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Health Insurance and Health

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Health Insurance and Health

  1. 1. Health Insurance & Health Jamaica: 2009 2. Per cent of Each Sex 70.00 Male Female 65.00 70-74 60-64Seeking Medical Care 60.00 50-54 55.00 40-44 30-34 50.00 R Sq Quadratic =0.751 20-24 45.00 10-14 8.00 10.00 12.00 14.00 16.00 18.00 20.00 Health Insurance 0-4 12 10 10 12 8 2 6 4 0 0 2 4 6 8 Per cent Paul Andrew Bourne
  2. 2. Health Insurance & Health  i  
  3. 3. Health Insurance & Health      Paul Andrew Bourne Director  Socio‐Medical Research Institute    ii  
  4. 4. ©Paul A. Bourne, 2011 First Published in Jamaica, 2011 by Paul Andrew Bourne 66 Long Wall Drive Stony Hill, Kingston 9, St. Andrew   National Library of Jamaica Cataloguing Data   Health Insurance & Health   Includes index  ISBN  Bourne, Paul Andrew   All rights reserved. Published, 2011  Cover designed by Paul Andrew Bourne  iii  
  5. 5. PrefaceThe population of Jamaica was estimates to be 2,698,810 people (end of year, 2009), with about49.3% males (sex ratio = 97.1) and 11% in the older age adulthood category (60+ years old).There are two features about the Jamaican population that must be noted here 1) the feminizationat older ages and 2) a high rate of growth at older ages (80+ years) compared to other agecohorts. There is evidence that showed that there is a strong statistical correlation betweenpeople ‘seeking medical care’ and ‘health insurance coverage’ in Jamaica. However, therelationship between the two aforementioned variables is curvilinear one as people will seekmore medical care with the ownership of more health insurance coverage, and this will fall aftermore than 18% of Jamaicans purchasing health insurance coverage. Despite the fact that there isdirect association between health insurance and health care seeking behaviour, in 2007, only21.2% of Jamaicans were holders of health insurance coverage (572,148 Jamaicans). With only 21 out of every 100 Jamaica being holders of health insurance in 2007, thisspeaks to the high cost of individual health coverage and it justifies the public health careutilization in this country and the switching from the public health care to the private health careutilization with increased income and wealth (socioeconomic status). This volumecomprehensively examines health insurance and health among Jamaicans, using survey data for2002 and 2007. Health Insurance and Health is but the commencement of those phenomena, and I hopethat this will foster more discussion in the future as well as guide research. Paul Andrew Bourne Director Socio-Medical Research Institute March 2011 iv  
  6. 6. AcknowledgementThe writing of a book is a time consuming and a tedious process, which is assisted by manypeople. A book is not a singulate effort and this must be recognized by the author(s), editor(s)and/or publisher(s). Like many other authors, I am indebted to many people who contributed indifferent ways to the completion of this book. These individuals are 1) Mrs. Evadney Bourne, 2)Kimani Bourne, 3) Kerron Bourne, 4) Paul Andrew Bourne, Jnr, who stayed up with me oncountless nights, and longer on Saturdays and Sundays. Ms. Neva South-Bourne, whose tirelessefforts and endless patience in proofreading some of the chapters as well as Mrs. CindiScholefield. I am also indebted to the Derek Gordon Databank, University of the West Indies,Mona (Jamaica) that made the dataset available from which many of the chapters emerged. Themajority of the chapters are published works in different journals, and I am grateful for theirpermission to use the materials in this book (North American Journal of Medical Sciences,Health, Current Research Journal in Social Sciences, International Journal of CollaborativeResearch on Internal Medicine and Public Health, HealthMed Journal, and Journal of Clinicaland Diagnostic Research; Journal of Applied Sciences Research). Finally, I would like to thankall my co-authored who wrote different articles with me. Any errors of omission or commissionin this book should not be ascribed to anyone or organizations as these are of the author. v  
  7. 7. Table of Contents  Preface ivAcknowledgement vChapter 1  1 Health  insurance  coverage  in  Jamaica:  Multivariate  analyses  using  two  cross‐sectional  survey data for 2002 and 2007   Chapter 2  31 Disparities  in  self‐rated  health,  health  care  utilization,  illness,  chronic  illness  and  other socioeconomic characteristics of the Insured and Uninsured   Chapter 3  63 Self‐reported health and medical care‐seeking behaviour of uninsured Jamaicans Chapter 4  87 Variations  in  health,  illness  and  health  care‐seeking  behaviour  of  those  in  the  upper  social hierarchies in a Caribbean society Chapter 5  113 Health of children less than 5 years old in an Upper Middle Income Country: Parents’ views Chapter 6  137 Health Inequality in Jamaica, 1988‐2007 Chapter 7  172 Social determinants of self‐reported health across the Life Course Chapter 8  194 Sociomedical Public Health in Jamaica Chapter 9  226  vi  
  8. 8. Modelling social determinants of self‐evaluated health of poor older people in a middle‐income developing nation Chapter 10  252 Self‐rated health of the educated and uneducated classes in Jamaica Chapter 11  278 Retesting and refining theories on the association between illness, chronic illness and poverty: Are there other disparities? Chapter 12  304 Variations  in  social  determinants  of  health  using  an  adolescence  population:  By  different measurements, dichotomization and non‐dichotomization of health Chapter 13  331 Childhood Health in Jamaica: changing patterns in health conditions of children 0‐14 years  Chapter 14  359 The uninsured ill in a developing nation  Chapter 15  391  Determinants of self‐rated private health insurance coverage in Jamaica Chapter 16  415 Difference  in  social  determinants  of  health  between  men  in  the  poor  and  the  wealthy  social strata in a Caribbean nation        vii  
  9. 9.  Health Insurance &  Health viii  
  10. 10. Chapter 1Health insurance coverage in Jamaica: Multivariate analyses using two cross- sectional survey data for 2002 and 2007 Paul Andrew BourneHealth insurance is established as an indicator of health care-seeking behaviour. Despite thisreality, no study existed in Jamaica that examines those factors that determine private healthinsurance coverage. This study bridges the gap in the literature as it seeks to determine correlatesof private health insurance coverage. The aim of this study is to understand those who possessHealth insurance coverage in Jamaica so as to aid public health policy formulation. This studyused two secondary cross-sectional data from the Jamaica Survey of Living Conditions (JSLC).The JSLC was commissioned by the PIOJ and the Statistical Institute of Jamaica (STATIN) in1988. The surveys were taken from a national cross-sectional survey of 25 018 respondents (for2002) and 6,782 people (for 2007) from the 14 parishes across Jamaica. The JSLC is a self-administered questionnaire where respondents are asked to recall detailed information onparticular activities. The questionnaire was modelled from the World Bank’s Living StandardsMeasurement Study (LSMS) household survey. There are some modifications to the LSMS, asJSLC is more focused on policy impacts. The surveys used stratified random probabilitysampling technique to draw the original sample of respondents. Descriptive statistics were usedto provide background information on the sample, and logistic regression was to determinepredictors of private health insurance coverage. Health insurance coverage can be predicted bysocio-demographic factors (such as area of residence; education, marital status, social support,social class, gender, age), and economic (consumption and income). The findings revealed somesimilarities and dissimilarities between data for 2002 and 2007. Area of residence, consumption,educational level, marital status, income and social support were determinants over the twoperiods. Asset ownership was a factor in 2002 but not in 2007. For 2007, age, gender and socialclass were factors and not for 2002. A dissimilarity in this study was with social support. It wasfound that in 2002, social support was negatively correlated with Health insurance coverage andthis shifts to a positive correlate in 2007. In 2002, age and gender were not associated withHealth insurance coverage but these became significant predictors in 2007. Interestingly, poorhealth status is not correlated with private health insurance coverage. More health insurancecoverage is owned by urban than by other town or rural residents. Health insurance coverage ismore structured for employed people who are in the private or public sectors more within urbanand other towns than rural areas indicating that rural residents, who are faced high poverty andself-employment, will be more likely in continuing their choice in home remedy or non-traditional medicine in order to address their ill-health. Health which is strongly correlated withincome means that poor individuals, families, societies, nations, will be less healthy and willneed assistance in the form of health insurance to be able to reduce mortality. 1  
  11. 11. IntroductionHealth is more than the absence of diseases (WHO, 1948); as the absence of diseases is anantithesis (negative definition) of health and does not capture the positive aspects to thisphenomenon. In the preamble to its Constitution in 1946, the WHO noted that health includessocial, psychological and physical wellbeing; indicating that any measurement of health mustinclude non-epidemiologic factors and that this must recognize the positive ingredients in theconstruction of health. One scholar coined the terms ‘Biopsychosocial model’ to explain thedifferent facets that must be understood, evaluated and treated in addressing the care ofunhealthy patients (Engel, 1960). Engel’s ‘Biopsychosocial model’ was employed to mean thathealth includes biological, social, psychology and other determinants. While one scholar opinedthat this definition of health as forwarded by the WHO as well as by extension Engel was toobroad and elusive, and creates a difficulty to measure (Bok, 2004), the WHO’s conceptualdefinition of health recognizes the importance of social and behavioural factors in determininghealth status. They cannot be omitted in medical care treatment nor should we seek ameasurement in order to operationalizing health as this will not be in keeping with the constructof the comprehensive phenomenon. Caldwell (1993) wrote that the behavioural and lifestyle practices are a major determinantin health (see also, Bourne, 2009), and that this in explaining mortality is not new. Caldwell’sperspective does not only highlight the role that people play in their own quality of life; but thattheir actions (or inactions) hold a crucible part of their health status. Smoking, alcoholconsumption, physical inactivity, wreckless driving, unhealthy diets and other choices are alldecisions people take in life that will either negatively or positively influence their health status,and later will become a public health challenge. The tendency of people to become involved in 2  
  12. 12. particular lifestyle practices account for pre-mature mortality for many of them. Materialdeprivation, psychosocial stressors, high levels of risky behaviour, unhealthy living conditions,social exclusion, perceived lack of control, limited access to good-quality health care,constrained choices and physical inactivity account for higher levels of dysfunctions. Accordingto the WHO (2005), 60% of all death are owing to chronic illness, and that 80% of chronicdysfunctions occur in low-to-middle income countries, which speaks to the growing lifestylepractices (or lack). Material deprivation and psychosocial stressors increased the risk of diseasesfor poor people and people in general which is embedded in the statistics of the WHOpublication. According to the WHO (2005, p. 66), 95% of Jamaicans with chronic dysfunctionsexperienced financial difficulties owing to their illness “…and [that] a high proportion of peopleadmitting such difficulties avoided some medical treatment as a result (p. 66). It was also notedthat in India diabetic patients spent significantly more of their annual salary on medical care. Thestatistics from the WHO (2005) showed that 25% of the poor’s annual income is spent on privatecare compared to 4% of people with higher incomes. People are aware that illnesses areinevitable, owing to the high cost of medical care in order to access health care services they willthen use health insurance coverage. Health care costs can be so high that people become poor;and the recurring nature of some ailments can deplete people’s income and wealth to the point ofpoverty. It is this reality that accounts for health insurance coverage. Health insurance coverageis a by-product for people because it is demanded for lower treatment costing when illnessesoccur. Therefore, health insurance coverage not only lowers treatment cost of illnesses but alsolowers the psychosocial stressor on income, and the family’s wellbeing. 3  
  13. 13. Morrison (2000) titled an article ‘Diabetes and hypertension: Twin Trouble’ in which heestablished that diabetes mellitus and hypertension have now become two problems forJamaicans and in the wider Caribbean. This situation was equally collaborated by Callender(2000) at the 6th International Diabetes and Hypertension Conference, which was held in Jamaicain March 2000. The researcher found that there was a positive association between diabetic andhypertensive patients - 50% of individuals with diabetes had a history of hypertension(Callender, 2000, p. 67). Those diseases are not only lifestyle causing, they can be expensive totreat especially if they are severe. Hence, health insurance coverage is sought in keeping with theprobability of illness. Health insurance is therefore a health care-seeking behaviour and it can be used toindicate people’s perception of a futuristic likelihood of illness. It can estimate people’s fear oftheir inability to afford medical costs, their preparation for not wanting to deplete income, lowerwealth and the lack of it can account for some premature mortality. From the findings of a cross-sectional study conducted by Powell et al. (2007) of some 1,338 Jamaicans, 19.0% ofrespondents perceived that their economic wellbeing to be ‘very bad’. In addition, when theyasked, “Does your salary and the total of your family’s salary allow you to satisfactorily coveryour needs?” 57.4% of them felt that this “does not cover” their expenses (Powell et al., 2007, p.29). In addition, out of a maximum score of 10, those in the lower class scored 5.9 for how dothey ‘feel about the state of their health’ compared to a score of 6.6 for those in the upper classand a score of 6.7 for the middle class. This again goes to the rationale of demanding healthinsurance coverage for the poor people. Bourne (2009) found that there is no significantstatistical relationship between health insurance and health care seeking behaviour or health 4  
  14. 14. insurance and good health of Jamaicans, suggesting that it is not inaffordability of health carethat drives health insurance coverage; but something else. An extensive review of health literature in Jamaica found no study that has examineddeterminants of health insurance coverage. Health insurance in Jamaica was a private good up to2007, and so it could only be had by those who were employed. Hence using data up to 2007would be examining Health insurance coverage of employed Jamaicans. The aim of this study isto have an understanding of those who possess Health insurance coverage in Jamaica, so as toaid public health policy formulation. In keeping with the aim, this study sought to determinecorrelates of Health insurance coverage in Jamaica, using cross-sectional data for 2002 and 2007.MethodsThis study used two secondary cross-sectional data from the Jamaica Survey of LivingConditions (JSLC). The JSLC was commissioned by the Planning Institute of Jamaica (PIOJ)and the Statistical Institute of Jamaica (STATIN) in 1988. These two organizations areresponsible for planning, data collection and policy guideline for Jamaica, and have beenconducting the JSLC annually since 1989. The two cross-sectional surveys used for this studywere conducted in 2002 and 2007 (World Bank, 2002; PIOJ & STATIN, 2003; PIOJ & STATIN,2008). The surveys were taken from a national cross-sectional survey of 25 018 respondents (for2002) and 6,782 people (for 2007) from the 14 parishes across Jamaica. The surveys usedstratified random probability sampling technique to drawn the original sample of respondents.The non-response rate for the 2002 survey was 29.7% and 26.2% for the 2007 survey. Thesample was weighted to reflect the population (World Bank, 2002; PIOJ & STATIN, 2003; PIOJ& STATIN, 2008). 5  
  15. 15. The JSLC is a self-administered questionnaire where respondents are asked to recalldetailed information on particular activities. The questionnaire was modelled from the WorldBank’s Living Standards Measurement Study (LSMS) household survey. There are somemodifications to the LSMS, as JSLC is more focused on policy impacts (World Bank, 2002).The questionnaire covers demographic variables, health, immunization of children 0–59 months,education, daily expenses, non-food consumption expenditure, housing conditions, inventory ofdurable goods and social assistance. Interviewers are trained to collect the data from householdmembers. The survey is conducted between April and July annually. 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 & Lemeshow (2000) to examine goodness of fit. Thecorrelation matrix was examined in order to ascertain whether autocorrelation (ormulticollinearity) existed between variables. Based on Cohen & Holliday (1982) correlation canbe low (weak) - from 0 to 0.39; moderate – 0.4-0.69, and strong – 0.7-1.0 (see also, Cohen &Cohen, 2003; Cohen, 1988). This was used to exclude (or allow) a variable in the model. In 6  
  16. 16. addition, variables were excluded from the model if they had in excess of 20% of the casesmissing. Odds Ratio (OR) was used to interpret each significant variable. Multivariate regression framework (Asnani et al., 2008; Hambleton et al., 2005) wasutilized to assess the relative importance of various demographic, socio-economic characteristics,physical environment and psychological characteristics, in determining the health status ofJamaicans; and this has also been employed outside of Jamaica (Cohen & Holliday, 1982; James,2001; Ross et al., 1990). This approach allowed for the analysis of a number of variablessimultaneously; and is used to examine health insurance coverage. Secondly, the dependentvariable is a binary dichotomous one and this statistic technique has been utilized in the past todo similar studies. Having identified the determinants of health status from previous studies,using logistic regression techniques, final models were built for Jamaicans as well as for each ofthe geographical sub-regions (rural, peri-urban and urban areas) and sex of respondents usingonly those predictors.ModelsThe current study will employ multivariate analyses in the study of health and medical careseeking behaviour of Jamaicans. The use of this approach is better than bivariate analyses asmany variables can be tested simultaneously for their impact (if any) on a dependent variable.HIt=f(Ht, Ai, Gi, HHi, ARi, lnC, ∑Di, EDi, MRi, Si, HTi, lnY, CRi, MCt, SSi, Ti , CIi, Pi, Eni, HSB,εi ) (1) Where HIi is health insurance coverage of person i, Ht (ie self-rated current health status in time t) is a function of age of respondents, Ai ; sex of individual i, Gi; household head of individual i, HHi; area of residence, ARi; house tenure of individual i, HTi; logged 7  
  17. 17. consumption per person per household member, lnC; summation of durable goods and asset owned, ∑Di; Education level of individual i, EDi; marital status of person i, MRi; social class of person i, Si;; logged income, lnY; crowding of individual i, CRi; medical expenditure of individual i in time period t, MCt; social support of individual i, SSi; social assistance (ie welfare) individual i, Ti; crime index, CIi; physical environment of individual i, Eni, health care seeking behaviour and an error term (ie. residual error). The final models that were derived from the general Equation (1) that can be used topredict Health insurance coverage of Jamaicans are Equation (2) and Equation (3): HIt(Jamaicans, 2002) =f(ARi, lnC, EDi, MRi, lnY, SSi, ∑Di, HSB, εi)(2) HIt(Jamaicans, 2007) =f(ARi, lnC, EDi, MRi, lnY, SSi, Ai, Gi, S i, HSB, εi )(3)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 (Bourne & Rhule, 2009). While self-reported ill-health is not an idealindicator of actual health conditions because people may underreport, it is still an accurate proxyof ill-health and mortality (Idler & Kasl, 1991; Idler & Benyamini, 1997; Bourne & Rhule,2009). Social supports (or networks) denote different social networks with which the individualis involved (1 = membership of and/or visits to civic organizations or having friends who visitones home or with whom one is able to network, 0 = otherwise). Psychological conditions are 8  
  18. 18. the psychological state of an individual, and this is subdivided into positive and negativeaffective psychological conditions (Diener, 2000; Harris & Lightsey, 2005). Positive affectivepsychological condition is the number of responses with regard to being hopeful, optimisticabout the future and life generally. Negative affective psychological condition is number ofresponses from a person on having lost a breadwinner and/or family member, having lostproperty, being made redundant or failing to meet household and other obligations. Health statusis a binary measure (1=good to excellent health; 0= otherwise) which is determined from“Generally, how do you feel about your health”? Answers for this question are in a Likert scalematter ranging from excellent to poor. Health care-seeking behaviour is derived from thequestion: Have you visited a health care practitioner, pharmacist or healer in the past four 4weeks, with an option of yes or no. For the purpose of the regression was coded as 1=yes,0=otherwise. Crowding is the total number of individuals in the household divided by thenumber of rooms (excluding kitchen, verandah and bathroom). Age is a continuous variable inyears.ResultsDemographic characteristic and bivariate analysesIn 2002 the sample was 25,018 respondents: 12,332 males (49.3%) and 12,675 females (50.7%).In 2007 the sample was 6,782 respondents with there being marginally more females (51.3%)than males (48.7%; Table 1.1). The findings in Table 1.1 revealed that urbanization was takenplace in 2002, there were 13.4% of respondents living in urban zones and this shifted to 29.5% in2007. The percentage of Jamaicans dwelling in rural areas declined from 61% in 2002 to 49.0%in 2007. In 2002, 12.5% of respondents indicated that they had an illness in the 4-week surveyperiod and this increased by 2.4% in 2007. Sixty-four percent of respondents reported havingvisited a health care facility (including a healer), and this increased to 66% in 2007. The social 9  
  19. 19. class categorization of Jamaicans remained relatively the same over the studied period; and thepercentage of respondents who had health insurance coverage increased from 11.0% in 2002 to20.2% in 2007. The mean number of visits made to health care institutions (including healers)declined from 1.7 days (SD=1.4 days) to 1.4 days (SD=1.1 days). On the other hand, crowdingincreased by 135% in 2007 over 2002; and medical care expenditure also increased by 29.1%over the period (Table 1.1). Based on Table 1.2, the mean annual income of respondents in 2002 was Ja $331,488.32(SD = JA $304,040.77) and this increased by 108.6% in 2007: Ja $691,560.45 (SD = Ja$128,742.65). On disaggregating income by area of residence, it was revealed that there wassignificant statistical difference between income of respondents and their area of residents. Onaverage, urban respondents received 1.6 times more income than rural residents in 2007 and thiswas similar in 2002 (approximately 1.5 times more). The disparity in income between urban andother town respondents was lower (in 2007 – 1.1 times more and this was the same in 2002) thanthat between urban and rural dwellers. A cross-tabulation between health status and self-reported illness revealed a significantstatistical correlations - χ2(df = 2) = 1,289.23, p < 0.001 (Table 1.3). Table 1.3 revealed that anindividual who reported poor health status was 9.3 times more likely to have an illness than thosestating a dysfunction. On the other hand, an individual who reported good health status was 2.0more likely not to report an illness than those reporting at least one ailment. Based on Table 1.3,more males (85.4%) reported good health status than females (79.2%) - (χ2(df = 2) = 44.666, p <0.001) - and the converse was true for poor health status, with 5.5% of females compared to4.2% of males. Based on Table 1.4, there was a change in pattern of 5-leading recurring illnesses inJamaica. In 2002, hypertension was the leading cause of self-reported dysfunctions (21.6%)followed by cold (19.9%); unspecified ailments (18.1%); diabetes mellitus (11.6%) and asthma(9.6%). However in 2007, the leading prevalence of self-reported ailments shifted to unspecified 10  
  20. 20. ailments (23.4%) followed by hypertension (20.6%); cold (14.9%), diabetes mellitus (12.3%)and 9.5% asthma cases. Furthermore, a significant statistical relationship was found betweendiagnosed recurring illness was gender in both years: In 2002 (χ2(df = 1) = 125.469, p < 0.001, n= 3,063) and in 2007 (2 χ2(df = 1) = 40.916, p < 0.001, n= 999; Table 1.4). Table 1.4 showed thatdiabetes mellitus and hypertension were significant more among for females than males and thatarthritis, unspecified illnesses, asthma diarrhoea and cold were more prevalent among males thanfemales. Table 1.5 showed that there was a significant statistical correlation between medical care-seeking behaviours and gender: In 2002 (χ2(df = 1) = 9.006, p = 0.003) and in 2007, (χ2(df = 1) =3.004, p < 0.048). In 2002 data revealed that more females sought medical care (66%) thanmales (60.7%); and this was the case in 2007: 67.6% for females and 62.3% for males (Table1.5). In 2007, there was a significant statistical correlation between health care-seekingbehaviour of Jamaicans and health insurance coverage (χ2(df = 1) = 16.712, p < 0.001). Theassociation was a very weak one (r = 0.128). However, the findings revealed that 76.2% (n =189) of people with private health insurance visited a health care practitioner compared to 62.0%(n = 468) those who do not have health insurance coverage.Multivariate analysesIn 2007, health insurance coverage in was correlated with logged consumption (OR = 1.90, 95%CI = 1.12 - 3.23); logged income (OR = 1.71, 95% CI = 1.02 - 2.87); durable goods (OR = 1.09,95% CI = 1.02 - 1.17); marital status (married: OR = 3.91, 95% CI = 2.47 - 6.20); area ofresidence (urban areas: OR = 2.24, 95% CI = 1.23 - 4.09); education (secondary: OR = 2.97, 11  
  21. 21. 95% CI = 1.46 - 6.00; tertiary: OR = 18.76, 95% CI = 8.12 - 43.43); and social support (OR =0.54, 95% CI = 0.36 - 0.80; Table 1.7). For 2002, health insurance coverage model was a predictive model (χ2 (df = 24) =451.35, p < 0.001; Hosmer and Lemeshow goodness of fit χ2=5.91, P = 0.66), with 92.4% of thedata being correctly classified (41.1% - correct classification of cases of self-rated Healthinsurance coverage and 98.4% of cases of self-rated no private health insurance coverage; Table1.7). The model (Table 1.7) can explain 44.7% of the variability in Health insurance coverage ofJamaicans (for 2002). Health insurance coverage in Jamaica for 2007 can be determined by 10 variables. Thesewere logged consumption (OR = 1.00, 95% CI = 1.00 - 1.00); logged income (OR = 1.00, 95%CI = 1.00 - 1.00); marital status (married: OR = 1.84, 95% CI = 1.52 - 2.22); area of residence(urban areas: OR = 1.30, 95% CI = 1.08 - 1.57); education (secondary or tertiary: OR = 1.45,95% CI = 1.09 - 1.92); and social support (OR = 1.33, 95% CI = 1.04 - 1.70); age (OR = 1.01,95% CI = 1.01 - 1.02); social class (upper class: OR = 1.61, 95% CI = 1.08 - 1.57) and by gender(male: OR = 0.81, 95% CI = 0.69 - 0.95). For 2007, the factors that determine health insurance coverage in Jamaica is a predictivemodel (χ2 (df = 20) =590.07, p < 0.001; Hosmer and Lemeshow goodness of fit χ2=7.25, P =0.51), with 79.4% of the data being correctly classified (40.4% - correct classification of cases ofself-rated Health insurance coverage and 96.4% of cases of self-rated no private health insurancecoverage). For 2007, the model can explain 49.1% of the variability in private health insurancecoverage.Discussion 12  
  22. 22. There are some sociodemographic determinants of Health insurance coverage in Jamaica thathave remained predictors. These include area of residence, consumption, education, maritalstatus, income and social support. Durable goods were a predictor of health insurance coveragein 2002; however, this is ceased to be the case in 2007. Over time, health insurance coveragewas determined by some additional factors such as age, gender, and social class. Of the 6predictors of Health insurance coverage in Jamaica that continued to be factors in both periods,there is dissimilarity. Social support which was a negative determinant in 2002 reversed to apositive one in 2007. It is expected that those with more social support would be less likely topurchase health insurance coverage as there is a higher probability that they can be assisted intimes of medical needs by the social networks with which they are apart. The church, civicassociations and societies, family, friends and associates are more likely to extend a helping handin time of medical need, and this account for the unwillingness of people to purchase privatehealth insurance because this socio-economic support is present. In 2007, the findings revealed that Health insurance coverage was positively correlated tosocial support which invalidates the aforementioned perspective. The inflation rate in Jamaicarose by 194% in 2007 over 2006, which indicates that net disposable individual and householdincome would have fallen substantially and that each individual would have seen an erosion ofhis purchasing power coupled with higher cost of living. The direct correlation between socialsupport and Health insurance coverage can be explained by social institutions encouraging itsmembers to purchase insurance to offset the increased costs. They probably may be less likely tooffer the same level of assistance to all its members like the previous period when costings werelower. The economic cost will create a challenge for those social networks to spread their limitedfinancial resources over a wider cross-section of people with diverse needs. This then is a part of 13  
  23. 23. the explanation why Health insurance coverage was the highest in Jamaica in 2007 (21.2%) overthe 2 decades; and in 2007, medical care-seeking behaviour was 66% which fell by 5.7% over2006. The current study revealed that married people were more likely to purchased privatehealth insurance than those who were never married and that there is no significant difference inpurchase of health insurance between those who were divorced, separated or widowed and thosewho were never married. In 2002, the findings showed that married people were 4 times morebuy Health insurance coverage compared to those who were never married and that this ratio fellto 2 times more in 2007. This lower of disparity in ownership of Health insurance coveragebetween the married and never married cohorts in Jamaica is an indication of people’swillingness to subsidize medical care cost with private health insurance coverage; the loweringof their disposable income owing to increased cost of living; increased awareness of seekingmedical care and the high cost of doing so; and the changing typology of diseases which requirecontinuous monitoring by health care practitioners and how this is likely to erode income andwealth, and that this would be best mitigated against through the provision of health insurance. An another interest finding that is embedded in the disparity of more married thanunmarried people owning private health insurance is the explanation for why married peoplehave a greater health status than unmarried people. Health insurance coverage is an indicator ofhealth care-seeking behaviour, which goes to the core of married people’s willing to addresshealth concerns owing to their recognition of the family (ie children and spouse) depending onthem for care, protection and financial support. According to Moore et al. (1997, 29), people whoreside with a spouse have a different base of support that those in other social arrangements (Seealso Smith & Waitzman 1994; Lillard & Panis 1996). Cohen & Wills (1985) found that 14  
  24. 24. perceived support from one’s spouse increased wellbeing (see also Smith & Waitzman 1994),while Ganster et al. (1986) reported that support from supervisors, family members and friendswas related to low health complaints. Koo, Rie & Park (2004) findings revealed that beingmarried was a ‘good’ cause for an increase in psychological and subjective wellbeing in old age.Smith & Waitzman(1994) offered the explanation that wives found dissuade their husband fromparticular risky behaviours such as the use of alcohol and drugs, and would ensure that theymaintain a strict medical regimen coupled with proper eating habit (see also Ross et al., 1990;Gore, 1973). In an effort to contextualize the psychosocial and biomedical health status ofparticular marital status, one demography cited that the death of a spouse meant a closure todaily communicate and shared activities, which sometimes translate into depression that affectthe wellbeing more of the elderly who would have had investment must in a partner (Delbés &Gaymu 2002, p. 905). Embedded in Smith and Waitzman finding is the positive effecting of marriage on men’shealth status. This speaks to culture of men’s unwillingness to seek medical care, and the role ofthe spouse in reducing this practice. The current study found that men were 19.2% less likely thatwomen own health insurance, indicating once again their unwillingness to seek medical care.Health literature has established that women are more likely to seek medical care than men(Stekelenburg et al., 2009; PIOJ & STATIN, 2001) and that this was concurred by the currentstudy. Interestingly, in 2002, for every 156 females that sought medical care there were 100males; but in 2007, the ratio widens to 160 females for every 100 males. Although femalessought more health care services than males, statistics revealed that the latter group spent moredays in illness (mean = 10.3 days) than females (mean number of days suffered from illness =9.3 days) (PIOJ & STATIN, 2008). 15  
  25. 25. Poor health status which is an indicator of health conditions means that females weremore likely to seek medical care to address those concerns compared to males who weresuffering from the different illnesses. Of the 3 specified chronic illnesses (arthritis, diabetesmellitus, and hypertension) females are influenced by the more severe types, and thus explain thegreater probability of them seeking medical care and buying health insurance coverage thanmales. This research found that in 2002, females were 2.1 times more likely to report havinghypertension and 1.5 times more likely to claim that they have diabetes mellitus than males. In2007, the disparity in self-reported hypertension fell to 1.7 times and increased to 2 times fordiabetes mellitus. For arthritis, the disparity was narrowly greater for males than females. In2002, for every 120 males that reported arthritis there were 100 females and this was 111 malesfor every 100 females in 2007. Men are not only unwilling culturally to display emotions, fear, weakness and illness,they are equally reserved about speaking of their health conditions. Such a position is embeddedin the culture, which states that boys should ‘suppress reaction to pain’ and to speak of illness tolower ones maleness (Chevannes, 2001, p. 37). Chevannes’s work explains the current findingsas well to provide in-depth information on statistics published in the Jamaica Survey of LivingConditions (JSLC). The JSLC (2000) reported that men were 0.7 times less likely to self-reportsicknesses, injuries and/or ailments compared to their female counterparts. In a number ofsocieties, traditional females seek health-care more than males, which allow for a bettermonitoring and diagnostic assessment of their health conditions as against men. Higher income means the individual, family, society and nation has more to it disposableto cover non-consumption items such as health insurance. Easterlin argued that “those withhigher income will be better able to fulfill their aspiration and, and other things being equal, on 16  
  26. 26. an average, feel better off” (Easterlin, 2001a, p. 472), indicating a bivariate relationship betweensubjective well-being and income. Stutzer & Frey (2003) found that the association betweensubjective wellbeing and income to be a non-linear one. According to Stutzer & Frey (2003) “Inthe data set for Germany, for example, the simple correlation is 0.11 based on 12, 979observations” (p. 9). The current study concur with Easterlin that greater income can purchaseother goods, which accounts for the positive correlation between income and private healthinsurance coverage. This is also in keeping with Brown et al.’s study (2008) which had incomeas a predictor of health care-seeking behaviour. The current research went further than Brown etal (2008) and Easterlin (2001) studies as it found that those who consume more on food and non-food items are more likely to own Health insurance coverage than those who consume less.Hence, it is expected that wealthy will be significantly more likely to own Health insurancecoverage than the poor. In Jamaica, statistics from the Planning Institute of Jamaica and Statistical Institute ofJamaica (2007) revealed that poverty is substantially a rural phenomenon and that the more ofthe wealthy live in urban area, then more urban dwellers having Health insurance coverage isreinforcing the literature that more money provide access to a wider spread of goods and servicesoutside of basic necessities. The current research has provided more interest information in theliterature as wide gap that existed in 2002 between the wealthy and the poor in regards toownership of private health insurance, narrowed in 2007. Another interesting finding of this study is the positive significant correlation betweenhealth insurance coverage and educational attainment. In 2002, those with tertiary leveleducation were 19 times more likely to own health insurance coverage in Jamaica and thisnarrowed substantially to 1.4 times more than those with primary and below education. The 17  
  27. 27. narrowing of the gap of those who owned health insurance coverage between the tertiary and theprimary level education can due to knowledge of ill-health, lowered income, the role of themedia in information the populace about the role of health insurance coverage in reducingmedical cost on seeking health care. Interestingly private health insurance companies in Jamaicahave expanded health insurance schemes to Credit Unions, and so this is giving greater access ofthis product to the poor who are mostly members of the Union. The positive significant correlation of age and health insurance coverage in Jamaica canbe accounted for by the biological changes and the high cost of medical care due to this futuristicprobability. Organism aged naturally, which explains biological ageing. Ageing is synonymouswith reduced functional limitations (or increased health conditions), suggesting that the olderpeople become they will be more willing to purchase Health insurance coverage due to the futurecost of medical care and the high likeliness of illness because of health conditions. Gompertz’slaw in Gavriolov & Gavrilova (2001) showed that there is fundamental quantitative theory ofageing and mortality of certain species (the examples here are as follows – humans, human lice,rat mice, fruit flies, and flour beetles (see also, Gavriolov & Gavrilova, 1991). Gompertz’s lawwent further to establish that human mortality increase twofold with every 8 years of an adultlife, which means that ageing increases in geometric progression. This phenomenon means thathuman mortality increases with age of the human adult, but that this becomes less progress inadvance ageing. Thus, biological ageing is a process where the human cells degenerate withyears (i.e. the cells die with increasing in age), which is well established in evolutionary biology(Medawar 1946; Carnes and Olshansky, 1993; Carnes et al., 1999; Charlesworth, 1994). A study on the elderly in the Caribbean Food and Nutrition Institute’s magazine Cajanusfound that 70% of individuals who were patients within different typologies of health services in 18  
  28. 28. Jamaica were senior citizens (Caribbean Food and Nutrition Institute1999; Anthony 1999), andthis emphasize the need of elderly to purchase health insurance in order to cover the cost ofhealth care. A study conducted by Costa, using secondary data drawn from the records of theUnion Army (UA) pension programme that covered some 85% of all UA, showed there is anassociation between chronic conditions and functional limitation – which include difficultywalking, bending, blindness in at least one eye and deafness (Costa 2002). Again this isreiterating the need to seek medical care owing to ageing, and justifying the positive correlationbetween age and health insurance coverage in this study. Interestingly health insurance is among the greatest predictor of health care-seekingbehaviour in the United States (Call & Ziegenfuss, 2007), and this is not the case in Jamaica asonly 21 out of every 100 Jamaicans possessed health insurance coverage in 2007. However ofthose who claimed to have private health insurance coverage, 8 out of 10 visited health carefacilities, suggesting that those with this facility would be a great predictor of health care-seekingbehaviour. It should be noted that Jamaica does not have a national health insurance coveragewhich is opened to the general populace. Instead (in 2007), the government introduced a nationalhealth insurance coverage in which people with particular ailments can access services andmedication at particular public institutions free and a national health insurance scheme whichcaters to the elderly Jamaicans (ages 60 years and older).ConclusionThe socioeconomic determinants of Health insurance coverage in Jamaica have expanded in2007 over 2002. Area of residence, consumption, income, educational attainment, marital statusand social support have remained factors in 2007 over 2002; but age, gender and social class arecurrently new sociodemographic variables that explain private health insurance in Jamaica. 19  
  29. 29. Furthermore, females seeking more medical care in Jamaica has been fundamentally linked toculture and this is undoubtedly so; but this study has found that the typology of their healthconditions is another pivotal rationale for this disparity. The reported health conditions withwhich males reported more of than females are illnesses that can be substantially over thecounter with non-traditional medicine, and so further goes to the reason for their low access oftraditional health care services. In Jamaica, the employment typology in area of residents is different and contributes tothe disparity in private health insurance coverage. Employment in rural area is substantially self-employment (ie farming) and this type of employment is not designed around private healthinsurance coverage. Health insurance coverage is more structured for employed people who arein the private or public sectors more within urban and other towns than rural areas indicating thatrural residents, who are faced high poverty and self-employment, will be more likely incontinuing their choice in home remedy or non-traditional medicine in order to address their ill-health. Health which is strongly correlated with income means that poor individuals, families,societies, nations, will be less healthy and will need assistance in the form of health insurance tobe able to reduce mortality. In concluding, the information with which this provided can be usedby public health services in formulating programmes that can be address the concerns of malesand rural poor. 20  
  30. 30. ReferencesAnthony, B.J. (1999). Nutritional assessment of the elderly. Cajanus 32, 201-216.Asnani, M.R., Reid, M.E., Ali, S.B., Lipps, G., Williams-Green, P. (2008). Quality of life in patients with sickle cell disease in Jamaica: rural-urban differences. Journal of Rural and Remote Health 8, 890-899.Bok, S. (2004). Rethinking the WHO definition of health: Working Paper Series, 14. Retrieved on May 26, 2007, from http://www.golbalhealth.harvard.edu/hcpds/wpweb/Bokwp14073.pdfBourne, P.A. (2009). Socio-demographic determinants of Health care-seeking behaviour, self- reported illness and Self-evaluated Health status in Jamaica. International Journal of Collaborative Research on Internal Medicine & Public Health 1(4),101-130.Bourne, P.A., & Rhule, J. (2009). Good Health Status of Rural Women in the Reproductive Ages. International Journal of Collaborative Research on Internal Medicine & Public Health 1(5):132-155.Brown, P.H., De Brauw, A., & Theoharides, C. (2008). Health-Seeking Behavior and Hospital Choice in China’s New Cooperative Medical System. Social Science Electronic Publishing.Caldwell, J.C. (1993). Health transition: The cultural, social and behavioural determinants of health in the Third World. Soc Sci Med 36,125-135.Call, K.T., Ziegenfuss, J. (2007). Health insurance coverage and Access to Care Among Rural and Urban Minnesotans. Rural Minnesota Journal 2:11-35.Callender, J. (2000). Lifestyle management in the hypertensive diabetic. Cajanus 33, 67-70.Caribbean Food and Nutrition Institute. 1999. Health of the elderly. Cajanus 32, 217-240.Carnes, B.A., & Olshansky S.J. (1993). Evolutionary perspectives on human senescence. Population. Development Review 19, 793-806.Carnes, B.A., Olshansky, S.J., Gavrilov, L.A., Gavrilova, N.S. & Grahn D. (1999). Human longevity: Nature vs. nurture - fact or fiction. Persp Biol. Med. 42: 422-441.Charlesworth, B. (1994). Evolution in Age-structured Populations (2nd ed). Cambridge: Cambridge University Press.Chevannes, B. (2001). Learning to be a man: Culture, socialization and gender identity in five Caribbean communities. Kingston, Jamaica: University of the West Indies Press.Cohen, L., Holliday, M. (1982). Statistics for Social Sciences. London: Harper & Row.Cohen, S., & Wills T.A. 1985. Stress, social support, and the buffering hypothesis. Psychological bulletin 98,31-357.Costa, D.L. (2002). Chronic diseases rates and declines in functional limitation. Demography 39, 119-138.Costa, D.L. (2000). Understanding the twentieth-century decline in chronic conditions among older men. Demography 37,53-72.Delbés, C., & Gaymu, J. (2002). The shock of widowed on the eve of old age: Male and female experience. Demography 3, 885-914.Diener, E. (2000). Subjective well-being: The science of happiness and a proposal for a national index. American Psychological Association 55, 34-43.Easterlin, R.A. (2001). Income and happiness: Towards a unified theory. Economic Journal 111, 465-484 21  
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  32. 32. Planning Institute of Jamaica, (PIOJ), & Statistical Institute of Jamaica (STATIN). 2003. Jamaica Survey of Living Conditions, 2002. Kingston: PIOJ, STATIN.Planning Institute of Jamaica, (PIOJ), & Statistical Institute of Jamaica (STATIN). 2001.Jamaica Survey of Living Conditions, 2000. Kingston: PIOJ, STATIN.Planning Institute of Jamaica, (PIOJ), & Statistical Institute of Jamaica (STATIN). 2000.Jamaica Survey of Living Conditions, 1999. Kingston: PIOJ, STATIN.Powell, L.A., Bourne P., & Waller L. (2007). Probing Jamaica’s Political culture, volume 1: Main trends in the July-August 2006 Leadership and Governance Survey. Kingston, Jamaica: Centre for Leadership and Governance.Ross, C. E., Mirowsky, J., & Goldsteen, K. (1990). The impact of the family on health. Journal of Marriage and the Family 52, 1059-1078.Smith, Ken R., and Waitzman, Norman J. 1994. Double jeopardy: Interaction effects of martial and poverty status on the risk of mortality. Demography 31:487-507.Stekelenburg, J., Jager, B., Kolk, P., Westen, E., Kwaak, A., &Wolffers, I. (2009). Health care seeking behaviour and utilization of traditional healers in Kalaboo, Zambia. Health Policy 71,67-81.Stutzer, A., & Frey, B.S. (2003). Reported subjective wellbeing: A challenge for economic theory and economic policy. Retrieved on August 31, 2007, from http://www.crema-research.ch/papers/2003-07.pdfWorld Bank, Development Research Group, Poverty and human resources. (2002). Jamaica Survey of Living Conditions (LSLC) 1988-2000: Basic Information. http://www.siteresources.worldbank.org/INTLSMS/Resources/.../binfo2000.pdf. (accessed August 14, 2009).World Health Organization, (W.H.O). (2005). Preventing Chronic Diseases a vital investment. Geneva: WHO. 23  
  33. 33. Table 1.1. Demographic characteristic of samples: 2002 and 2007Variable 2002 2007 Number Percent Number PercentGender Male 12,332 49.3 3,303 48.7 Female 12,675 50.7 3,479 51.3Area of residence Urban 3,357 13.4 2,002 29.5 Other 6,401 25.6 1,458 21.5 Rural 15,260 61.0 3,322 49.0Illness Yes 3,010 12.5 980 14.9 No 21,103 87.5 5,609 85.1Visits health care facilities Yes 1,966 63.9 658 65.5 No 1,113 36.1 347 34.5Social class Poor 9,931 39.7 2,697 39.4 Middle 4,984 19.9 1,351 19.9 Upper 10,099 40.0 2,734 40.3Private Health Insurance Coverage Yes 2,671 11.0 1,314 20.2 No 21,546 89.0 5,203 79.8Health status Good 5,397 82.2 Fair 848 12.9 Poor 320 4.9 24  
  34. 34. Table 1.2. Income, Crowding, Age, by Area of residence: 2002 and 2007Characteristic Year Category Mean SD p-valueIncome Ja$ 2002† Urban $440,451.50 $521,519.38 < 0.001 Other towns $385,625.70 $276,644.12 Rural $284,810.20 $231,540.04 Total $331,488.32 $304,040.77 2007†† Urban $865,674.20 $673,512.10 < 0.001 Other towns $771,300.50 $597,582.65 Rural $551,633.70 $389,765.68 Total $691,560.45 $128,742.65Crowding 2002 Urban 2.0 persons 1.4 persons > 0.05 Other towns 2.0 persons 1.4 persons Rural 2.0 persons 1.4 persons Total 2 persons 1.4 persons 2007 Urban 4.3 persons 2.4 persons < 0.001 Other towns 4.6 persons 2.3 persons Rural 5.0 persons 2.5 persons Total 4.7 persons 2.5 personsAge 2002 28.2 yrs 22.0 yrs 2007 29.9 yrs 21.8 yrsNo of visits to health care 2002 1.7 days 1.4 daysfacilities 2007 1.4 days 1.1 daysMedical expenditure 2002† $1,144.14 $2,946.02 2007†† $1,477.07 $4,711.15†Ja $40.97 = US $1.00††Ja $80.47 = US $1.00 25  
  35. 35. Table 1.3. Health status by self-reported illness, and gender: 2007Characteristic Category Health status (%) Total Good Fair PoorSelf-reported dysfunction1 0 89.1 8.7 2.2 5569 ≥1 42.8 36.8 20.4 976 Total 5381 845 319 6545Gender2 Male 85.4 10.4 4.2 3195 Female 79.2 15.3 5.5 3370 Total 5397 848 320 65651 2 χ (df = 2) = 1,289.23, p < 0.001, c=0.4052 2 χ (df = 2) = 44.666, p < 0.001, c=0.082 26  
  36. 36. Table 1.4. Self-reported diagnosed recurring illness by gender and years (2002, 2007)Yea Sex Self-reported diagnosed recurring illness (%) Tota r l Col Diarrhoe Asthm Diabete Hypertensio Arthriti Othe No d a a s n s r200 Male 22.9 3.1 11.4 9.3 12.9 7.6 20.1 12. 1252 5 2 Femal 17.8 2.4 8.3 13.2 27.6 6.3 16.6 7.7 181 e 1 Total 610 83 294 356 661 209 553 297 306 3200 Male 17.2 2.7 11.7 7.7 14.4 6.0 25.4 14. 4027 9 Femal 13.4 2.7 8.0 15.4 24.8 5.4 22.1 8.2 597 e Total 149 27 95 123 206 56 234 109 999 27  
  37. 37. Table 1.5. Medical Care-Seeking Behaviour by Gender, 2002, 2007 2002 2007Medical Care-Seeking Behaviour Male Female Male FemaleYes1 60.7 66.0 62.3 67.6No2 39.3 34.0 37.7 32.4Total 1266 1813 406 5991 2 χ (df = 1) = 9.006, p = 0.003, n = 3,0792 2 χ (df = 1) = 3.004, p = 0.048, n= 1,005 28  
  38. 38. Table 1.6. Health insurance coverage by Area of Residence, 2007 Area of Residence Health Insurance Other Urban towns Rural Total No coverage 72.0 77.9 85.5 79.8 Private Coverage 19.2 15.1 7.1 12.4 Public Coverage 8.7 7.0 7.4 7.7 Total 1939 1401 3177 6517 χ2(df = 4) = 184.347, p < 0.001, n = 6,517 29  
  39. 39. Table 1.7. Logistic Regression: Predictors of Private Health Coverage in JamaicaCharacteristic 2002 2007 OR 95% CI OR 95% CIAge 1.00 0.98-1.02 1.01 1.01-1.02***Log consumption 1.90 1.12-3.23* 1.00 1.00-1.00*Log income 1.71 1.02-2.87* 1.00 1.00-1.00***Log medical expenditure 0.99 0.81-1.21 1.00 1.00-1.00Household head 4.61 0.21-99.16 1.03 0.86-1.23Medical care seeking behaviour 0.88 0.42-1.83 1.65 1.07-2.41*SexMale 0.88 0.60-1.30 0.81 0.69-0.95*Marital statusSeparated, divorced or widowed 1.38 0.49-3.88 1.19 0.87-1.64Married 3.91 2.47-6.20*** 1.84 1.52-2.22***†Never married 1.00 1.00Area of residenceUrban 2.24 1.23-4.09** 1.30 1.08-1.57*Other towns 1.19 0.75-1.89 1.11 0.90-1.36†Rural 1.00 1.00EducationSecondary 2.97 1.46-6.00** 1.45 1.09-1.92*Tertiary 18.8 8.11-43.43***†Primary or below 1.00 1.00House tenure: owned 1.76 0.16-19.4Social classMiddle 0.88 0.32-2.41 0.96 0.63-1.46Upper 1.88 0.68-5.24* 1.61 1.04-2.49*†Lower 1.00 1.00Social support 0.54 0.36-0.80** 1.33 1.04-1.70*Health statusGood health 0.93 0.56-1.53 1.05 0.84-1.31Durable goods index (excluding land) 1.09 1.01-1.17*Physical environment 0.78 0.48-1.27Crime index 1.01 0.99-1.03Asset ownership (ie land or property) 0.79 0.51-1.22Psychological conditionNegative affective conditions 0.96 0.91-1.02Log crowding 1.33 0.88-2.02 1.07 0.98-1.16Social welfare 0.79 0.52-1.20Time spent in health care facilitiesPublic 0.96 0.79-1.20 1.00 1.00-1.00Private 1.43 0.02-85.3 1.00 1.00-1.00Illness 4.01 0.44-36.43 1.14 0.90-1.43Injury 0.68 0.36-1.75 1.12 0.57-2.20N 25,007 6,565Chi2 451.3 590.1Nagelkerke R2 0.45 0.49LR 776.4 4,126.8*P< 0.05, **P< 0.01, ***P< 0.001 30  
  40. 40. Chapter 2 Disparities in self-rated health, health care utilization, illness, chronic illness and other socioeconomic characteristics of the Insured and Uninsured Paul A. BourneThis study examines self-rated health status, health care utilization, income distribution, andhealth insurance status of Jamaicans, and the disparity by the insured and uninsured. It alsomodels self-rated health status, health care utilization, income distribution, and how these differbetween the insured and uninsured. Cross-sectional data from the 2007 Jamaica Survey of LivingConditions (JSLC), conducted by the Planning Institute of Jamaica (PIOJ) and the StatisticalInstitute of Jamaica (STATIN), were used to analyse the information for this study. The JSLC isa modification of the World Bank’s Living Standard Household Survey, with a sample of 6,783respondents. Analytic models, using multiple logistic and linear regressions, were used todetermine factors which explain self-rated health status, health care utilization, and incomedistribution. Disparities in self-rated health status, health care utilization, and income distributionwere examined by the insured and uninsured. Majority (61.1%) of those who reported beingdiagnosed with a chronic condition were 60+ years old (diabetes mellitus, 59.3%; hypertension,60.2%; arthritis, 67.9%) and 2.4% were children. The mean age of those with chronic illness was62.3 years (SD = 16.2), and this was 61.5 years (SD = 16.5) for the uninsured and 63.8 years (SD= 15.8) for those with insurance coverage. Only 20.2% of respondents had health insurancecoverage (private, 12.4%; NI Gold, public, 5.3%; other public, 2.4%). Most of the chronically illwere uninsured (67%). More people with chronic illnesses who had health insurance coveragewere elderly, (65.9%), compared to uninsured chronically ill elderly (58.4%). Majority of healthinsurance was owned by those in the upper class, (65%), and 19%, by those in the lowersocioeconomic strata. Insured respondents were 1.5 times (Odds ratio, OR, 95% CI = 1.06 –2.15) more likely to rate their health as moderate-to-very good compared to the uninsured, andthey were 1.9 times (95% CI = 1.31-2.64) to seek more medical care, 1.6 times (95% CI = 1.02-2.42) more likely to report having chronic illness, and more likely to have greater income (β =0.094) than the uninsured. Illness is a strong predictor of why Jamaicans seek medical care (R2 =71.2% of 71.9%), and health insurance coverage accounted for less than one-half percent of thevariance in health care utilization. However, health care utilization is a strong predictor of self-reported illness, but it was weaker than illness explaining health care utilization (61.1% of66.5%). Public health insurance was mostly had by those with chronic illnesses (76%) comparedto 44% private health coverage and 38% had no coverage (χ2 = 42.62, P < 0.0001). With thehealth status of the insured being 1.5 times more than the uninsured, their health care utilizationbeing 1.9 times more than the uninsured and illness being a strong predictor of health careseeking, any reduction in the health care budget in developing nations denotes that vulnerable 31  
  41. 41. groups (such as elderly, children and the poor) will seek less care, and this will further increasethe mortality among those cohorts.IntroductionThis study examines self-rated health status, health care utilization, income distribution, andhealth insurance status of Jamaicans, and the disparity between the insured and uninsured. It alsomodels self-rated health status, health care utilization, income distribution, and how these differbetween the insured and uninsured. The current findings revealed that 20.2% of Jamaicans hadhealth insurance coverage (i.e. 2,140,316 Jamaicans are uninsured, using end of year populationfor 2007), suggesting that a large percent of the population are having to use out of pocketpayment or government’s assistance to pay their medical bills. The health of individuals within a society goes beyond the individual to thesocioeconomic development, standard of living, production and productivity of the nation.Individuals’ health is therefore the crux of human’s development, survivability and explains therationale as to why people seek medical care on the onset of ill-health. In seeking to preservelife, people demand and utilize health care services. Western societies are structured that peoplemeet health care utilization with a combination of approaches. These approaches can be anycombination of out of pocket payment, health insurance coverage, government assistance andfamilies’ aid. In Latin America and the Caribbean, health care is substantially an out of pocketexpenditure aided by health insurance policy and government’s health care policy. Within thecontext of the realities in those nations, the health of the populace is primarily based on thechoices, decisions, responsibility and burden on the individual. Survival in developing nations 32  
  42. 42. are distinct from Developed Western Nations as Latin America and Caribbean peoples’willingness, frequency, and demand for health care as well as health choices are based onaffordability. Affordability of health care is assisted by health insurance coverage; as theprovisions of care offered by the governmental policies mean that the public health care systemwill be required to meet the needs of many people. Those people will be mostly children, elderlyand other vulnerable groups. The public health care system in many societies often time involve long queues, longwaiting times, frustrated patients and poor people who are dependent on the service. In order tocircumvent the public health care system, people purchase health insurance policies as a meansof reducing futuristic health care cost as well as an avoidance of the utilization of public healthcare. Uninsurance in any society means a dependency on the public health care system,premature mortality and oftentimes public humiliation. The insured on the other hand are able tocircumvent many of the experiences of the poor, elderly, children and other vulnerable cohortswho rely on public health care system. Insurance in developing nations, and in particularJamaica, is private system between the individual and a private insurance company. Because ofthe nature of health insurance and insurance, people buy into a pool which is usuallyaccommodated through employment. Such a reality excludes retired elderly, unemployed,unemployable, and children of those cohorts. In seeking to understand health care non-utilizationand high mortality in developing nations, insurance coverage (or lack of) becomes crucial in anyhealth discourse. There is high proportion of uninsured in the United States and this is equally the reality inmany developing nations, particularly in Jamaica [1-6]. According to the World HealthOrganization (WHO), 80% of chronic illnesses were in low and middle income countries, and 33  
  43. 43. 60% of global mortality is caused by chronic illnesses [7]. It can be extrapolated from theWHO’s findings thatuninsurance is critical in answering some of the health disparities within and among groups andthe sexes in the society. The realities of the health inequalities between the poor and the wealthyand the sexes in a society and those in the lower income strata having more illnesses and inparticular chronic conditions [7-12] is embedded in financial deprivation. The WHO stated that “In reality, low and middle income countries are at the centre ofboth old and new public health challenges” [7]. The high risk of death in low income countriesis owing to food insecurity, low water quality, low sanitation coupled with in access to financialresources [11, 13]. Poverty makes it insurmountable for poor people to respond to illness unlesshealth care services are free. Hence, the people who are poor will suffer even more so fromchronic diseases. The WHO captures this aptly “...People who are already poor are the mostlikely to suffer financially from chronic diseases, which often deepens poverty and damage longterm economic prospects” [7]. This goes back to the inverse correlation between poverty andhigher level education, poverty and non-access to financial resources, and now poverty andillness. According to the WHO [7], “In Jamaica 59% of people with chronic diseasesexperienced financial difficulties because of their illnesses...” and emphasize the importance ofhealth insurance coverage and the public health care system for vulnerable groups. Previous studies showed that health insurance coverage is associated with health careutilization [1-6], and this provides some understanding of health care demand (or the lack of) indeveloping countries. Studies have been conducted on the general health of the insured and/oruninsured, health care utilization and other health related issues [1-6] have used a piecemealapproach, which means that there is a gap in the literature that could provides more insight into 34  
  44. 44. the insured and uninsured. While the current body of health literature provide pertinentinformation on health and health care utilization and how these differ based on the insured anduninsured, health choices are complex and requires more than piecemeal inquiry.Materials and methodsData methodsThis study is based on data from the 2007 Jamaica Survey of Living Conditions (JSLC),conducted by the Planning Institute of Jamaica (PIOJ) and the Statistical Institute of Jamaica(STATIN). The JSLC is an annual and nationally representative cross-sectional survey thatcollects information on consumption, education, health status, health conditions, health careutilization, health insurance coverage, non-food consumption expenditure, housing conditions,inventory of durable goods, social assistance, demographic characteristics and other issues [14].The information is from the civilian and non-institutionalized population of Jamaica. It is amodification of the World Bank’s Living Standards Measurement Study (LSMS) householdsurvey [15]. Overall, the response rate for the 2007 JSLC was 73.8%. Over 1994 households ofindividuals nationwide are included in the entire database of all ages [16]. A total of 620households were interviewed from urban areas, 439 from other towns and 935 from rural areas.This sample represents 6,783 non-institutionalized civilians living in Jamaica at the time of thesurvey. The JSLC used complex sampling design, and it is also weighted to reflect thepopulation of Jamaica.Statistical analysis 35  
  45. 45. Statistical 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 an Analysis of Variance (ANOVA) was used to test the equality of meansamong non-dichotomous categorical variables. Means and frequency distribution wereconsidered significant at P < 0.05 using chi-square, independent sample t-test, and analysis ofvariance f test, multiple logistic and linear regressions.Analytic ModelsCross-sectional analyses of the 2007 JSLC were performed to compare within and between sub-populations and frequencies. Logistic regression examined the relationship between thedichotomous binary dependent variable and some predisposed independent (explanatory)variables. A pvalue < 0.05 was selected to established statistical significance. Analytic models, using multiple logistic and linear regressions, were used to ascertainfactors which are associated with (1) self-rated health status, (2) health care utilization, (3) self-reported illness, (4) self-reported diagnosed chronic illness, and income. For the regressions,design or dummy variables were for all categorical variables (using the reference group listedlast). Overall model fit was determined using log likelihood ratio statistic, odds ration and r-squared. Stepwise regressions were used to determine the contribution of each significantvariable. All confidence interval (CIs) for odds rations (ORs) were calculated at 95%.Results 36  
  46. 46. Demographic characteristic of sampleThe sample was 6,783 respondents (48.7% males and 51.3% females). Children constituted31.3%; other aged adults, 31.3%; young adults, 25.9%; and elderly, 11.9%. The elderlycomprised 7.7% young-old, 3.2% old-old and 1.0% oldest-old. Majority of the sample had noformal education (61.8%); primary, 25.5%; secondary, 10.8% and tertiary, 2.0%. Two-thirds ofthe sample sought health in the last 4-weeks; 69.2% were never married; 23.3% married; 1.7%divorced; 0.9% separated and 4.9% were widowed respondents. Almost 15% reported an illnessin the last 4-weeks (43.3% had chronic conditions, 30.4% had acute conditions and 26.3% didnot specify the condition). Of those who reported an illness in the last 4- weeks, 87.9% providedinformation on the typology of conditions: cold, 16.7%; diarrhea, 3.0%; asthma, 10.7%; diabetesmellitus, 13.8%; hypertension, 23.1%; arthritis, 6.3%; and specified conditions, 26.3%. Marginalmore people were in the upper class (40.3%) compared to the lower socioeconomic strata(39.8%). Only 20.2% of respondents had health insurance coverage (private, 12.4%; NI Gold,public, 5.3%; other public, 2.4%). Majority of health insurance was owned by those in the upperclass (65%) and 19% by those in the lower socioeconomic strata.Bivariate analyses Sixty-one percent of those with chronic conditions were elderly compared to 16.6% ofthose with other conditions (including acute ailments). Only 39% of those with chronicconditions were non-elderly compared to 83.4% of those with other conditions – (χ2 = 187.32, P< 0.0001). Thirty-three percent of those with chronic illnesses had health insurance coveragecompared to 17.8% of those with acute and other conditions - (χ2 = 26.65, P < 0.0001). 37  
  47. 47. Furthermore examination of self-reported health conditions by health insurance status revealedthat diabetics recorded the greatest percent of health insurance coverage (43.9%) compared tohypertensive, (28.2%); arthritic (25.5%); acute conditions’ patients (17.0%) and other healthconditions respondents (18.8%). Sixty-seven percent of respondents who reported beingdiagnosed with chronic conditions sought medical care in the last 4-weeks compared to 60.4% ofthose with acute and other conditions (χ2 = 4.12, P < 0.042). Those with primary or beloweducation were more likely to have chronic illnesses (45.0%) compared to secondary level(6.1%) and tertiary level graduants (11.1%) - (χ2 = 23.50, P < 0.0001). There was nostatistical association between typology of illness and social class - (χ2 = 0.63, P = 0.730): upperclass, 44.6%; middle class, 41.1% and lower class, 43.0%. This study found significant statistical association between health insurance status and (1)educational level (χ2 = 45.06, P < 0.0001), (2) social class (χ2 = 441.50, P < 0.0001), and (3) agecohort (χ2 = 83.13, P < 0.0001). Forty-two percent of those with at most primary level educationhad health insurance coverage compared to 16.3% of secondary level and 42.2% of tertiary levelrespondents. Thirty-three percent of upper class respondents had health insurance coveragecompared to 16.7% of those in the middle class and 9.4% of those in the lower socioeconomicstrata. Almost 33% of the oldest-old had health insurance coverage compared to 15.1% ofchildren; 18.4% of young adults; 23.6% of other aged- adults; 28.6% of young-old and 24.9% ofold-old. A significant statistical association was found between health insurance status and areaof residence (χ2 = 138.80, P < 0.0001). Twenty-eight percent of urban dwellers had healthinsurance coverage compared to 22.1% of semi-urban respondents and 14.5% of rural residents.Furthermore, similarly a significant relationship existed between health care seeking behaviourand health insurance status (χ2 = 33.61, P < 0.0001). Fourteen percent of those with health 38  
  48. 48. insurance sought medical care in the last 4-weeks compared to 9.0% of those who did not havehealth insurance coverage. Likewise a statistical association was found between health insurancestatus and typology of illness (χ2 = 26.65, P < 0.0001). Fifty-eight percent of those withinsurance coverage had chronic illnesses compared to 38.3% of those without health insurance.Concurringly, 42% of those with insurance coverage had acute or other conditions compared to62% of those who did not have health insurance coverage. Further examination revealed thatother public health insurance was mostly had by those with chronic illnesses (76%) compared toNI Gold (public, 65%) and 44% private health coverage (χ2 = 42.62, P < 0.0001). Private healthcoverage was most had by those with non-chronic illnesses (56%) compared to 35% with NIGold (public) and 25% other public coverage. No significant statistical difference was found between the average medical expenditureof those who had insurance coverage and non-insured (t = 0.365, P = 0.715) – mean averagemedical expenditure of those without health insurance was USD 10.68 (SD = 33.94) and insuredrespondents’ mean average medical expenditure was USD 9.93 (SD = 18.07) - (Ja. $80.47 = US$1.00 at the time of the survey). There was no significant statistical relationship between health care utilization (public-private health care visits) and health conditions (acute or chronic illnesses) – χ2 = 0.001, P =0.975. 49.2% of those who had chronic illnesses used public health care facilities compared to49.3% of those with acute conditions. There is a statistical difference between the mean age of respondents with non-chronicand chronic illnesses (t = - 23.1, P < 0.0001). The mean age of some with chronic illnesses was62.3 years (SD = 16.2) compared to 29.3 years (SD = 26.1) for those with non-chronic illnesses.Furthermore, the mean age of insured respondents with chronic illnesses was 63.8 years (SD = 39  

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