarrhoea 6.5 1.4 Respiratory 16.1 13.4 Chronic: Diabetes 6.5 8.5 Hypertension 11.3 21.1 Arthritis 1.6 3.5 Other (unspecified) 45.2 39.4Area of residence 0.756 Urban 32.2 31.9 Peri-urban 21.4 22.5 Rural 46.4 45.6No. of visits to health care facilities Mean (SD) 1.2 (0.5) 1.5 (1.3) 0.144Age Mean (SD) 28.4 yrs (8.8) 28.5 yrs (8.9) 0.746Medical expenditure Mean (SD) in US $ 16.67 (42.01) 16.42 (26.82) 0.971†US$ 1.00 = Ja. $ 80.47 137
    • Table 5.6. Logistic regression: Explanatory variables of good health status, n = 2, 832 Std. Explanatory variable Error Odds ratio 95.0% C.I. P R2 Social determinants: Age 0.01 0.97 0.96-0.99 < 0.0001 0.004 Crowding 0.03 0.95 0.90-1.00 0.043 0.003 Tertiary 0.28 1.47 1.27-1.81 0.007 0.003 †Primary 1.00 Male 0.14 1.45 1.11-1.91 0.007 0.006 MiddleClass 0.18 1.45 1.02-2.07 0.041 0.003 †Poor classes 1.00 Married 0.21 1.63 1.09-2.43 0.018 0.004 †Single 1.00 Other town 0.18 1.61 1.12-2.30 0.009 0.005 †Rural 1.00 Medical expenditure 0.00 0.99 0.99-1.00 0.017 0.006 Health care- seeking 0.29 0.35 0.20-0.62 < 0.0001 0.009 Biological condition: Self-reported illness 0.24 0.17 0.11-0.28 < 0.0001 0.153Hosmer and Lemeshow goodness of fit χ = 4.4 (8), P = 0.82 2-2LL = 1615.7Nagelkerke R2 =0.196†Reference group 138
    • Chapter6 Health of males in JamaicaStudies in the Caribbean on males have been on marginalization; fatherhood; masculinity andnone on the changing pattern of diseases. This study aims to 1) provide a detailedepidemiological profile of health conditions; 2) indicate the changing pattern of healthconditions; 3) calculate the mean age of having reported illness or not; 4) compute the mean ageof particular health conditions; 5) state whether the mean age of having particular illness arechanging; 6) determine whether there is a significant statistical correlation between healthstatus and self-reported illness; 7) identify factors that correlate with health status; and8)ascertain the magnitude of each determinant of health status. The current study usedsecondary cross-sectional data taken from two nationally representative surveys. A subsample of12,332 males out of 25,018 respondents and 3,303 males from 6,783 respondents were extractedfrom 2002 and 2007 surveys respectively. The Statistical Package for the Social Sciences forWindows, Version 16.0 was used for the analysis. Multiple logistic regressions were used toexplanatory variables of the models. There is a diabetes mellitus epidemic among Jamaicanmales as the yearly average increase was 156% for the studied period. Predictors of poor self-reported illness of males in Jamaica for 2002 were age (Odds ratio, OR = 1.044; 95% CI =1.038, 1.049; P < 0.05); urban area (OR = 1.547, 95% CI = 1.172, 2.043; P < 0.05);consumption (OR = 1.183; 95% CI = 1.056, 1.327; P < 0.05). Non self-reported illness of malesin Jamaica for 2007 can be predicted by good health status (OR = 17.801; 95% CI = 10.761,29.446; P < 0.05); fair health status (OR = 2.403; 95% CI = 1.461, 3.951; P < 0.05); age (OR= 0.967; 95% CI = 0.957, 0.977; P < 0.05); urban area (OR = 1.579, 95% CI = 1.067, 2.336; P< 0.05); and consumption (OR = 0.551; 95% CI = 0.352, 0.861; P < 0.05). The findings are farreaching and can be used to guide health policy formulation and intervention programmes in thefuture. 139
    • IntroductionIn the Caribbean, studies on males have been primarily on masculinity and fatherhood [1-6];male marginalization [7-10]; survivability [11], self-reported illnesses, health-care utilization andmortality [12-25]. Those studies exclude a comprehensive examination of the health status ofmales as well as an inquiry into the changing pattern of illnesses facing this cohort. The PlanningInstitute of Jamaica, (PIOJ) & Statistical Institute of Jamaica, (STATIN), however, haveprovided general self-reported illness and medical care-seeking behaviour of the population andthese have been disaggregated by sexes [26]. Although those issues provide pertinentinformation, they are insufficient for public health practitioners to sufficiently plan interventionprogrammes. Since 1989, when PIOJ & STATIN began collecting data, with a modified World BankLiving Conditions instrument, males have reported less illness than females; visited health care-practitioners less than females; yet their life expectancy has been between 2-6 years less than thatof their female counterparts [27]. Concurringly, STATIN’s data revealed that of the 5 leadingcause of mortality in Jamaica, males outnumbered females in 4 categories [28]; and themorbidity figures published by the Jamaican Ministry of Health (MOH) showed that theyoutnumbered females in 7 of the 10 leading cause of illnesses [29,30]. Those results demonstratethat males’ health cannot be left to self-reported illness, healthcare utilization and medical careexpenditure. Despite the value of such information health is more than illness, mortality and/orlife expectancy. In the late 1940s, the health discourse was such that World Health Organization (WHO)in the Preamble to its Constitution joined the debate and offered a conceptual definition of health[31]. The WHO [31] penned that health is more than the mere absence of diseases to include 140
    • social, psychological and physiological wellbeing. This was adopted by Engel [32-36] who evencoined the term ‘biopsychosocial model’ as the new thrust in mental ill patient care. He like theWHO opined that humans are mind, body and social agents which denote that their care mustincorporate all these facets as against the old biomedical approach, which was only concernedabout diseases and not wellbeing. This approach has revolutionalized the how health care isdelivered, measured and planned for. Those are very reasons why an inquiry into more than self-reported illness, healthcare utilization and medical care expenditure is needed as the health ismore than illness (subjective or objective). This brings into focus the subjective or objectivediscourse into health, and their usage in health research and diagnostic health care. In response to a need to expand the measures of health away from diagnosed illness,mortality and life expectancy (or objective indexes), researchers like Diener [37,38]; Veenhoven[39]; Frey & Stutzer [40-43]; Diener & Seligman [44]; Diener et al. [45]; Hutchinson et al. [21];Easterlin [46,47] have used happiness, life satisfaction and self-rated health status [20,48]. Thosemeasures are subjective indexes, which the scholars opined assess health more than the negativeor narrow objective indexes. In keeping with the limitation of objective indexes, the WHO [49]devised an approach to discount life expectancy by removing time spent in illness to producewhat is termed healthy life expectancy (or disability adjusted life expectancy). DisabilityAdjusted Life Expectancy (DALE) summarizes the expected number of years to be lived in whatmight be termed the equivalent of "full health" [49]. This approach resulted in Jamaicans losing9 years of life owing to disabilities. The healthy life expectancy provides yet another account forhealth status of males; but there is a fundamental weakness that has not been address. Healthylife expectancy therefore lacks extensive coverage of an individual’s health; but accompanyingthe subjective indexes are biases and validity issues. 141
    • There are empirical evidences to show that self-reported health is an indicator of generalhealth. Schwarz & Strack [50] opined that the person’s judgments are prone to systematic andnon-systematic biases. However, Diener [37] argued that the subjective index seemed to containsubstantial amounts of valid variance, suggesting that subjective measures provide some validityin assessing health, this was concurred by Smith [51] with good construct validity and is arespectably powerful predictor of mortality risks [52], disability [53] and morbidity [54], thoughthese properties vary somewhat with national or cultural contexts [52]. Studies using self-reported health and mortality found a significant relationship between a subjective and anobjective measure [52, 54]; life expectancy [55]; disability [53]. Bourne [55]) found that thecorrelation between life expectancy and self-reported health status was a strong one (r = 0.731);and that self-rated health accounted for 53% of the variance in life expectancy. Hence, the issueof the validity of subjective and objective indexes is good, with Smith [51] opined that theconstruct validity between the two being a good one. Using subjective indexes to measure health, studies have shown that there are manypredictors (or variables) of these measures. Income, marital status, education, and othersociodemographic variables [12-18, 20, 21, 40, 46-48, 56] have been found to significantcorrelate with health status. Those studies have not singled out males in the examination ofhealth issues, suggesting that the experiences of males and females are congruent or similar.WHO [57] forwarded that there is a disparity between contracting many diseases and the genderconstitution of an individual. Rice [58], in concurring with WHO, argued that differences indeath and illnesses are the result of differential risks acquired from functions, stress, life stylesand ‘preventative health practices’ [58]. With health disparity between the sexes caused by 142
    • particular issues with a nation, it is for this reason why health research must examine the sexesdifferently in order to understand each subgroup. The current study fills this gap in the health literature by examining the health of males inJamaica. The objectives of this study are 1) provide a detailed epidemiological profile of healthconditions; 2) indicate the changing pattern of health conditions; 3) calculate the mean age ofhaving reported illness or not; 4) compute the mean age of particular health conditions; 5) statewhether the mean age of having particular illness are changing; 6) determine whether there is asignificant statistical correlation between health status and self-reported illness; 7) identifyfactors that correlate with health status; and 8)ascertain the magnitude of each determinant ofhealth status.Methods and materialSetting and designThe current study used secondary cross-sectional data taken from two nationally representativesurveys. A subsample of 12,332 males out of 25,018 respondents and 3,303 males from 6,783respondents were extracted from 2002 and 2007 surveys respectively (Figure 6.1). The onlycriterion upon which the subsample was selected was based on being male. The survey (JamaicaSurvey of Living Conditions, JSLC) is a modification of the World Bank Survey on LivingConditions [59-61] (PIOJ & STATIN, 1988-2008; World Bank, 2002). The JSLC begancollecting data in 1989, and each year a new module is included based on particularsociopolitical issues with the economy leading up to the survey period. A self-administeredquestionnaire is used to collect the data from Jamaicans. Trained data collectors are used togather the data; and these individuals are trained by the Statistical Institute of Jamaica. 143
    • The survey was drawn using stratified random sampling. This design was a two-stagestratified random sampling design where there was a Primary Sampling Unit (PSU) and aselection of dwellings from the primary units. The PSU is an Enumeration District (ED), whichconstitutes a minimum of 100 residences in rural areas and 150 in urban areas. An ED is anindependent geographic unit that shares a common boundary. This means that the country wasgrouped into strata of equal size based on dwellings (EDs). Based on the PSUs, a listing of all thedwellings was made, and this became the sampling frame from which a Master Sample ofdwelling was compiled, which in turn provided the sampling frame for the labour force. Onethird of the Labour Force Survey (i.e. LFS) was selected for the JSLC. The sample was weightedto reflect the population of the nation. The non-response rate for the survey for 2007 was 26.2%and 27.7% [59-61].Figure 6.1: Sample Composition of Study Population 144
    • MeasurementAn explanation of some of the variables in the model is provided here. Self-reported illnessstatus is a dummy variable, where 1 = reporting an ailment or dysfunction or illness in the last4 weeks, which was the survey period; 0 if there were no self-reported ailments, injuries orillnesses [17, 18, 62]. While self-reported ill-health is not an ideal indicator of actual healthconditions because people may underreport, it is still an accurate proxy of ill-health andmortality [52, 53]. Health status is a binary measure where 1=good to excellent health; 0=otherwise which is determined from “Generally, how do you feel about your health”? Answersfor this question are in a Likert scale matter ranging from excellent to poor. Age group wasclassified as children (ages less than 15 years); young adults (ages 15 through 30 years); otheraged adults (ages 30 through 59 years); young-old (ages 60 through 74 years); old-old (ages 75through 84 years) and oldest-old (ages 85+ years). Medical care-seeking behaviour was takenfrom the question ‘Has a health care practitioner, header, or pharmacist being visited in the last 4weeks?’ with there being two options Yes or No. Medical care-seeking behaviour therefore wascoded as a binary measure where 1=Yes and 0= otherwise.Statistical analysis usedDescriptive statistics such as mean, standard deviation (SD), frequency and percentage were usedto analyze the socio-demographic characteristics of the sample. Chi-square analyses were used toexamine the association between non-metric variables; and t-test for metric and dichotomousvariables and F statistic was utilized for metric and non-dichotomous variables. Logisticregressions analyses the relationship between 1) poor self-reported illness and some socio-demographic variables (for 2002); as well as 2) not reported an illness and some socio- 145
    • demographic, economic variables and health status (for 2007). The statistical Package for theSocial Sciences (SPSS) for Windows, Version 16.0 was used for the analysis. Ninety-fivepercent confidence interval was used for the analysis, and the final models (ie equations) werebased those variables that P < 0.05. Odds Ratio (OR) was interpreted for each significantvariable. Initially the enter approach was used in logistic regression followed by stepwise toascertain the contribution of each significant variable for the final models. In order to exclude multicollinearity between particular independent variables, correlationmatrix was examined in order to ascertain if autocorrelation (or multicollinearity) existedbetween variables. Based on Bryman & Cramer [63], correlation can be low (weak) - from 0 to0.39; moderate – 0.4-0.69, and strong – 0.7-1.0. This was used to exclude (or allow) a variablein the model. Moderately to highly correlated variables were excluded from the model. Anotherexclusion criterion that was used is 30% of missing cases.ResultsDemographic characteristic of sampleTable 6.1 revealed a shift in percent of divorced (+ 0.8%); widowed (+ 0.7%); separated (-0.4%);never married (+1.7%) and married males (-1.4%) between 2002 and 2007. There was also apercentage shift in the sample reported having had an illness in the 4-week period of the survey.Concomitantly, there was a decline in percent of sample with hypertensive and arthritic cases inthe chronic illness category, with an increase in diabetic cases. In 2007, 62.3% of males soughtmedical care compared to 60.7% in 2002. The increase was not limited to medical care-seekingbehaviour as the percentage of males with health insurance coverage increased by 10.5% to19.3%. Massive urbanization is occurring in male population as in 2002, 62.7% of malesdwelled in rural zones and this decline to 50.1% in 2007, with 16% more males resided in urban 146
    • zones and 3.4% decline in semi-urban males. In the period (2002-2007), consumption andincome increased by 2.24 and 2.17 times respectively.Health statisticsIn 2007, it was the first time in the 2 decade history on collecting data on Jamaicans that healthstatus was obtained. The findings revealed that 39.0% of sample indicated very good healthstatus; 46.4% good health; 10.4%, fair health and 4.3% poor-to-poorest health, with 0.8%indicated very poor health status. A cross tabulation between health status and self-rated illness revealed a significantstatistical correlations - χ2 (df = 4) = 602.354, P < 0.001, with the association being a weak one,correlation coefficient = 0.399. Twenty-one percent of the sample indicated having had an illnessthat reported poor-to-poorest health status compared to 1.9% of sample that revealed no illnessrecorded poor-to-poorest health status (Table 6.2). Continuing, 3.3 times more of the respondentswho indicated not having an illness had very good health status compared to those who indicatedhaving an illness. In 2002, the mean age of a male who reported an illness was 39.32 ± 28.97 yearscompared to 27.26 ± 20.45 years – t-test = 18.563, P < 0.001. In 2007, the mean age of thosewith illness marginally increased to 40.64 ± 29.44 years compared to 27.61 ± 19.80 years forthose who did not have an illness - t-test = 11.355, P < 0.001. Based on Figure 6.2, the mean age of males with particular chronic illness has declineover the period. Interestingly, the greatest percentage decline was observed in unspecified healthconditions. In 2002, the mean age for males with unspecified health condition was 55.79 ± 28.81years and this fell to 40.67 ± 27.01 years in 2007. In 2007, the mean age for males with diabetesmellitus was 61.94 ±12.01 years; 66.76 ± 15.95 years for those with hypertension and 70.29 ± 147
    • 10.85 years for those with arthritis. Further examination revealed that there is statisticaldifference between the mean of those with chronic illness (P > 0.001); but this existed betweenthe chronic and the acute illnesses as well as the unspecified health conditions: for 2002 – Fstatistic = 15.62, P < 0.001 and for 2007 – F statistic = 31.601, P < 0.001.Multivariate analysisPredictors of poor self-reported illness by some explanatory variablesIn 2002, current poor health status of males in Jamaica was found to be significantly correlatedwith age; area of residence; consumption, social support and marital status (χ2 = 545.320, P < 0.001-2 Log likelihood = 4277.79) (Table 6.3). Table 6.3 revealed that predictors of poor self-reported illnessof males in Jamaica for 2002 were age (OR = 1.044; 95% CI = 1.038, 1.049; P < 0.05); urbanarea (OR = 1.547, 95% CI = 1.172, 2.043; P < 0.05); consumption (OR = 1.183; 95% CI =1.056, 1.327; P < 0.05). Further analysis show that age was the most significant predictor of poorhealth status accounting for 14.3% of the model (ie 15.1%); with area of residence accountingfor 0.2% (Table 6.5). In 2007, current poor health status of males in Jamaica was found to be significantlyassociated with health status; age of respondents; consumption, and area of residence - (χ2 =463.61, P < 0.001; -2 Log likelihood = 1103.314) (Table 6.4). Based on Table 6.4 revealed thatpredictors of poor self-reported illness of males in Jamaica for 2002 were age (OR = 1.044; 95%CI = 1.038, 1.049; P < 0.05); urban area (OR = 1.547, 95% CI = 1.172, 2.043; P < 0.05);consumption (OR = 1.183; 95% CI = 1.056, 1.327; P < 0.05). The findings here show that foreach year that a male ages, he is 1.04 times more likely to report an illness; and that urban malesare 1.6 times more likely to report an illness with reference to rural males. Further analysis show 148
    • that age was the most significant predictor of poor health status accounting for 14.3% of themodel (ie 15.1%); with area of residence accounting for 0.2% (Table 6.5). Based on Table 6.4, non self-reported illness of males in Jamaica for 2007 can bepredicted by good health status (OR = 17.801; 95% CI = 10.761, 29.446; P < 0.05); fair healthstatus (OR = 2.403; 95% CI = 1.461, 3.951; P < 0.05); age (OR = 0.967; 95% CI = 0.957, 0.977;P < 0.05); urban area (OR = 1.579, 95% CI = 1.067, 2.336; P < 0.05); and consumption (OR =0.551; 95% CI = 0.352, 0.861; P < 0.05). On disaggregating the explanatory power, it wasrevealed that good health status accounted for 30% (out of 37.6%) of the why males do notreport an illness; age accounted for 5.4%; fair health accounted for 0.8%; consumption, 0.9% andarea of residence, 0.5% (Table 6.5). Concomitantly, Table 6.4 revealed that a male who reportedgood health status with reference to one who indicated poor health status is 17.8 times morelikely not to report an illness; and that the more a male spent in consumption expenditure, he is0.449 times less likely not to report an illness.DiscussionThe current study revealed that men were willing to state their general health status (usingresponse rate, 97%); but that they were unwilling to report the typologies of illness that theywere diagnosed with (response rate, 0.7% in 2002 and 12.2% in 2007). Income of malesincreased by least 2 times in 2007 over 2002; however, health care-seeking behaviour increasedby only 1.6%. Embedded in the finding is males reluctance to seek medical care, and this againcan be seen in of 8.8% increase in health insurance coverage in 2007 over 2002 7% was due topublic health insurance although this is fee. The number of diabetic cases in 2007 increased by2.3 times over 2002, and there declines in the mean age at which males reported illness. Themean age at which a male who had self-reported being diagnosed with diabetes fell to 61.94 149
    • years; hypertension, 66.8 years; arthritis, 70.3 years and unspecified health conditions, 40.7years from 55.8 years. Hence, why the reluctance to seek medical care with the aforementionedcontext? Chevannes [1] provided some explanation for men’s general behaviour using sociallearning theory. He forwarded the perspective that a young male imitates the roles of societymembers through role modeling as to what constitute acceptable and good roles [1]. Youngmales are grown to be strong, masculine, brave and fewer traits must shun the appearance ofweakness and its associated attributes. The male child therefore as a part of his socialization is toaccept that the illness is correlated with weakness, and that he must not be willing participateinto health care seeking behaviour unless it is unavoidable. This definition of unavoidable isembedded into severity, and being unable to rectify the complaint outside of health carepractitioners. This gender role of sexes is not limited to Jamaica or the Caribbean but a studycarried out by Ali and de Muynck [64] on street children in Pakistan found a similar genderstereotype. A descriptive cross-sectional study carried out during September and October 2000,of 40 school-aged street children (8-14 years) revealed severity of illnesses and when ill-healththreatens financial opportunities that males sought medical care. Another finding was that[65]. Chevannes noted males suppressed response a pain, accounting for a low turn out to healthcare facilities and justifies a higher mortality rates as on attend medical care facilities it is oftentoo later and death is probable outcome. Hence the lowered age with which are diagnosed with particular chronic illness (such asdiabetes mellitus, hypertension and arthritis) does not change this embedded culturalizationwhich began prior to formal schooling and justifies why higher education does not often time 150
    • change this practice. Understanding the psyche of men and how this is fashioned aids in thecomprehension of their reluctance to visit health care facilities. The current findings indicate thaturbanization is taken place with males in Jamaica. The migration to urban zones is primarily tofacilitate economic opportunities which account for the drastic increase in income. Ali & deMuynck [64] study provides some understanding for the marginal increase in health care seekingbehaviour in Jamaica as this figure is accounted for males who were ill to the point of beingunable to work and that the ill-health threatens their economic livelihood. Another explanation for males’ withdrawal from visits to health care facilities is due tothe gender composition of those facilities. Males are culturalized to be strong, provide for hisfamily and chief among these is to show a female his masculinities which are tied to strength,physique and financial ability. It follows that with the higher percentage of health care workersbeing females, this retard the males’ masculinity as he conceptualizes visits to these institutionsas a show of his weakness. In protection of this masculinity, males will go to any extent tomaintain their image, which includes the sacrificing of life. This is embedded in the healthreported figures for the sexes. In 2002, 14.6% of females reported an illness compared to 10.2%for males, and in 2004 the disparity widens as the figures were 13.6% for females and 8.9% formale [26]. The current work showed the contribution of health status in explaining illness (or non-illness) of males. Current health status therefore accounted for 79.8% (30% out of 37.6%) of thevariability in current illness (or lack of), which lower than that of Hambleton et al.’s work.Hambleton et al. found that 87.5% (ie 33.5% out of 38.3%) of current illness account currenthealth status of elderly Barbadians. Embedded the findings of this research and that ofHambleton et al’s studies is synonymous conceptualization of illness and self-rated health status 151
    • in two Caribbean societies. This work holds some comparability with Hambleton et al.’s studywith respect to explanatory power and contribution of illness to health status. Hambleton et al.’sresearch is not only validating the current study and vice versa, this work demonstrates theimportance of illness to health and how despite the works of Engel and the WHO, health ofmales in contemporary Jamaica is still substantially conceptualized as illness. It is this definitionof health that guide risk perception, health care utilization and demand for healthy lifestylemeasures. Simply put, a male who is not experiencing symptoms of illness (pain, etcetera) doesnot construed that he needs to practice healthy lifestyle choices such as exercise, eat healthy,periodically visit a doctor, have the sufficient sleep, and refrain from bad lifestyle choices suchas smoking and consuming alcoholic beverages. Outside of definitions of health status, thefactors which account for self-reported illness or health status may not necessarily the sameacross different cohorts. Many empirical studies have established the strong correlation between marital status andhealth status. This work found that there was no significant difference between health status ofmarried males and males who were never married; but that divorced, separated and widowedmales were 1.4 times more likely to report an illness. A part of this rationale for the higherprobability of increased illness is owing to 1) the lost owing to separation which may be viadeath or physical separation, 2) the psychological tenet in investment and its lose from parting;and, 3) the financial separation cost which are likely to account for depression, suicide and otherforms of illness. A study by Able et al. [66] found that the rate of suicide in male Jamaicans was9 times higher than that for females, and they opined that a part of this is owing to suppressedfeeling of this sex. Although divorce, separation or widowhood have a psychosocial influence onmales, being married do not provide a benefit of better health. 152
    • Empirical evidence now exists that provide pertinent findings on the determinants of self-reported illness and self-rated health status of Jamaican males, disparities between both and therole of illness in health status. These findings demonstrate the not only the great health statusexperienced by the Jamaican males, but also the increased life expectancy which are accountedfor by better sanitation, quality and food quality, and other contributions of public health over thedecades. Statistics support the exponential increase in life expectancy of the Jamaican male from37.02 years (1880-1882) to 71.26 years (2002-2004) (Table 6.6) [27, 27, 67, 68], indicatingimprovements in healthy life expectancy. Despite the living longer in 2002 over 1880-1882, andonly 12 out of every 100 reported suffering from an illness in the surveyed period, the realityexist that there is a diabetes epidemic occurring among males in the country. This research revealed that diabetes mellitus increased by over 933% in 2007 over 2002,demonstrating that the average increase per year was 156%. Such an epidemic is hidden in thelow self-reported illness (2002, 10.2%; 2007, 12.1%), high life expectancy (Table 6.6), and self-rated health status by the study population. The challenge of public health special is to addressthis new health epidemic, and the reduced age at which males are reporting particular chronicillnesses (hypertension, arthritis and diabetes mellitus). Embedded in these findings is livinglonger with certain health conditions. These are implicit implications of those results for publichealth policy formulation, budgetary expenditure on healthcare, lower healthy life expectancy,lower production and productivity as the individual will require some time for healthcareutilization and absence from school, and work. Clearly the brewing diabetes mellitus epidemicamong males has been undiscovered by researchers and policy makers for years because of thelow report of illnesses, particularly diabetes mellitus. The 20th century brought with it massive changes in typologies of diseases and shift in 153
    • mortality from infectious diseases such as tuberculosis, pneumonia, yellow fever, Black Death(i.e. Bubonic Plague), smallpox and ‘diphtheria’ to diseases such as cancers, heart illnesses,hypertension and diabetes mellitus. Although diseases have shifted from infectious todegenerate, chronic non-communicable illnesses have arisen and are still lingering within all theadvances in science, medicine and technology, the Jamaican males are experiencing massiveincreases in diabetes mellitus since 2002. Using the absolute percentages of diabetic males inJamaica, it appears that this health condition is low and does not need for examination which isthe deceptive nature of this epidemic. Morrison [24] an article entitled ‘Diabetes andhypertension: Twin Trouble’ established that diabetes mellitus and hypertension have nowbecome two problems for Jamaicans and in the wider Caribbean. This situation was equallycollaborated by Callender [22] at the 6th International Diabetes and Hypertension Conference,which was held in Jamaica in March 2000. She found that there is a positive association betweendiabetic and hypertensive patients - 50% of individuals with diabetes had a history ofhypertension [22]. Based on the findings of the current study and works of Morrison [24] andCallender [22], it is not a problem but an epidemic experienced by males in Jamaica. Thechallenge for public health specialists, therefore, is to implement an immediate surveillance ofthis chronic illness among males and to formulate effective strategies to reduce, combat andaddress not only the current health problems but lifestyle changes which are required for presentgeneration.ConclusionThe current study provides a comprehensive examination of males’ health in Jamaica which canbe used by public health and other policy-makers in formulate intervention for this cohort.Interestingly in this work is that the mean age of males who reported being diagnosed with 154
    • unspecified health conditions has declined by 27 years; but we are not cognizant of whatconstitutes this category of illness. With average age of contracting this health conditions being40.7 years, could this group holds some answers to the high mortality of Jamaican males.Another issue which must be further examined is the exponential increase in diabetes mellitusamong the sample (over 933%), indicating that there is a diabetes mellitus epidemic affectingmales. Outside of the diabetes epidemic that is faced by Jamaican males, there is the fact that theaverage age of males with particular chronic conditions such as diabetes mellitus, hypertensionand arthritis has fallen over the studied period, demonstrating that those conditions are affectingyoung males and that this cannot be felt unaddressed. In summary, interesting, despite the broadened definition offered by the WHO on health,in contemporary Jamaica, self-rated health is still fundamentally conceptualized as self-reportedillness. Such a conceptual perspective indicates not only their cognitive domain of health, it alsoprovides insights into healthcare utilization, health behaviour, and other risk behaviours that theJamaican males will engaged in.Conflict of interestThe author has no conflict of interest to report.AcknowledgementThe author thank the Data Bank in Sir Arthur Lewis Institute of Social and Economic Studies,the University of the West Indies, Mona, Jamaica for making the dataset (Jamaica Survey ofLiving Conditions) available for use in this study. In addition to the aforementioned, the authorwould also like to extend sincere appreciation to Dr. Samuel McDaniel, Biostatistician andmathematician, Department of Mathematics, The University of the West Indies, who checked thestatistical accurateness of this manuscript, and made suggestions for its improvements. 155
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    • Table 6.1. Sociodemographic characteristics of sample, 2002 and 2007Variable 2002 2007 n % n %Marital status Married 2007 25.7 522 24.3 Never married 5421 69.4 1528 71.1 Divorced 64 0.8 34 1.6 Separated 85 1.1 16 0.7 Widowed 234 3.0 50 2.3Self-reported illness Yes 1217 10.2 388 12.1 No 10699 89.8 2820 87.9Self-reported diagnosed illness Cold - - 69 17.2 Diarrhoea 5 5.7 11 2.7 Asthma 6 6.8 47 11.7 Diabetes mellitus 3 3.4 31 7.7 Hypertension 39 44.3 58 14.4 Arthritis 16 18.2 24 6.0 Other 19 21.6 102 25.4 Not diagnosed - - 60 14.9Income quintile Poorest 20% 2454 19.9 671 20.3 Poor 2345 19.0 640 19.4 Middle 2440 19.8 636 19.3 Wealthy 2482 20.1 667 20.2 Wealthiest 20% 2611 21.2 689 20.9Health care-seeking behaviour Yes 769 60.7 253 62.3 No 497 39.3 153 37.7Health insurance coverage Yes 1251 10.5 612 19.3 No 10699 89.5 2560 80.7Area of residence Rural 7727 62.7 1654 50.1 Semi-urban 3062 24.8 706 21.4 Urban 1543 12.5 943 28.5Income Median (Range) Ja $251,795.96 Ja $545,950.17 (Ja. $6,423,253.16.72) (Ja. $5,228,700.28)Age Mean ±SD 28.28 ± 21.7 years 29.11 ± 21.6 yearsConsumption Median (Range) Ja $55,508.45 Ja $123,697.30 (Ja. $1,992,283.72) (Ja. $1,621,147.12)Duration of illness Median (Range) 10.5 days (90 days) 7.1 days (15 days)Cost of medical care Public Median (Range) Ja $150.00 (Ja. S12,000) Ja $294.96 (Ja. $20,000) Private Median (Range) Ja $800.00 (Ja $ 29,000) Ja $1130.39 (Ja $ 13,000)In 2002, US $1.00 = Ja. $50.87In 2007, US $1.00 = Ja. $80.47 160
    • Table 6.2. Health status and self-rated illness Self-rated illnessHealth status Yes NoVery good 50 (13.0) 1193 (42.6)Good 129 (33.4) 1351 (48.2)Fair 125 (32.4) 205 (7.3)Poor 66 (17.1) 44 (1.6)Very poor 16 (4.1) 8 (0.3)Total 386 2801χ2 (df = 4) = 602.354, P < 0.001 161
    • Table 6.3. Predictors of poor self-reported illness by some explanatory variables, 2002 Wald Odds Variable Std error statistic P ratio CI (95%) Age 0.01 222.66 0.000 1.04 1.04 1.05 Urban areas 0.14 9.47 0.002 1.55 1.17 2.04 Other towns 0.16 1.31 0.252 1.20 0.88 1.62 †Rural areas 1.00 Log Consumption 0.06 8.34 0.004 1.18 1.06 1.33 Separated_Div_Wid 0.15 4.77 0.029 1.38 1.03 1.85 Married 0.10 1.39 0.239 1.12 0.93 1.36 †Never married 1.00 Physical environment 0.09 0.89 0.347 1.08 0.92 1.28 Secondary 0.10 0.02 0.893 1.01 0.83 1.23 Tertiary 0.21 0.09 0.768 1.06 0.70 1.61 †Primary or below 1.00 Rented – house tenure 0.17 0.02 0.895 0.98 0.70 1.37 Owned 0.12 0.03 0.876 1.02 0.80 1.30 †Squatted 1.00 Social support 0.08 6.23 0.013 1.23 1.05 1.44 Constant 0.66 92.87 0.000 0.00χ2 = 545.320, P < 0.001-2 Log likelihood = 4277.79Hosmer and Lemeshow goodness of fit χ2=4.324, P = 0.827Nagelkerke R2 =0.151Overall correct classification = 88.9%Correct classification of cases of poor self-rated health = 99.8%Correct classification of cases of good self-rated health =1.8%†Reference group 162
    • Table 6.4. Predictors of not self-reporting an illness by some explanatory variables, 2007 Wald Odds Variable Std error statistic P ratio CI (95%) Good health status 0.26 125.72 0.000 17.80 10.76 29.45 Fair health status 0.25 11.93 0.001 2.40 1.46 3.95 †Poor health status 1.00 Age 0.01 39.85 0.000 0.97 0.96 0.98 Middle Class 0.26 0.01 0.918 1.03 0.62 1.70 Upper class 0.36 0.34 0.558 1.24 0.61 2.53 †Lower class 1.00 Married 0.19 0.71 0.399 0.85 0.58 1.24 Divorced, separated or other 0.31 0.01 0.954 1.02 0.55 1.88 †Never married 1.00 Health insurance 0.20 0.02 0.899 0.98 0.67 1.43 Urban area 0.20 5.22 0.022 1.58 1.07 2.34 Other towns 0.22 2.86 0.091 1.44 0.94 2.20 †Rural areas 1.00 Log Consumption 0.23 6.84 0.009 0.55 0.35 0.86 Constant 2.60 10.30 0.001 4158.20χ2 = 463.61, P < 0.001-2 Log likelihood = 1103.314Hosmer and Lemeshow goodness of fit χ2=4.272, P = 0.832Nagelkerke R2 =0.376Overall correct classification = 88.9%Correct classification of cases of poor self-rated health = 99.8%Correct classification of cases of good self-rated health =1.8%†Reference group 163
    • Table 6.5. Model summary of logistic regression analyses, 2002 and 2007Model (2002) Nagelkerke R SquareAge 0.143Age+urban area 0.145Age+urban area+consumption 0.148Age+urban area+consumption+social support 0.149Age+urban area+consumption+social support+ marital status 0.151Model (for 2007) Nagelkerke R SquareGood health 0.300Good health+age 0.354Good health+Age+fair health 0.362Good health+Age+fair health+consumption 0.371Good health+Age+fair health+consumption+urban area 0.376 164
    • Table 6.6: Expectation of Life at Birth by Sex, 1880-1991, JamaicansPeriod Average Expected Years of Life at Birth Male Female 0 e e01880-1882 37.02 39.801890-1892 36.74 38.301910-1912 39.04 41.411920-1922 35.89 38.201945-1947 51.25 54.581950-1952 55.73 58.891959-1961 62.65 66.631969-1970 66.70 70.201979-1981 69.03 72.371989-1991 69.97 72.641999-2001 70.94 75.582002-2004 71.26 77.07Sources: Demographic Statistics (1972-2007) [27, 28, 67]; Statistical Yearbook of Jamaica, 1999 [68].e0 is at birth 165
    • Figure 6.2. Mean age for males with particular self-reported diagnosed illness 166
    • Chapter7 Modelling social determinants of self-evaluated health of poor older people in a middle-income developing nationOver the last 2 decades (1988-2007), poverty in Jamaica has fallen by 67.5%, and this is withinthe context of a 194.7% increase in inflation for 2007 over 2006. It does not abate there, asJamaicans are reporting more health conditions in a 4-week period (15.5% in 2007) and at thesame time this corresponds to a decline in the percentage of people seeking medical care. Olderpeople’s health status is of increasing concern, given the high rates of prostate cancer,genitourinary disorders, hypertension, diabetes mellitus and the presence of risk factors such assmoking. Yet, there is a dearth of studies on the health status of older people in the two poorquintiles. This study examined (1) the health status of those elderly Jamaicans who were in thetwo poor quintiles, and (2) factors that are associated with their health status. A sample of 1,149elderly respondents, with an average age of 72.6 years (SD=8.7 years) were extracted from atotal survey of 25,018 Jamaicans. The initial survey sample was selected from a stratifiedprobability sampling frame of Jamaicans. An administered questionnaire was used to collect thedata. Descriptive statistics were used to examine background information on the sample, andstepwise logistic regression was used to ascertain the factors which are associated with healthstatus. The health status of older poor people was influenced by 6 factors, and those factorsaccounted for 26.6% of the variability in health status: Health insurance coverage (OR=13.90;95% CI: 7.98-24.19), age of respondents (OR=7.98; 95% CI: 1.02-1.06), and secondary leveleducation (OR=1.82; 95% CI: 1.35-2.45). Males are less likely to report good health statusthan females (OR=0.56; 95% CI: 0.42-0.75). Older people in Jamaica do not purchase healthinsurance coverage as a preventative measure but as a curative measure. Health insurancecoverage in this study does not indicate good health but is a proxy of poor health status. Thedemand of the health services in Jamaica in the future must be geared towards a particular agecohort and certain health conditions, and not only to the general population, as the socialdeterminants which give rise to inequities are not the same, even among the same age cohort. 167
    • 1. INTRODUCTIONFactors determining the poor health status of the elderly in Jamaica can be viewed from theperspective of a socio-medical dichotomy. Such factors include poverty (resulting in one’sinability to access loans, quality education and health care), lifestyle (e.g. smoking, sedentaryhabits, sexual and dietary practices and physical inactivity), resulting in prostate cancer,genitourinary disorders, hypertension, diabetes mellitus and premature death. In 2005, the WorldHealth Organization began a thrust in examining the social determinants of health, and despitethat reality there is a lack of literature in this regard on the elderly poor people in Jamaica. Theseparameters were explored in the current research by using a sample of 1,149 elderly poorJamaicans. The findings of this paper reveal that the cost of medical care is positively correlated withhealth conditions, and that economic constraints account for the decline in the elderly seekingmedical care. Older people in Jamaica do not purchase health insurance coverage as apreventative measure but as a curative measure. Health insurance coverage in this study does notindicate good health, but on the contrary, it is a proxy of poor health status. It is also noted thatincome is positively correlated with a higher standard of living and life expectancy. In support ofthis claim, studies have shown that life expectancy in many developing countries [1], inparticular the Caribbean (Barbados, Guadeloupe, Jamaica, Martinique, Trinidad and Tobago) hasexceeded 70 years, and they are now experiencing between 8-10% of their population living to60+ years old. Life expectancy, which is a good indicator of the health status of a populace, ishigher in countries with high GDP per capita. This means that income is able to purchase betterquality products [2], and indirectly affects the length of years lived by people. GDP per capita isused as an objective valuation of standard of living [3-12]. While a country’s GDP per capita 168
    • may be low, life expectancy is high because health care is free for the population. Despite thisfact, material living standards undoubtedly affect the health status and wellbeing of people, aswell as the level of females’ educational attainment [6] and the nutrition intake of the poor. Onthe other hand, when there is economic growth, the society has more to spend on nutrition, healthcare, better physical milieu, better quality food, safer sanitation and education. Good health is, therefore, linked to economic growth, something which is established in aplethora of studies by economists. Developing countries (a term synonymous with poverty) donot only constitute low levels of democracy, civil unrest, corruption [13], high mortality andcrude birth rates, but one must also include nutritional deficiency [14]. The WHO in 1998 putforward the position that 20% of the population in developing countries do not have access toenough food to meet their basic needs and provide vital nutrients for survival. In the Caribbean, and in particular Jamaica, poverty is typical, and many of the ills thataffect other developing nations outside of this region are the same. The poor in this society arefacing insurmountable challenges in buying the necessary health care. In 2007, between 51 and53% of those in the poor quintiles in Jamaica sought medical care, compared to 61-68 % of thosein the middle-to-wealthiest quintiles. When those who had reported that they were ill were askedwhy they had not sought medical care, 51% of those in the poorest quintile indicated that they‘could not afford it’, with 36.7% of those in the poor quintile giving the same response, and thepercentage declines as the wealth of the person increases to the wealthiest quintile (7.7% of thosein the wealthiest quintile). Over the last 2 decades (1988-2007), poverty in Jamaica has fallen by 67.5% and this isin the context of a 194.7% increase in inflation for 2007 over 2006. Jamaicans are reporting morehealth status in a 4-week period (15.5% in 2007) and at the same time this is associated with a 169
    • decline in the percentage of people seeking medical care. Older people’s health status is ofincreasing concern, given the high rates of prostate cancer, genitourinary disorders, hypertension,diabetes mellitus and the presence of risk factors such as smoking in earlier life. Yet, there is adearth of studies on the health status of older people in the two poor quintiles. Works which have examined the social determinants of health have used data for thepopulation [2,3], but none emerged from a literature research using data for poor old people. Thisstudy examined (1) the health status of those elderly Jamaicans who were in the two poorquintiles, and (2) factors that are associated with their health status.2. M ATERIALS AND M ETHODS2.1 SampleA sample of 1,149 elderly respondents was extracted from a larger survey of 25,018 Jamaicans.The sample was based on being 60+ years old, and being classified in the two poorest incomecategorizations. The initial survey sample (n = 25, 018) was across the 14 parishes, and wasconducted between June and October 2002. The sample (n=25,018 or 6,976 households out of aplanned 9,656 households) was drawn using a stratified random sampling technique. This designwas a two-stage stratified random sampling design, where there was a Primary Sampling Unit(PSU) and a selection of dwellings from the primary units. The PSU is an Enumeration District(ED), which constitutes of a minimum of 100 dwellings in rural areas and 150 in urban zones.An ED is an independent geographic unit that shares a common boundary. This means that thecountry was grouped into strata of equal size based on dwellings (EDs). Based on the PSUs, a 170
    • listing of all the dwellings was made, and this became the sampling frame from which a MasterSample of dwellings was compiled, and which provided the frame for the labour force. Thesurvey adopted was the same design as that of the labour force, and it was weighted to representthe population of the country. The survey was a joint collaboration between the Planning Institute of Jamaica and theStatistical Institute of Jamaica. The data were collected by a comprehensive administeredquestionnaire, which was primarily completed by heads of households for all householdmembers. The questionnaire was adapted from the World Bank’s Living StandardsMeasurement Study (LSMS) household surveys, and was modified by the Statistical Institute ofJamaica with a narrower focus, to reflect policy impacts as well. The instrument assessed: (i) thegeneral health of all household members; (ii) social welfare; (iii) housing quality; (iv) householdexpenditure and consumption; (v) poverty and coping strategies, (vi) crime and victimization,(vii) education, (viii) physical environment, (ix) anthropometrics measurement andimmunization data for all children 0-59 months old, (x) stock of durable goods, and (xi)demographic questions.Data were stored and retrieved in SPSS for Windows, version 16.0 (SPSS Inc; Chicago, IL,USA). The current study is explanatory in nature. Descriptive statistics were presented toprovide background information on the sampled population. Following the provision of theaforementioned demographic characteristics of the sub-sample, chi-square analyses were used totest the statistical association between some variables, t-test statistics and analysis of variance(i.e. ANOVA) were also used to examine the association between a metric dependent variableand either a dichotomous variable or non-dichotomous variable respectively. Logistic regressionwas used to examine the statistical association between a single dichotomous dependent variable 171
    • and a number of metric or other variables (Empirical Model). The logistic regression was usedbecause in order to test the association between a single dichotomous dependent variable and anumber of explanatory factors simultaneously, it was the best available technique. A p-value <0.05 (two-tailed) was selected to indicate statistical significance in this study. Where collinearityexisted (r > 0.7), variables were entered independently into the model to determine those thatshould be retained during the final model construction. To derive accurate tests of statisticalsignificance, SUDDAN statistical software was used (Research Triangle Institute, ResearchTriangle Park, NC), and this was adjusted for the survey’s complex sampling design.2.2 MeasureSocial determinants. These denote the conditions under which people are born, grow, live, workand age, including the health system.Crowding. This is the total number of persons living in a room with a particular household. , where is each person in the household and r is the number of roomsexcluding kitchen, bathroom and verandah.Age: This is a continuous variable in years, ranging from 15 to 99 years.Old/Aged/Elderly. An individual who has celebrated his/her 60th birthday or beyond.Negative Affective Psychological Condition: Number of responses from a person on having losta breadwinner and/or family member, loss of property, having been made redundant, failure tomeet household and other obligations.Private Health Insurance Coverage (or Health Insurance Coverage) proxy Health-SeekingBehaviour, is a dummy variable which speaks to 1 for self-reported ownership of private healthinsurance coverage, and 0 for not reporting ownership of private health insurance coverage.Gender: Gender is a social construct which speaks to the roles that males and females performin a society. This variable is a dummy variable, 1 if male and 0 if otherwise. 172
    • Health conditions: The report of having had an ailment, injury or illness in the last four weeks,which was the survey period. This variable is a binary measure, where 1=self-reported healthstatus or illnesses, and 0=otherwise (not reporting an illness, injured or dysfunctions).Poverty: In this study, the definition of poverty is the same as that used to estimate poverty inJamaica. It is established from the basis of a poverty line. In order to compute the per capitapoverty line in each geographical area (Kingston Metropolitan Area, Other Towns and RuralAreas), the cost of living for a basket of goods is divided by an average family of five. Thebasket of goods is established by the Ministry of Health based on the normal nutrients of theaverage family. Based on a per capita approach, there are five per capita income quintiles, withthe poorest being below the poverty line (quintile 1) and the wealthiest being in quintile 5.Elderly, Aged or Old persons. Using the same definition offered by the United Nations in theReport of the World Assembly on Ageing, July 26-August 6, 1982 in Vienna, that the elderly arepersons who are 60+ years old.Older-poor (elderly-poor, aged-poor). All aged persons below and just above the poverty line(quintiles 1 & 2) in Jamaica.3. RESULTS3.1 Demographic characteristics of sampleConsistent with the demographic characteristics of the ageing population, the sample was 1,149of which there were 45% males (N=517) compared to 55% females (N=632). The mean age ofthe sample was 72.6 years (SD=8.7 years). Most of the sample were married (40%, N=452),50.5% (N=580) of the sample were in the poorest 20% of per capita income quintile, 95%(N=1,087) were not receiving retirement income; those who were heads of households (98.3%, 173
    • N=1,129), those who had at most primary education (65.2%, N=700) and those who did not havehealth insurance coverage (86.0%, N=973) (Table 7.1 ). Thirty-seven percent (37.2%) of the sample indicated having had an illness in the last 4-week period. Approximately 64% of the respondents indicated that they sought health care fortheir health conditions. When the respondents were asked if they had visited a health practitionerfor any other reason during the last 12 months, 57.1% reported yes and 30.3% reported going for‘regular checkups’. Of those who indicated yes, 37.2% visited public health care institutions, and18.7% went to private clinics, compared to 5.7% who claimed that they attended both health carefacilities. The typologies of illness included colds (1.4%), diabetes mellitus (5.7%), hypertension(42.9%) and arthritis (31.4%), while 18.6% did not specify their health condition(s). Only 2% ofthe respondents had health insurance coverage; 61% purchased the prescribed medication; and81.8% of those who indicated having not bought their medication reported that they could notafford it. The median number of days for how long an illness lasted was 7 days, with a medianmedical expenditure of US $7.85 (US $1.00 = Ja. $50.97).3.2 Bivariate Correlation of Health Status and Age CohortOf the 1,149 sample respondents for this study, 98.8% (N=1,135) were used for the statisticalcorrelation between health status and gender. Of the 1,135 respondents, there were 688 young-old, 327 old-old and 120 oldest-old poor Jamaicans. There was a correlation between the twoabove-mentioned variables – χ2 (df=2) = 22.863, p-value < 0.001. On an average, 46% of theaged-poor (N=523) reported that they had at least one illness/injury in the survey period. Themost health status was reported by the oldest-old poor (59.2%, N=71), 52.9% (N=173) and theleast by the young-old (40.6%, N=279). Embedded in these findings is that for every 1 young- 174
    • old poor who indicated that he/she had an illness/injury, there are 1.5 oldest-old and 1.3 old-oldpoor.3.3 Multivariate AnalysisThe results of the multiple logistic regression model (in Table 7.2), were statistically significant[Model χ2 (df=18) = 229.47; -2Log likelihood = 1130.37; p-value < 0.001]. Table 7.2 showedthat 26.6% of the variances in the health status of older people in Jamaica were accounted for bythe independent variables used in the multiple logistic regressions. The mold revealed that therewere 6 statistically significant factors that determined health conditions. These predictors are age(OR=1.04, 95% CI=1.02-1.06), health insurance coverage (OR=13.90, 95% CI=7.98-24.19),physical environment (OR=1.42, 95% CI=1.06-1.89), cost of medical care (OR=1.00, 95%CI=1.00-1.00), secondary level education (OR=1.82, 95% CI=1.35-2.45) with reference toprimary and below education, and gender of respondents (OR=0.56, 95% CI=0.42-0.75).Controlling for the effect of other variables, the average likelihood of reporting illness/injury in a4-week reference period declined by 17 times for those who had dysfunctions. The model had statistically significant predictor power (Model χ2 (df=18) = 229.47; -Homer and Lemeshow goodness of fit χ2= 3.739, P=0.880), and correctly classified 70% of thesample (correctly classified 55.4% of those with dysfunctions and 82.3% of those withoutdysfunctions) (Table 7.2). The logistic regression model can be written as: Log (probability ofdysfunctions/probability of not reporting dysfunctions) = -4.185 + 0.039 (Age) + 2.632 (HealthInsurance coverage, 1= yes, 0=no) + 0.348 (Physical Environment, 1=yes, 0=no) + 0.000 (Costof Medical Care) + 0.598 (Secondary level education=1, 0=primary and below) – 0.581 (Sex). 175
    • 4. DISCUSSIONPeople are living longer [15], which means that on average the elderly are living 15-20 yearsafter retirement. Demographic ageing at the micro and macro levels implies a demand for certainservices such as geriatric care. In addition to preventative care, there will be a need for particularequipment and products (i.e. wheelchairs, walkers etc.). Then there are future preparations forpension and labour force changes, along with the social and economic costs associated withageing, as well as the policy based research to better plan for the reality of these age groups. TheWorld Health Organization (WHO), in explaining the ‘problems’ that are likely to occur becauseof population ageing, argues that the 21st Century will not be easy for policy makers as it ispivotal in the preparation process to postpone ailments and disabilities, and the challenge ofproviding a particular standard of health for the populace [16]. What constitutes populationageing? Some demographers have put forward the benchmark of 8-10% as an indicator ofpopulation ageing [17]. Within the construct of Gavrilov and Heuveline’s perspective, theJamaican population began experiencing this significant population ageing as of 1975 (using 60+years for ageing) or 2001 (if ageing is 65+ years). The issue of population ageing will doublecome 2050, irrespective of the chronological definition of ageing, but what about the elderlypoor health conditions? Let us examine the disparity between long life and quality of lived years. Ali, Christian &Chung [18] who are medical doctors, cite the case of a 74 year-old man who had epilepsy, andpresented the findings in the West Indian Medical Journal. They write that “Elderly patients arefrequently afflicted with paroxysmal impairments of consciousness, because they frequentlyhave chronic medical disorders such as diabetes mellitus and hypertension, and can also be on 176
    • many medications….Many elderly patients may have more than one cause for this symptom”[18]. The case presented by the medical doctors emphasizes the point we have been arguingthat long life does not imply quality of lived years. Although the case study cited here does notconstitute a general perspective on all the elderly, other quantitative studies have concurred withAli, Christian and Chung’s general findings. Scientists agree that biological ageing meansdegeneration of the human body, and such a reality means that longer life will not mean qualityyears. Population ageing is going to be a socioeconomic, psychological and political challengetoday, tomorrow and in the future of developing countries and nations like Jamaica. Thisreinforces the position postulated by the WHO that healthy life expectancy [19] is where weought to be going, as the new thrust is not living longer but how many of those years are livedwithout dysfunctions. Within the context of healthy life expectancy, studies that will be used toguide policy are those that incorporate many determinants, and not only biological conditions[20-25]. But none of those studies examined poor old people. Hambleton [20] and Bourne [23-25] are Caribbean scholars who have researched social determinants using the population of thepoor, and this gap to date in the literature needs to be addressed, as the elderly constitute avulnerable group, and the poor elderly group is even more vulnerable. Any policy which seeks toreduce poverty must take into account the poor elderly. ‘Ageing in poverty’ implies that persons remain in their local environments with theability to live in their own home - wherever that might be - for as long as confidently andcomfortably possible. It inherently includes not having to move from ones current residence inorder to secure the necessary support services in response to changing needs. The ageing ofCaribbean populations has been accompanied by a shift to chronic non-communicable diseases 177
    • as major causes of morbidity. While overall national trends have been reported, examination oflocal patterns of morbidity are increasingly important, as they have implications for the servicesto be provided, the mix of human resources, and the maintenance of health and functional statusthat facilitate ageing in place. Research has shown that crowding is strongly correlated with the wellbeing of the elderly(ages 60+ years) [23]; however this phenomenon, which is synonymous with poverty, does notinfluence the health status of poor elderly Jamaicans. Embedded in this finding is the fact thatolder people, in particular those in poor quintiles, interpret people around not as a negative forcebut as good social networking and interaction. What, then, influences their health conditions? Poverty speaks to a particular environment; Pacione [26] showed that one’s physicalenvironment affects one’s quality of life, and other scholars have agreed with this finding. Thecurrent study concurs with Pacione and others, in that the physical milieu is positively correlatedwith health conditions. Although Michael Pacione’s work was on the general population,Bourne’s works [23, 24] examined the elderly population (ages 60+ years) and found a negativeassociation between physical environment and wellbeing, and this study concurred with that ofthe aforementioned researcher on the correlation between physical environment and healthconditions. In this study, an important finding is to refine the correlation. Health insurance coverage is among the many indicators of the health-seeking behaviourof a populace. For the poor elderly, it is the most significant predictor of health conditions. Thecorrelation is a strong positive one, indicating that health insurance coverage is a good proxy formore ill-health than good health. The current research found that those elderly poor who ownedhealth insurance were 14 times more likely to report dysfunctions (or injuries) than those whodid not. Health insurance is, therefore, a cost reducer for those who are aware that they are ill, 178
    • and it is not in demand as a preventative measure. Arising from this fact is the role played by thecosts of medical and curative care. Health is influenced by more than disease-causing pathogens.[27] The cost of medical care is positively correlated with health conditions, suggesting thatthe more dysfunctions (or injuries) that the elderly poor report, the more they are likely to spendon medical care. The elderly poor are prevented from seeking preventative care as againstcurative care. The latest data published by the Planning Institute of Jamaica and the StatisticalInstitute of Jamaica[28] showed that 37.3% of elderly people are at least poor, with 20.6% fallingin the poorest quintile. This further explains the rationale for the reduction in the demand formedical care within the context of a precipitous increase in inflation in 2007 over 2006 (194%).With the steady rise in the cost of health care, as well as the increase in general food and non-alcoholic beverage prices in Jamaica, coupled with the fact that illness in older age requires care,the elderly poor are facing increasingly difficult times. The severity of the economic situationhas seen a dramatic increase in the number of Jamaicans not seeking medical care forillness/injury. Although there is a decline in the general population seeking medical care (66%),more of the elderly do seek health care (72.3%) and this is owing to recurrent chronic illnesswhich was shown to affect 74.2% of them28. Illnesses/injuries are precipitously affecting theelderly, and the data showed that self-reported illness for the elderly was 2.3 times more (36.6%)than in the general population (15.5%) [28]. In 2007, the elderly poor who constitute 38% of thepoor-to-poorest in the population are mostly household heads (67.3%) and often unemployed,and within this context they must provide for their own health needs and those of their family,despite the harsh economic challenges and increased cost of health care. 179
    • In 2002, 12.9% of Jamaicans were unable to afford medical care, and approximately 4years later, the figure had risen by 162.8% to 33.9% in 2007. This is within the context of a26.3% decline in poverty for the same period. Generally poverty has been falling over the last 2decades in Jamaica, and inflation has fluctuated, justifying the increased amount spent on foodand beverages [28], and the corresponding reduction in health care expenditure. In Jamaicaremittances, which subsidize income for many households, have fallen by 7.7% and thereduction is 33% for those in the poor-to-the-poorest income quintiles. If the cost of medical careis positively correlated with the health status of the elderly poor, then can it be said that the poorelderly have more ill-health within the context of biological ageing and lowered access toemployment income? Marmot [2] opined that there is a direct association between income andpoor health, and this further helps us to understand the embedded health challenge of the elderlypoor, as they must meet the increasing costs of medical care, cost of living, lower income,illnesses and severity of health conditions. On examining the health statistics for 2007 [28], theindication was that 50.8% of those in the poorest income quintile were unable to afford to seekmedical care, and the figure was 36.7% of those in the poor quintile. In order to understand theseverity of the situation regarding the aged-poor people in Jamaica, let us analyze theaforementioned within the context of the aged-poor. The official statistical publication forJamaica for 2007 [28] showed that 20.6% percent of the elderly people are in the poorest quintileand 17.7% in the poor quintile which means that a little over half of the aged-poorest in Jamaica(10.4%) were unable to afford medical care, and 6.5% of the aged-poor had financial difficultyaffording medical care expenditure. One of the choices that must be made by the aged-poor inJamaica is a switch from the formal medical care service to utilizing home remedies and over-the-counter medications, instead of visiting their personal physicians or health care facilities. 180
    • Since 1988 when the Jamaican authorities began collecting data on self-reported healthconditions, men have been reporting less health status than women [28]. The reporting of lessillness does not mean that men are healthier than women, as the same statistical report [28]shows that women seek more medical care than men. Morbidity data for the sexes in Jamaica istypical, as in Mexico City, Havana and Santiago-Chile at least 60% of females compared to 50%of males aged 60+ years old reported fair-to-poor health [29]. Continuing, Buenos Aires,Montevideo and Bridgetown-Barbados had twice the figures of the aforementioned geo-politicalzones [29]. This is in keeping with women’s protective role of self, and their willingness to havea regard for their future health status accounts for a higher health status and not a lower one,although they report more dysfunctions than men. If life expectancy were to be used to proxygood health status, females are healthier than men given that they outlive them by 6 years inJamaica and 8 years in the world. Furthermore, in 2000-2005, life expectancy for men was 69.5years and 74.7 years for women, and come 2045-2050 they both would have gained an additional2 and one-quarter years more to their life span. The equal and constant rate of change in the lifeexpectancy of both sexes in Jamaica highlights the fact that men do not enjoy better overallhealth status than their female counterparts. More years of life for both sexes means that the lifecourse opens itself to coronary heart disease, stroke and diabetes mellitus, and so morbidity mustbe examined in this discourse. Studies done by the Ministry of Health reveal that of the five leading causes of mortalityin Jamaica, which are malignant neoplasm, heart disease, diabetes mellitus, homicide andcerebrovascular diseases [30], more men die from more of the aforementioned conditions thanwomen. Malignant neoplasms are 39% greater for men than women; cerebrovascular diseasesare 14% higher for females than males; heart disease was 71.2 per 100, 000 for men and 66.1 per 181
    • 100,000 for women; and diabetes mellitus was 64% more for females than males [30]. Thegreater vulnerability of men to particular mortality than women is typical across Latin Americaand the Caribbean [29], pointing to gender bias (that is feminization) in visits to health carefacilities, which are embedded in the life expectancy rates and visits to health care institutions.The matter of reporting less health status, once again, does not imply a healthier person, as healthis not on a continuum, with ill-health on one extreme and good health on the other. Health ismore in keeping with cyclical flow, and changes over the life course with time, experiences andsocio-physical environmental conditions. Hence, asking about ill-health is not a good proxy forhealth status, as in 2007 a group of Caribbean scholars conducted a national representativeprevalence survey of some 1,338 Jamaicans, and found that those who indicated themselves to beof the lower class had the least self-reported health status [13]. The discipline of gerontology – scientific inquiry into the biological, psychological, andsocial aspects of ageing - has shown that ageing is not necessarily without increased healthconditions; it is natural for aged people to complain and die more of dysfunctions than other agecohorts [31, 32] and that is directly related to their basal metabolic rate [33] and the nature of thelife course of the aged [34]. Here functional ageing is an explanation for the image of ageing,and it can be measured by normal physical changes, diminished short-term memory, reducedskin elasticity and a decline in aerobic capacity. It is well established in the research literaturethat age is directly correlated with health status for the elderly, and in this study the findingconcurs with the literature. The current research shows that age is the second most significantpredictor of health status for the elderly poor, and explains why the disparity in poor health inLatin and America and the Caribbean is higher for older persons than younger people [29].Population ageing is synonymous with more disability and more non-communicable diseases 182
    • such as malignant neoplasms, hypertension, diabetes, and heart diseases than younger ages.Donald Bogue [35] noted that health problems increase with ageing, and that one’s health issuesintensify with ageing. Therefore, an unhealthy lifestyle – tobacco consumption, physicalinactivity, unprotected sex, and unhealthy diet - over the life course will affect the elderly inlatter life, and the declining health of the elderly poor is the same within the sub-categories of theelderly – young-old, old-old and oldest old. Issues of the elderly cannot be discussed without an examination of area of residence.This study found no correlation between the aged-poor’s health status and area of residence.Using data since 1989 (from various issues of the Jamaica Survey of Living Conditions),population ageing is biased by gender as well as by specific area of residence. Over the lastdecade (1997-2007), the number of elderly Jamaicans living in rural areas has declined from54.3% to 46.6% (a rate of 14.1%). For the same period, the rate of increase of the aged populacein the Kingston Metropolitan Area (100% cities) was 19.5%, down from 27.2% (in 1997) whilethe increase in the aged population over the same period in Other Towns was 12.9% over 18.5%in 1997. Regarding the prevalence of poverty for the region (2007), rural poverty was 3.8 timesmore than that in Other Towns, and 2.5 times more than that in the Kingston Metropolitan Area.Despite the compounding economic challenges of poverty coupled with ageing, the poor-elderlyin Jamaica do not experience a difference in their health status owing to area of residence. Herethe health issues of the aged poor are independent of their area of residence, suggesting that inthe population the poor are age-residence insensitive. This contradicts research literature on thehealth status of the elderly which has shown a correlation between the aged and their areas ofresidence [23,24,48], indicating that the physical characteristics of the aged poor are the same in 183
    • different areas of residence, and therefore do not account for any poor health, disability,functional inability or psychological conditions. Like the WHO [36], the researcher believes that although ageing is a biologicalphenomenon, it cannot be due only to biological conditions, as ageing relates to bio-psycho-social [20, 25, 37-49] and environmental conditions [23-26], since people – biological organisms– must operate in a socio-physical milieu throughout their life span, and this demands anexpansion of biological conditions in the ageing discourse. The very nature of gerontology mustcoalesce biopsychosocial and environmental conditions in assessing ageing and the health of theaged, which are in keeping with the WHO’s Constitution of 1948, and this has also beenestablished in many Caribbean scholarships [20,23-25,42-49]. Within the context of the above-mentioned challenges for elderly people, when this is coupled with poverty which affects 10.2%of elderly Jamaicans (N=29,794) in 2007, it intensifies the challenges experienced by elderlypeople. With the increased cost of food and non-alcoholic beverages, fuel and householdsupplies, housing and household operational expenses, the health status of the older-poor willcontinue to deteriorate, as they will not be able to afford health care services. The decline inmedical care-seeking behaviour of Jamaicans speaks to the challenges of older people and therise in instances of switching to alternative medicine. This is further intensified by poverty; andrural poverty, which is more severe than that found in urban areas [50], will further compoundthe challenges of the health status of the aged populace. Older people who are poor must operatewithin the same biopsychosocial and physical environment during their lifetimes as otherpersons. Even among the WHO commissioned studies [51-53], as well as other studies on thesocial determinants of health [2,3, 20-25], the population of the poor elderly were not examined. 184
    • Likewise in the Caribbean, scholars have examined the social determinants of the population orthe elderly population, with poverty being an independent variable [20, 23-25]. Any policy thatseeks to address the health status of the elderly poor must take into consideration, or concentrateand/or rely on, not only the population in general, but the cohort of the elderly in particular. Theexperiences and demands of the elderly are not the same as the general population, and thecurrent study shows that social determinants of health are somewhat different for the generalelderly population and the poor elderly cohort. The WHO [51] opined that the socialdeterminants of health for the most part account for the health inequities between and withinnations, which substantiates the differences that emerged between the elderly in other studies[20, 23-24] and the current study of the poor elderly. These findings are far-reaching, and can beused to guide policy and research. The elderly-poor in Jamaica are experiencing ‘health poverty’which cannot be alleviated by unresearched policies or research policies on the generalpopulation, but by the elderly cohorts in particular.5. Conclusion In summary, the number of elderly persons who reported health conditions in Jamaica is3 times more than that for the nation (i.e. 12.6%), suggesting that health care expenditure forJamaicans is substantially used to address health care needs for the aged population. With thenumber of elderly come 2025 estimated to be 14.5% over 10.9% for 2007, health careexpenditure will be primarily absorbed in caring for this age cohort. Public health practitionersmust begin programmes to deal with this pending reality. Ageing is a process which denotes thatthe high number of health conditions affecting the elderly would have started earlier, based onsome of the decisions that they undertook (or did not) leading up to their current age. Hence,there is a need to have a public health campaign geared towards the promotion of healthy 185
    • lifestyle practices for ages close to sixty years, in conjunction with one for children and for theworking-age population. The programme should target check-ups, preventative care, signs of theonset of particular health conditions, and the distinction between ill health and good health carepractices. The demand of the health services in Jamaica in the future must be geared towards aparticular age cohort and certain health conditions, and not only to the general population, as thesocial determinants which give rise to inequities are not the same even among the same agecohort.6. DisclosureThe author reports no conflict of interest for this study.7. DisclaimerThe researcher would like to note that while this study used secondary data from the JamaicaSurvey of Living Conditions, none of the errors in this paper should be ascribed to the PlanningInstitute of Jamaica or the Statistical Institute of Jamaica, but to the researcher.8. AcknowledgementThe dataset for this study was made available from the databank of SALISES (Sir Arthur LewisEconomic Institute), Faculty of Social Sciences, the University of the West Indies, Mona,Jamaica and for this the researcher is indebted and greater appreciate this gesture. 186
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    • Table 7.1: Socio-demographic characteristics of sampleDescription N PercentGender Male 517 45.0 Female 632 55.0Marital status Married 452 40.0 Never married 357 31.6 Divorced 10 0.9 Separated 22 1.9 Widowed 290 25.6Per capita Income quintile Poorest 580 50.5 Poor 569 49.5Retirement Income No 1087 95.0 Yes 57 5.0Household head No 20 1.7 Yes 1129 98.3Health Insurance coverage No 973 86.0 Yes 158 14.0Educational LevelPrimary and below 700 65.2Secondary 363 33.8Tertiary 10 0.9Age 72.63 years (SD=8.7 years)Total Medical Care Expenditure $1,067.64 (SD=$2,000.00)Per capita consumption $30,998.07 (SD=$9,833.00)US $1.00 = JA$50.97 190
    • Table 7.2: Logistic Regression: Socio-demographic correlates of health status of poor olderpeople in Jamaica, N=1,033 OR 95.0% C.I. Variable Age 1.04 1.02 - 1.06*** Retirement income 0.75 0.38 - 1.49 Per capita consumption 1.00 1.00 - 1.02 Separated, divorced or widowed 1.07 0.74 - 1.55 Married 1.11 0.77 - 1.58 Never married (reference group) 1.00 Health insurance 13.90 7.98 - 24.19*** Environment 1.42 1.06 - 1.89* Household head 3.34 0.37 - 30.01 Cost of medical care 1.00 1.00 - 1.05** Secondary 1.82 1.35 - 2.45*** Tertiary 0.43 0.07 - 2.63 Primary and below (reference group) 1.00 Semi-urban 0.78 0.51 - 1.19 Urban areas 0.86 0.50 - 1.49 Rural areas (reference group) 1.00 Sex 0.56 0.42 - .75*** Living arrangement 1.20 0.77 - 1.88 Crowding 0.89 0.78 - 1.02 Crime index 1.00 0.98 - 1.03 Positive affective 0.96 0.90 - 1.01Model Chi-square (df =18) = 229.47, p-value < 0.0001-2Log likelihood = 1130.37;Nagelkerke R-square = 0.266Hosmer and Lemeshow test P = 0.880*P < 0.05, **P < 0.01, ***P < 0.001 191
    • Chapter8 Ill-males in an English-Speaking Caribbean Society Paul A. Bourne, Christopher A.D. Charles, Donovan A. McGrowderPrevious studies which have examined men’s health have used a piecemeal approach in theinvestigation of health, illness, health care utilization, psychological conditions, crime andvictimization. The present study seeks to elucidate information on crime and victimization,health conditions (acute and chronic), health-seeking behaviour, health care utilization,medication compliance, health insurance coverage of males who are ill, and an inquiry was ofthe typology of illness by particular demographic characteristics. Models were used to evaluatefactors which account for health insurance coverage and health care seeking behaviour. Socio-demographics, health conditions, health-seeking behaviour, crowding, crime and psychologicalconditions were obtained from the 2002 Jamaica Survey of Living Conditions Survey, a nationalprobability cross-sectional survey. Only self-reported ill males were included in the presentanalysis (n = 1,217 respondents). Multivariate models were used to analyze the associationsbetween (1) health-seeking behaviour and socio-demographics, crime, psychological and healthfactors and (2) health insurance coverage and socio-demographics, and psychological factors.The prevalence rate of ill males in Jamaica was 99 per 1,000 males. Thirty-four out of every 100ill males were 60 years and older; and 44 out of every 100 ill males were in the upper incomegroup compared with 37 per 100 in the lower class. There was a statistical association betweenarea of residence, and age cohort (χ2 = 47.343, P < 0.0001); health insurance coverage (χ2 =42.462, P < 0.0001); marital status (χ2 = 21.147, P = 0.007); socioeconomic strata (χ2 = 192
    • 48.145, P < 0.0001) and age in years (F = 19.935, P < 0.0001.The findings are far-reachingand can be used to improve the health and quality of life of Jamaican males.IntroductionJamaica, like many developing and developed nations, continues to grapple with healthdisparities within the nation and among socio-economic groups and areas of residence [1, 2].Previous studies found that differences in health outcomes continue unabated despitegovernment’s investment in health and the health care system [1, 2, 3]. Health disparities exist inthose societies between genders [4, 5], and it is found that mens health is poor compared towomens, according to a range of measures and variations across ethnicity and socio-economicclasses [6]. Men are more likely than women to be mentally ill and they are at greater risk ofheart disease and stroke. Men in routine and manual jobs are more likely to smoke and havechronic health problems than other men, and the diagnoses of both prostate and testicular cancerhave increased since the early 1990s [6]. In terms of accessing and utilizing health services, menare slower to notice signs of illness, and when they do, they are less likely to consult their doctor[7, 8]. Men in Jamaica have not fully accessed and utilized the health care services provided bythe government [9]. Health care in Jamaica is free to all citizens and legal residents atgovernment hospitals and clinics. The health system offers primary, secondary, and tertiary care.Ambulatory care at the community level is delivered through a network of 343 health centres.Secondary and tertiary care is offered via 23 government hospitals and the teaching hospital ofthe University of the West Indies, with a combined capacity of 4,802 beds [10]. Hospitals areclassed as A, B, C, or Specialist, depending on the level of complexity of the services offered. 193
    • There are three Type A hospitals, all located in large urban areas and providing the mostspecialized services. The four Type B hospitals, like the Type A hospitals, are mostly situated inurban areas. They provide inpatient and outpatient services and support referrals from Type Cfacilities (found in rural areas), of which there are currently 11 in the country. There arepresently four specialist hospitals [10]. Approximately 38% of the population utilizes the publicsector for ambulatory care, 57% use the private sector, and 5% use both sectors. Private sectorhealth services are provided through an extensive network of professionals offering specialistservices, and by family doctors throughout the island. Several non-governmental organizationsprovide health services for a nominal fee [11]. Gender comparative studies reveal that men are less likely to go to the doctor for physicaland mental health problems and to have a customary place of healthcare [12, 13]. According toStakelum and Boland, the main reasons for men being reactive, rather than proactive, in themaintenance and promotion of their own health, includes a lack of awareness as to when theyshould attend for screening, due to the absence of a preventative healthcare ethos in the currentdelivery of general practice; men are not socialized into the health culture from an early age, andare therefore less likely to develop the confidence needed to seek preventative help; also, menare less likely to interpret their symptoms as arising from physical conditions, which may be aform of denial bound up in what men regularly refer to as the ‘macho principle’ [14]. In a studyby Figueroa et al. significantly more men (86/463 or 18.6%) than women (40/927 or 4.3%), (p <0.0001) reported that they had never had their blood pressure taken by a health professional [9]. Previous works on crime in the Caribbean [15, 16] have not examined crime along withthe psychological state of individuals, their health, health care-seeking behaviour and othervariables. Generally, scholars concurred with each other’s findings that the majority of crimes 194
    • are perpetuated by and against young males, yet the discussion has never been broadened toinclude their health and health care. Outside of Latin America and the Caribbean, studies whichhave been conducted on crime and victimization, health, psychological conditions and healthcare-seeking behaviour among men have used an unsystematic approach to the examination ofthe various phenomena [17-19]. Likewise, investigations on health care-seeking behaviour [20-22] have used the same unsystematic approach as those on crime, so there are gaps in theliterature. The gap in health literature therefore denotes that public health in Latin America andthe Caribbean, and in particular Jamaica, does not have empirical data on crime, health, health-seeking behaviour and the psychological affective state of the males, as well as health conditions,socio-economic strata, area of residence and their associations in order to guide policyformulation. With 49% of Jamaica’s population being males (1,321,646 in 2007; 1,289,898 in 2002),failing to examine their health from a broad perspective means that we are neglecting a segmentof the population which can provide pertinent information in order to address many of the socialills in the society. If public health seeks to address the health of the population, it also holds truefor a sub-population which accounts for almost 50% of the people in a particular geopoliticalspace. Despite the voluminous studies conducted over the years on health, literature is lacking inthe Latin American and Caribbean region on men’s health, in particular regarding health status,health care-seeking behaviour, psychological conditions, and crime and victimization in a singlepiece of research. Therefore, based on the afore-mentioned concerns, this study, using cross-sectionalsurvey data for 2002 on ill Jamaicans males, evaluated how health conditions, health-seekingbehaviour, crime, negative and positive affective psychological conditions, health careutilization, health insurance coverage and other demographic variables have an impact on the 195
    • health status of males who are ill. This was done using models to evaluate these factors in orderto shed some light on these aspects, and increase our awareness and understanding of the issuesthat affect the health and quality of life of Jamaican males. The present study seeks to elucidateinformation on crime and victimization, health conditions (acute and chronic illness), health-seeking behaviour, health care utilization, medication compliance, health insurance coverage ofmales who are ill, and an inquiry was of the typology of illness by particular demographiccharacteristics. Models were used to evaluate factors which account for health insurancecoverage and health care seeking behaviour.MethodsDataDemographic and socio-economic data, as well as data on health conditions, health-seekingbehaviour, crowding, crime and psychological conditions, among other variables, were obtainedfrom the 2002 Jamaica Survey of Living Conditions (JSLC) Survey, [23]. This is a nationalrepresentative probability survey which has been conducted yearly since 1988, and is amodification of the World Bank’s Living Standard Household Survey [24]. The sample for the2002 JSLC Survey was 25,018 respondents (49.3% males, n = 12,332). The JSLC is a cross-sectional survey which used stratified random sampling techniques to draw the sample. It is anational probability survey, and data was collected across the 14 parishes of the island. Thedesign for the JSLC was a two-stage stratified random sampling design where there was aPrimary Sampling Unit (PSU) and a selection of dwellings from the primary units. The PSU isan Enumeration District (ED), which constitutes a minimum of 100 residences in rural areas and150 in urban areas. An ED is an independent geographic unit that shares a common boundary.This means that the country was grouped into strata of equal size based on dwellings (EDs).Based on the PSUs, a listing of all the dwellings was made, and this became the sampling frame 196
    • from which a Master Sample of dwellings was compiled. The present work extracted only ill(sick) males (n = 1,217 respondents) to constitute the study population from the 2002 JSLC. TheJSLC Survey involved the administration of a questionnaire where respondents were asked torecall detailed information on particular activities. The data was weighted to reflect thepopulation of Jamaica, and the non-response rate the initial survey (2002 JSLC) was 27.7% [25].Since 1989, the Planning Institute of Jamaica and the Statistical Institute of Jamaica have beencollecting data on the health status of Jamaicans (JSLC), and the JSLC revealed that whilepeople will declare that they have an illness, the response rate for the typology of healthconditions is low [25]. This is even lower among males than females [25], which mean that forthis research we will examine the typology of illness based on the response rate in order tounderstand those whom response. Thus, we examine variables that have missing cases, usingreplacing missing values and compare the replaced cases with those of the actual response inorder to determine whether there are differences between the two results. The findings revealedno difference between the actual responses and the replaced missing cases, meaning that there isno need to adjust for missing cases. However, based on the high non-response for typology ofillness, this variable was omitted from the multiple regression analyses as it would substantiallyreduce the sample size of the dependent variables.Analytic ModelThe use of econometric analyses (multiple logistic regressions) is well established in healthliterature as applicable for the examination of many variables single dependent variable [21].Bourne [21] modeled social determinants of health and healthcare seeking behaviour ofJamaicans. Thus, the theoretical models have been established in health literature that a singlemethod can be allowed for the testing of many possible variables which account on health status, 197
    • or health care seeking behaviour. Bourne [21], using logistic regression analyses, found that ageof respondents, area of residence, logged consumption (proxy of income), social class andmarital status were factors of health care seeking behaviour. The current work modified Bourne’smodel [21] by introducing a number of other possible variables such as psychological conditions(negative affective and positive affective conditions), crowding, and crime. Like modelingfactors for health care seeking behaviour, studies have shown that this is equally valid inexamining health insurance coverage (or ownership) [26,27]. This research will use the samelogistic dependent variable (health insurance coverage, 1= yes, 0 = otherwise) like the literature[26,27] to inquire about those factors which account for health insurance coverage among ill menin Jamaica.StatisticsStatistical analyses were performed using the Statistical Packages for the Social Sciences v 16.0(SPSS Inc; Chicago, IL, USA) for Windows. Descriptive statistics such as mean, standarddeviation (SD), frequency and percentage were used to analyze the socio-demographiccharacteristics of the sample. Chi-square was used to examine the association between non-metric variables, and Analysis of Variance (ANOVA) and t-tests were used to test therelationships between metric and/or non-dichotomous categorical or dichotomous variables.Pearson’s Product Moment Correlation (r) tested associations between two metric variables.Logistic regression examined the relationship between the dependent variable and somepredisposed independent (explanatory) variables, because the dependent variable was a binaryone (self-reported health status: 1 if reported good health status and 0 if poor health). A P valueless than 0.05 was used to establish statistical associations between variables. The final model 198
    • was based on those variables that were statistically significant (P < 0.05), and all other variableswere removed from it. (P > 0.05). Categorical variables were coded using the ‘dummy coding’scheme. Where collinearity existed (r > 0.7), variables were entered independently into themodel to determine those that should be retained during the final model construction. To deriveaccurate tests of statistical significance, we used SUDDAN statistical software (ResearchTriangle Institute, Research Triangle Park, NC), and this was adjusted for the survey’s complexsampling design. In this study, missing data were noted and analyzed in order to examine theiractual respondents. It was noted that the characteristics of the missing data were the same asresponses, and so missing data were omitted and not stipulated in the current work because oftheir similarity to the valid responses.MeasurementA detailed description of the variables used in this study (crowding; social hierarchy; health-seeking behaviour; self-reported illness; age cohort; psychological conditions [26,27], and crime)can be found in the Annex.ResultsThere was a low response level to questions related to illness and the purchasing of medication,and a moderate response rate on health care utilization (Table 8.1). The total dependency ratiowas 193 per 100 of the working age population (old age dependency ratio was 101, and childdependency ratio was 92). The mean age of those in the sample with primary education or belowwas 68.7 years (SD = 12.5); secondary, 48.5 years (SD = 20.7) and tertiary, 41.5 years (SD =15.3; F = 129.4, P < 0.0001]. None of the tertiary level ill males reported a chronic condition. 199
    • However, 65.3% of those who indicated being diagnosed with a chronic illness had at mostprimary level education.Of those with chronic illness, 75.3% had visited a health care practitioner in the last four weeksand 66.2% dwelled in rural areas. The average number of crimes experienced by the sample was2.2 (SD = 8.1, maximum = 88), and average number of persons per room (i.e. crowding) was 1.7(SD = 1.3, maximum = 11). There were significant statistical relationships between crime andcrowding (r = 0.82, P = 0.004). Furthermore, a significant statistical difference was foundamong social hierarchy and crowding (F = 99.559, P < 0.0001). Crowding in lower socio-economic households was 2.3 persons (SD = 1.5) compared to 1.9 persons (SD = 1.3) in middlesocio-economic households and 1.2 persons (SD = 0.8) in upper class households. Furthermore,a negative correlation was found between crime and age of respondents (r = - 0.084, P = 0.003).However, no significant difference in crowding was found among areas of residence (F = 1.383,P = 0.251). In addition, no statistical relationship existed between: (i) crime and negativeaffective conditions (P = 0.575), and (ii) crime and positive affective conditions (P = 0.063). Themean negative psychological condition was 5.0 (SD = 3.3, maximum = 17) and positivepsychological condition was 3.0 (SD = 2.6, maximum = 6). A significant association existedbetween negative and positive affective conditions, with there being a weak association (r = -0.245, P < 0.0001). There was no significant statistical difference among (i) those with typology of illness(i.e. acute and chronic conditions) and negative affective psychological conditions (t = 1.103, P= 0.290), and (ii) typology of illness and positive affective conditions (t = - 0.376, P = 0.742).There was a significant relationship between age in years and typology of illness (acute andchronic) (χ2 = 48.52, P < 0.0001), and age cohort and typology of illness (t = -7.951, P < 0.0001; 200
    • Table 8.2). There was a statistical association between area of residence, and age cohort (χ2 =47.343, P < 0.0001); health insurance coverage (χ2 = 42.462, P < 0.0001); marital status (χ2 =21.147, P = 0.007); socio-economic strata (χ2 = 48.145, P < 0.0001) and age in years (F =19.935, P < 0.0001; Table 8.3). There was a statistical association between the mean crimes andvictimization index, and area of residence (F = 7.502, P = 0.001); age cohort (F = 3.209, P =0.007); and marital status (F = 2.684, P = 0.030; Table 8.5). A significant statistical association existed between age cohort and typology of illness (χ2= 73.586, P < 0.001) in Table 8.5. Concurring with this, the findings revealed that chronic illnessis substantially an age phenomenon compared to acute health conditions. The use of Analysis ofVariance for further examination of the health conditions by mean age of respondents (F =15.620, P < 0.0001) provided more information than chi-square analysis. The mean age ofrespondents with diarrhoea was 22.2 years (SD = 36.4); asthma, 14.7 years (SD = 24.2); diabetesmellitus, 63.3 years (SD = 13.5); hypertension, 70.2 years (SD = 8.6); arthritis, 72.6 years (9.2)and other chronic conditions, 55.8 years (SD = 28.8).There was a statistical difference between the mean age of the sample in relation to marital status(F = 104.13, P < 0.0001). The mean age of a married respondent was 64.1 years (SD = 14.7);never married, 42.3 years (SD = 20.5); separated, 65.7 years (SD = 7.5); divorced, 69.0 years(SD = 7.5) and widowed ill males, 74.6 years (SD = 10.4). Further examination revealed thatthere was no statistical difference between the mean ages of married, separated and divorcedrespondents who were ill (P > 0.05). The mean age of those with chronic health conditions was66.8 years (SD = 17.3) compared to 18.1 years (SD = 29.0) for those with acute health conditions(t = - 7.950, P < 0.0001). 201
    • In this study the prevalence of ill males in Jamaica was 99 per 1,000 males, and 49 per1,000 Jamaicans in the general population. Concurring with this, the findings revealed that 43out of every 100 rural males are poor (22 are in the poorest 20%) compared to 24 per 100 ofsemi-urban males (9 are in the poorest 20%) and 26 per 100 of those in urban areas; 34 per 100ill males were 60 years and older; 44 per 100 ill males were in the upper income group (25 in thewealthiest 20%) compared with 37 per 100 in the lower class (18 in the poorest 20%); half of thesample used public health facilities; 61 per 100 sought medical care in the last 4-week period;47% completed taking their medication; and 7.2% responded to the typology of illness. Of thosewho stated a particular illness, the majority had hypertension (44% or a prevalence of 32 per1,000 ill males). Almost 88% of those who stated an illness indicated a diagnosed chroniccondition (prevalence rate of 63 per 1,000 ill males), and 46% of those with chronic conditionswere in the upper class (prevalence rate of 29 per 1,000 ill males) and 31% in the lower incomestrata (20 per 1,000 ill males). The chronic health condition prevalence rate among married illmales was the greatest (35 per 1,000 ill males) followed by never-married ill males (18 per 1000ill males). Crime and victimization against ill males was very low (mean number of occurrenceswas 2.2 ± 8.1, maximum occurrences = 88). However, it was substantially an urban as well as ayoung male phenomenon. In addition, crowding was mostly a lower income group issue, and itwas positively correlated with crime. The health-seeking behaviour of ill males in Jamaica is determined by their age, theirclass status and being married (Table 8.6). The four variables that were significantly related tohealth insurance coverage of ill males in Jamaica were health care facilities, being married,residing in an urban area and attaining tertiary education (Table 8.7). 202
    • DiscussionThe present study concurs with the literature that crime is substantially perpetuated againstyoung urban males [15-16]. According to some authors [17, 28] crime and victimization affecthealth care service utilization and demand for care, but this study showed that it has a lowprevalence among ill males, making its public health cost still a challenge for our society.Furthermore, this study revealed that half of the ill males utilize public health care facilities,indicating that crime and victimization are costly for the state, but more importantly our countryis losing younger males in their working and productive years, which in the future will burdenthe working age population. Smith and Kington [29] stated that money buys health, which suggests that males in thelower socio-economic strata could have more illness than those in the upper income group.According to Marmot [30], material deprivation accounts for dietary and nutritional deficiencies,poor physical milieu and inadequate sanitation, which erodes the physical health of theindividual. Van et al. [31] found that persons living in poverty in the Netherlands were morelikely to suffer from chronic illness compared with those in the upper income strata. Conversely,this study showed that ill males in the upper income group experienced more chronic illnesscompared with those in the lower socio-economic group. These findings are not in accordancewith those of Van et al [31], and worked out by the World Health Organization. The WHO [32]found 80% of chronic illnesses in persons living in low and middle income countries. Howeverin Jamaica, a middle income country, ill males in the upper class reported 1.2 times more chronichealth conditions. Another key finding resulting from the research is that two-thirds of the illmen in this study were in the dependent age population (children, 32%; elderly, 34%). 203
    • Interestingly, children did not report hypertension, diabetes mellitus or arthritis, but they hadunspecified chronic illnesses such as asthma. From the findings in the study it is evident that money cannot buy health for ill males inJamaica; however the lack of it does limit their access to health care. The study also showed thatjust over a quarter of the ill males who were prescribed medications by medical practitionerswere unable to fill the entire prescription primarily due to a lack of money (57%). Furthermore,forty-three percent of ill males residi