Poverty & Health


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This book evaluates the interconnectivity among poverty, health and other social factors, particularly among Jamaicans.

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Poverty & Health

  1. 1. Poverty & Health Paul Andrew Bourne
  2. 2. Poverty & Health i
  3. 3. Poverty & Health Paul A. Bourne Socio-Medical Research Institute Socio-Medical Research Institute Kingston, Jamaica ii
  4. 4. ©Paul A. Bourne, 2011First Published in Jamaica, 2011 byPaul Andrew Bourne66 Long Wall DriveStony Hill,Kingston 9,St. AndrewNational Library of Jamaica Cataloguing DataPoverty and HealthIncludes indexISBNBourne, Paul AndrewAll rights reserved. Published, 2011Cover designed by Paul Andrew BourneSocio-Medical Research InstituteKingston, Jamaica, West Indies iii
  5. 5. To Kimani & Kerron This one is yours iv
  6. 6. ContentsPreface viiAcknowledgement viiCHAPTER 1: Overview of Poverty and Health 1CHAPTER 2: Poverty, Unemployment, Illness, Health Insurance and Health-care Seeking Behaviour in Jamaica: A Multivariate Analysis 24CHAPTER 3: Modelling social determinants of self-evaluated health of poor older people in a middle-income developing nation 51CHAPTER 4: Disparities in self-rated health, health care utilization, illness, chronic illness and other socioeconomic characteristics of the Insured and Uninsured 76CHAPTER 5: Self-evaluated health and health conditions of rural residents in a middle-income nation 108CHAPTER 6: Determinants of self-reported health conditions of people in the lower socioeconomic strata, Jamaica 135CHAPTER 7: The uninsured ill in a developing nation 160CHAPTER 8: Self-reported health and medical care-seeking behaviour of uninsured Jamaicans 191CHAPTER 9: Health Inequality in Jamaica, 1988-2007 215CHAPTER 10: Impact of poverty, not seeking medical care, unemployment, inflation, self- reported illness, and health insurance on mortality in Jamaica 249CHAPTER 11: Health Disparities and the Social Context of Health Disparity between the Poorest and Wealthiest quintiles in a Developing Country 284CHAPTER 12: Is income a stronger determinant of self-rated health status than other socioeconomic and psychological factors? 312CHAPTER 13: Health insurance coverage in Jamaica: Multivariate analyses using two cross- sectional survey data for 2002 and 2007 339 v
  7. 7. CHAPTER 14: Retesting and refining theories on the association between illness, chronic illness and poverty: Are there other disparities? 369CHAPTER 15: Health of females in Jamaica: using two cross-sectional surveys 393CHAPTER 16: Childhood Health in Jamaica: changing patterns in health conditions of children 0-14 years 412CHAPTER 17: Inflation, Public Health Care and Utilization in Jamaica 439CHAPTER 18: Health status and Medical Care-Seeking Behaviour of the poorest 20% in Jamaica 482CHAPTER 19: Self-rated health and health conditions of married and unmarried men in Jamaica 510CHAPTER 20: Self-evaluated health of married people in Jamaica 537 vi
  8. 8. PrefaceThe issue of poverty is well discussed and this discourse is well documented in the literature.The World Health Organization found that 80% of chronic illnesses were in low and middleincome countries, 60% of global mortality is caused by chronic illness, 65-70% of people whomentioned that they were unable to afford medication claimed that they were unable to afford it,suggesting that poverty retards the quality and productive of human capital, and that povertyaccounts for some of the premature mortality.In Jamaica, rural poverty is twice more than urban poverty (PIOJ & STATIN, 2007). Despitethis a more social inequalities in Jamaica, the issue of poverty has never been comprehensivelystudy in a single volume. Poverty and Health is an introductory examination of matterssurrounding the two phenomena, with emphasis on Jamaicans and sub-populations.AcknowledgementLike many books that have been written prior to this one, I am also indebted to many peoplehave contributed differently and some invariably to the completion of this project. I would like toextend my sincere gratitude to them. These persons are 1) Ms. Neva South-Bourne for her advicein penning my ideas, 2) Mrs. Evadney Bourne, my wife, for support, understanding and patiencewhen things were difficult and surmountable at times, 3) all my co-writers, 4) God, for hiswisdom, 5) the Data Bank in Sir Arthur Lewis Institute of Social and Economic Studies, theUniversity of the West Indies, Mona, Jamaica for making the dataset available for use in thisstudy, and 6) all my associates (including best friends) whose love, support and encouragementprovided the impetus that I drew from to complete this project. I would also like to single out thedifferent journals that gave me the permission to reproduce some of the chapters – includingNorth American North of Medical Sciences, and Current Research in Social Sciences. vii
  9. 9. Poverty & Health viii
  10. 10. Chapter 1Overview of Poverty and HealthThe WHO (2005) opined that 80% of chronic illnesses were in low and middle income countries,suggesting that illness interfaces with poverty and other socio-economic challenges. Povertydoes not only impact on illness, it causes pre-mature deaths, lower quality of life, lower life andunhealthy life expectancy, low development and other social ills such as crime, high pregnancyrates, and social degradation of the community. According to Bourne, Beckford and McGrowder(inprint), there is a positive correlation between poverty and unemployment; poverty and illness;and crime and unemployment. Embedded in those findings are the challenges of living inpoverty, and the perpetual nature of poverty and illness, illness and poverty, poverty andunemployment, economic deprivation and psychological frustration of poor families. Sen (1979)encapsulated this well when he forwarded that low levels of unemployment in the economy isassociated with higher levels of capabilities. This highlights the economic challenge ofunemployment and equally explains the labour incapacitation on account of high levels ofunemployment, which goes back to the WHO’s perspective that chronic illnesses are moreexperienced by low-to-middle income peoples. According to WHO (2005), 60% of globalmortality is caused by chronic illness, and this should be understood within the context that four-fifths of chronic dysfunctions are in low-to-middle income countries. Jamaica is among those countries classified as a developing nation (or low income).Hence, the challenges which were stated earlier also influence the quality of life of some people 1
  11. 11. within the society. In 1988, Jamaica’s unemployment rate was 18.9% and 2 decades later (2007),this fell by 67.2% (to 6.2%) which indicates close to full-employment (PIOJ & STATIN 2007).This significant reduction in unemployment rates cannot be the only indicator used to evaluatethe socio-economic status of Jamaica and for a hasty conclusion to be drawn that the quality oflife of Jamaicans is better in 2007 compared to 1988. In 1988, inflation rate in Jamaica was 8.8%and this increased by over 90%, suggesting that the economic cost of living of Jamaicans wassubstantially higher than twenty years earlier. Importantly to note that the inflation rate in 2007(16.8%) increased by 194.7% over 2006. This then explains why in 2007, the number ofJamaicans seeking medical care fell to 66% over 70% in the previous year; while self-reportedwas 15.5%, the highest in the 20-year period. In Jamaica, rural poverty is twice more than urban poverty (PIOJ & STATIN, 2007).This may create the impression that urban poverty is low and does not demand an examination.Poverty is poverty and whether it occurs in rural, peri-urban or urban areas; its effect is the same.Hence, when poverty is coupled with unemployment, chronic illnesses and ageing, it createssocio-economic challenges that can result in pre-mature death. In an article titled ‘Poverty and household size’, Lanjouw and Ravallion (1995) argue thatthere is substantial evidence to show that a strong negative association exists between householdsize and consumption per person in developing countries. This postulation highlights the how itis that household size is probabilistically low in relation to access to post-secondary education.From Lanjouw and Ravallion work (on Pakistan data), the poor who are predominantly fromlarge household size in developing countries will not be able to spend needed financial resourceson education despite its offerings because a large proportion of their income (i.e. consumption) 2
  12. 12. must be spent on food, water, cooking utensils, firewood (i.e. fuel), clothing and housing. A partof Lanjouw and Ravallion’s work spoke to the association that exist in poor household, which isthat they tend to have larger families. Buhmann, et al (1988), by means of cross-country information from a LuxembourgIncome Study data base on 10 developed countries, and Coulter, et al (1992), using the UnitedKingdom Family Expenditure Survey data, both find associative relationship between inequalityand poverty estimates within the context of household size and consumption. A study conductedby Meenakshi and Ray (2000) on 68,102 households in rural India, concurs with the findings ofprevious studies that an inverse relationship exists between household size and consumption.With the robustness of household size of the poor and the degree of material deprivation, theyare then less likely to access secondary and so post-secondary education. This is primarily dueto incapacitation and not ability or intellectual capacity of the people. It, therefore, can beconstrued from studies that poverty may be caused from household size, which the influencesaccess to post-secondary education. One of the components of poverty is high rates of unemployment and so it is highlyprobabilistic that the poor will reside within a particular geo-political zone due to financialconstraints. The poor are more likely to live in low-income areas, slums, dilapidated building,within poor socio-economic surroundings, and in violent prone areas (Joseph RowntreeFoundation, 2000, p. 3 - 5). Statistics for Jamaica revealed that unemployment is highest amongthe poor and so is the lowest level of education. According to the WHO (2005) 80% of chronic diseases occur in low and middle incomecountries (p 4). The WHO stated that “In reality, low and middle income countries are at the 3
  13. 13. centre of both old and new public health challenges” (WHO, 2005, p. 9). The high risk of deathin low income countries is owing to food insecurity, low water quality, low sanitation coupledwith inaccess to financial resources. Poverty makes it insurmountable for poor people to respondto illness unless health care services are free. Hence, the people who are poor will suffer evenmore so from chronic diseases. The WHO captures this aptly “...People who are already poor arethe most likely to suffer financially from chronic diseases, which often deepen poverty anddamage long term economic prospects” (WHO, 2005, p. 11). Again this goes back to the inversecorrelation between poverty and higher level education, poverty and non-access to financialresources, and now poverty and illness. Jamaicans enjoy high life expectancy (over 75 years for men and 77 years for women) inspite of a relative low per capita Gross Domestic Product (GDP per capita), high crime rates, andthe fact that the country is among the developing nations. In a recently concluded study byBourne, McGrowder and Beckford (in print), a moderate positive correlation was found betweenillness and unemployment, illness and poverty and poverty and private health insurancecoverage. Powell, Bourne and Waller (2007), using probability sampling cross-sectional surveyof 1,338 Jamaicans, found that the poor (ie lower class) has the lowest self-evaluated healthstatus, with the middle class reported the greatest health status. “In Jamaica 59% of people withchronic diseases experienced financial difficulties because of their illness...”(WHO, 2005, p. 66).This goes to the previous findings that argued about the negative association between povertyand education, and poverty and tertiary education; and the positive correlation between povertyand illness. Poverty is not only eroding people’s standard of living (ie economic wellbeing), it isdirectly associated with increased chronic and non-chronic illness and the challenges of onesinability to access health care services. This can be seen in a finding of WHO (2005), which 4
  14. 14. indicated that in 2000, 65-70% of people who mentioned that they were unable to affordmedication claimed that they were unable to afford it, suggesting that poverty retards the qualityand productive of human capital.Health Issues in particular Caribbean territoriesIn an article published by Caribbean Food and Nutrition Institute, the prevalence rate of diabetesmellitus affecting Jamaicans is higher than in North American and “many European countries”.(Callender 2000, 67). Diabetes Mellitus is not the only challenge faced by patients, butMcCarthy (2000) argues that approximately 30% to 60% of diabetics also suffer fromdepression, which is a psychiatric illness. Such a situation further complicates the woes of theelderly as they seek to balance other psycho-sociological conditions with the diabetes andhypertension as well as the stress that is frequently associated with the illness. Morrison (2000) titled an article ‘Diabetes and hypertension: Twin Trouble’ in which heestablishes 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. They found that there is a positive association between diabetic and hypertensivepatients - 50% of individuals with diabetes had a history of hypertension (Callender 2000, 67).Prior to those scholars’ work, Eldemire (1995) finds that 34.8% of new cases of diabetes and39.6% of hypertension were associated to senior citizens (i.e. ages 60 and over). 5
  15. 15. AsthmaAsthma is a chronic inflammation of the bronchial tubes that causes swelling and narrowing ofthe airways. The result is difficulty breathing, the bronchial narrowing is usually either totally orpartially reversible with treatments. The muscles around the bronchial tubes tighten, causing theairways to narrow. This is known as bronchospasm or bronchoconstriction. Mucus is producedwithin the bronchial tubes further restricting air flow Bronchial tubes that are chronically inflamed may become overly sensitive to allergens orirritants; the airways may become "stressed out" and remain in a state of heightened sensitivity.This is called "bronchial hyper-reactivity" however, it is clear those asthmatics and allergicindividuals, without apparent asthma have a greater degree of bronchial hyper-reactivity thannon-asthmatic and non-allergic persons. In sensitive individuals, the bronchial tubes are more likely to swell and constrict whenexposed to triggers such as pollen, tobacco smoke, or exercise. Amongst asthmatics, some mayhave mild bronchial spasms and no symptoms while others may have severe bronchial spasmsand chronic symptoms. Prevalence rates for asthma world-wide are said to be rising on average by 50% everydecade. According to the World Health Organization, asthma is now a serious public healthproblem with over 100 million sufferers worldwide. World-wide, deaths from this condition havebeen reported to have reached over 180,000 annually. In the United States alone, the number ofasthmatics has leapt by over 60% since the early 1980s and deaths have doubled to 5,000 a year.The economic costs associated with asthma are estimated to exceed those of TB and HIV/AIDS 6
  16. 16. combined world wide. The prevalence of asthma in the Caribbean is among the highest in theworld and the disease is associated with an unacceptable high morbidity and mortality. Asthma affects people differently. Each individual is unique in their degree of reactivityto environmental triggers. This naturally influences the type and dose of medication prescribed,which may vary from one individual to another. The normal bronchial tubes allow rapid passageof air in and out of the lungs to ensure that the levels of oxygen and carbon dioxide remainconstant in the bloodstream. The outer walls of the bronchial tubes are surrounded by smoothmuscles that contract and relax automatically with each breath. This allows the required amountof air to enter and exit the lungs to achieve the normal exchange of gases. The contraction andrelaxation of the bronchial smooth muscles are controlled by two different nervous systems thatwork in harmony to keep the airways open The lining of the bronchial tubes contains cells that are intended to protect the bronchialmucosa from microbes, allergens, and irritants inhaled, which can cause the bronchial tissue toswell. These inflammatory cells play an important role in allergic reactions and their presencecauses the bronchial tissue to be a major unit for an allergic inflammatory process. Asthma causes a narrowing of the airways, which interferes with the normal movementof air in and out of the lungs; it involves only the bronchial tubes and does not affect the air sacsor the lung tissue. The narrowing that occurs in asthma is caused by three major factors:Inflammation; Bronchospasm, and Hyper-reactivity. The first and most important factor causing narrowing of the bronchial tubes isinflammation. The bronchial tubes become red, irritated, and swollen. The inflammation 7
  17. 17. increases the thickness of the walls of the bronchial tubes and results in a narrower passagewayfor the flow of air. It occurs in response to an allergen or irritant and results from the action ofchemicals such as histamines and others. The inflamed tissues produce excessive amounts of"sticky" mucus into the tubes which can clump together block the smaller airways. During an attack of asthma, the muscles around the bronchial tubes tighten and cause theair way to narrow further; this is called bronchospasm. The inflamed and constricted airways become highly sensitive, or reactive to triggerssuch as allergens, irritants, and infections. Exposure to these triggers may result in progressivelymore inflammation and narrowing. The combination of these three factors results in difficultywith breathing out and as a result, the air needs to be forcefully exhaled to overcome thenarrowing, thereby causing a wheezing sound. Individuals with asthma frequently cough in anattempt to expel the thick mucus plugs. As a result of the reduced air flow less oxygen reachesthe bloodstream and if very severe, carbon dioxide accumulates in the blood. The severity of anasthma attack depends on how many agents activated the symptoms and how sensitive the lungsare to them.DiabetesDiabetes is a disease in which the body does not produce or properly use insulin it ischaracterized by abnormally high levels of sugar in the blood. When the amount of glucose inthe blood increases, e.g., after a meal, it triggers the release of the hormone insulin from thepancreas. Insulin stimulates muscle and fat cells to remove glucose from the blood and 8
  18. 18. stimulates the liver to metabolize glucose, causing the blood sugar level to decrease to normallevels. In people with diabetes, blood sugar levels remain high. This may be due to insulin notbeing produced at all, is not made at sufficient levels, or is not as effective as it should be. Themost common forms of diabetes are type 1, reported to be approximately 5% of all diabetics andan autoimmune disorder, and type 2, which is associated with obesity and representsapproximately 95 % of all diabetics. Type 1 diabetes, most commonly occurs in children and is a result of the bodys immunesystem attacking and destroying the beta cells of the pancreas rendering it unable to produceinsulin. The trigger for this autoimmune attack is not clearly understood, but results in the end ofinsulin production. In contrast, type 2 diabetes is a condition in which a resistance to the effects of insulin ora defect in insulin secretion comes about. It commonly occurs in adults who are obese. There aremany risk factors that contribute to the high blood sugar levels in these individuals but animportant factor is the bodys resistance to insulin, basically ignoring its insulin secretions. Asecond factor is the falling production of insulin by the beta cells of the pancreas; an individualwith type 2 diabetes may have a combination of deficient secretion and deficient action ofinsulin. The World Health Organization estimates that more than 180 million people worldwidehave diabetes and this number is likely to more than double by 2030. Almost 80% of diabetesdeaths occur in low and middle-income countries, about half of diabetes deaths occur in people 9
  19. 19. under the age of 70 years; 55% of diabetes deaths are in women. WHO projects those diabetesdeaths will increase by more than 50% in the next 10 years without urgent action. Most notably,diabetes deaths are projected to increase by over 80% in upper-middle income countries between2006 and 2015. The driving force behind the high prevalence of diabetes is said to be the rise of obesityin the population. It can be difficult to maintain a healthy weight as there is a combination ofunhealthy foods and a sedentary lifestyle which is in contrast to years ago, when people weremore active and unhealthy fast foods were not as abundant. As a result, many persons are obeseand poverty is increasing the risk as finance is limited Type 2 diabetes is common in people who eat too much fat and carbohydrate, too littlefibre, and get too little exercise. In contrast, people who live in areas that have not adopted awestern lifestyle tend not to get type 2 diabetes, regardless of their genetic risk. Obesity is astrong risk factor for type 2 diabetes and is most risky for young people and for people who havebeen obese for a long time.GlaucomaGlaucoma is a common eye condition in which the fluid pressure inside the eyes rises because ofslowed fluid drainage from the eye. If untreated, it may damage the optic nerve and other parts ofthe eye, causing the loss of vision or even blindness. The optic nerve is the major nerve of vision; it receives light from the retina and transmitsimpulses to the brain which is perceived as vision. Glaucoma is characterized by a pattern ofprogressive damage to the optic nerve that usually begins with a loss of side vision. If glaucoma 10
  20. 20. is not diagnosed and treated early, it can progress to loss of central vision and blindness. Theelderly and people with family histories of the disease are at greatest risk. There are nosymptoms in the early stage. Often, by the time the patient notices vision loss; glaucoma can behalted but not reversed. Glaucoma is usually, but not always, associated with elevated pressure in the eye calledintraocular pressure. Generally, it is this elevated eye pressure that leads to damage of the opticnerve. In some cases, glaucoma may occur in the presence of normal eye pressure. This form ofglaucoma is believed to be caused by poor regulation of blood flow to the optic nerve. There are several different types of glaucoma, including open-angle glaucoma and acuteangle-closure glaucoma. Open-angle glaucoma is the common adult-onset type. Acute angle-closure glaucoma is a less common form but one that can rapidly impair vision. The treatment of glaucoma may include medication, surgery, or laser surgery. Eye dropsor pills alone can usually control glaucoma, although they cannot cure it. Some drugs aredesigned to reduce pressure by slowing the flow of fluid into the eye, while others help toimprove fluid drainage. Surgery to help fluid escape from the eye was once extensively used, butexcept for laser surgery, it is now reserved for the most difficult cases. In laser surgery forglaucoma, a laser beam of light is focused on the part of the anterior chamber where the fluidleaves the eye. This results in a series of changes, making it easier for fluid to exit.HypertensionHigh blood pressure or hypertension is a term used to refer to high pressure in the arteries. Highblood pressure does not mean excessive emotional tension, although emotional tension and stress 11
  21. 21. can temporarily increase blood pressure. Normal blood pressure is below 120/80; blood pressurebetween 120/80 and 139/89 is called "pre-hypertension", and a constant blood pressure of 140/90or above is considered as high blood pressure. The numerator or the systolic blood pressure corresponds to the pressure in the arteries asthe heart contracts and pumps blood into the arteries. The denominator or the diastolic pressurerepresents the pressure in the arteries as the heart relaxes after the contraction. The diastolicpressure reflects the lowest pressure to which the arteries are exposed. An elevation of the systolic and or diastolic blood pressure increases the risk ofdeveloping cardiac disease, renal disease, atherosclerosis, arteriosclerosis, eye damage, andstroke. These complications of hypertension are often referred to as end-organ damage becausedamage to these organs is the end result of chronic high blood pressure. For this reason, thediagnosis of high blood pressure is important so efforts can be made to normalize blood pressureand prevent complications. Previously, it was thought that rises in diastolic blood pressure were a more importantrisk factor than systolic elevations, but it is now known that in people 50 years or older systolichypertension represents a greater risk. Reports are that many persons are living with undiagnosedhypertension making it a major public health problem.Poverty depicts deprivation of material resources, inadequacies to access some goods andservices, lower nutritional intakes, lower capabilities and education, high unemployment,unhealthy diet, and lower health status (World Bank, 2006; WHO 2005; Younger, 2002; Sen,1979). Hence, it is not surprising that chronic illnesses are greater in lower and middle 12
  22. 22. income countries than in the developed nations. Importantly, in any discussion on poverty isits direct effect on income, wealth, productive, employment and the family. Despite one’swealth, chronic illness can deplete this in a short time. If illness can cause poverty, whathappens to the poor who are interfacing with many chronic dysfunctions. The WHO (2005)offered some explanation for poverty and chronic illness, when it opined that this can resultin premature mortality. The current study examines poverty and illness, illness on a family and thechallenges of an urban poor woman and the challenges of intervention mechanism to alleviatethe psychosocial challenges that the family faced owing to poverty and chronic illnesses. Theimpact of illness on an urban poor family is extensive, far reaching, catastrophic, dehabilatingand can result in premature death. Illness coupled with poverty as well as being a woman is ahallmark for psychosocial challenges for public health practitioners, health care workers,community aides, social workers, and intervention specialists. Poverty increases the riskfactors of illnesses and can further erode the economic livelihood of the person, family,community, society and country. Illness reduces an individual ability to carry out his/her function, and thereforeretards employment status. When chronic illnesses become severe and long lasting, theeconomic burden of this can destroy a family and this does not include the psychosocialchallenges of reduced daily activities of the individual. When illness influences the head ofhousehold, this is always problematic for the individual and by extension the other familymembers. If the illness results in unemployment, there is a greater probability that otherfamily members will be incapacitated of educational and other goods and services. This 13
  23. 23. oftentimes results in an association between activities inability and socio-economic burdenon the family (Elmstahl et al., 1996). Morrison (2000) titled an article ‘Diabetes and hypertension: Twin Trouble’ in whichhe established that diabetes mellitus and hypertension have now become two problems forJamaicans and in the wider Caribbean. This situation was equally collaborated by Callender(2000) and Steingo (2000) at the 6th International Diabetes and Hypertension Conference,which was held in Jamaica in March 2000. They found that there is a positive associationbetween diabetic and hypertensive patients - 50% of individuals with diabetes had a history ofhypertension (Callender 2000, 67; Steingo 2000, 75). Those diseases are not only lifestylecausing, they are expensive to treat especially if they become severe. Hence, health insurancecoverage is sought in keeping with the probability of illness but it remains beyond the reach ofthe poverty stricken. From the findings of a cross-sectional study conducted by Powell, Bourne and Waller(2007) of some 1,338 Jamaicans, 19.0% of respondents perceived their economic wellbeing to be‘very bad’. In addition, when they were asked, “Does your salary and the total of your family’ssalary allow you to satisfactorily cover your needs”, 57.4% of them felt that this “does notcover” their expenses (Powell, Bourne and Waller 2007, 29). Added to this out of a maximumscore of 10, those in the lower class scored 5.9 for how do they ‘feel about the state of theirhealth’ compared to a score of 6.6 for those in the upper class and a score of 6.7 for the middleclass. This again speaks to the difficulty that is faced by poor Jamaicans, and when this isaccompanied by illness, unemployment, low education and poverty in the extended, this makes itsignificantly more difficulty for the family member who is the head of the household. 14
  24. 24. In this study the client was one in a family that experienced poverty, and the introductionof chronic illness of the person’s mother meant that she had to rearrange her life in keeping withaiding her parent to cope with the illness. In order to care for her parent, she had to leave her job.The state of unemployment coupled with chronic illness of her parent eventually eroded theclient’s financial basis. The client was thrust into the status of the head of the household, and thismeant that she had to provide for the family socially, economical and psychological. When the client became ill in addition to being unemployed, meant that she was now force tocare for a family in poverty while being ill, unemployment, and psychosocially challenged by hernew reality. Illness further sank the client into more poverty, deprivation, further inability totake care of the extended family and herself and this resulted in a period of depression. Thechallenges for this family compounded when young household members began to be abusive,disrespectful, disobedient, unsympathetic and preceded in the dismemberment of the familystructure. This family saw household members becoming involved with ‘gunmen’, men andspouses as a medium of intent to change their economic base. Household members removedfrom the family home, but instead of changing the cycle of poverty that they grew up in, fell preyto it. Those younger siblings of the client’s parents began having children and this was suchthat some of them have eight children for eight different fathers, and these children became the responsibility of the unhealthy client. Despite the unselfishessness of the client tohold the family together and to offer other members an opportunity to learn from her mistake aswell as to provide for them, the failure to accomplish such mammoth tasks have seeminglycreated psychosocial challenges for the client as well as the extended family. 15
  25. 25. While the intervention provides some relief for the client, and that some aspects will beforthcoming, the researchers fear that continuous socio-economic interventions by students of theMaster in Public Health (MPH) will create a dependency syndrome in this family. Theresearchers are cognizant that poverty is difficult to break (read Dereck Gordon, 1987), but thereis another side to this reality as poverty could breathe complacency, dependency and deepenitself. It is germane that while we seek to alleviate the sufferings of poor people, includingchildren and women, our efforts should not be misunderstood by members in the society that theUniversity of the West Indies is here to aid them for their actions (or inactions) that result in theircurrent state. Chronic illness can erode economic livelihood, health, family structure and theinterpersonal relationship between and among family members. An occasional intervention isdifficult to make a substantial impact on a poor family’s socioeconomic position and this is mademore difficult when a family member is suffering from a chronic illness and there is wide spreadfamily unemployment. The US Information Service in speaking of the issue of poverty uses the United Nationsreport of 1996 to argue that: … the quality of peoples lives cannot be measured by income alone. It says that while Pakistan has had enviable economic growth, 61 percent of the population there lacks the health, education and nourishment needed to climb out of poverty. Argentinas income is among the highest in the developing world, but 20 percent of its rural population live in financial poverty and 29 percent lack access to safe water (US Information Service, 1996). From the US Information Service’s monograph, the poor is unable to access education,and some writers argue that this is not to any doings of their own. In its monograph, the USInformation Service has not afford a perspective on the levels of education to which poor isunable to access. The researcher believes that this is even more difficult the higher one climbs on 16
  26. 26. the education rung. This is even supported by US Information Service’s citation of the UNreport that: To reduce inequality while promoting growth, the report suggests that national authorities need to give more attention to human development, poverty reduction, and employment policies, especially for women; expand access to land and credit; boost investment in and access to education and health…(US Information Service, 1996). There is a convergence in principle that access to education reduces poverty. Academics,researchers, non-governmental and governmental institutions are saying that access to qualityeducation is the hallmark of poverty alleviation. According to the US Department of State, Food security and alleviating hunger hinge, among other things, on defining property rights for small-scale farmers, on technology, and on providing social safety nets to the most vulnerable groups, says U.S. Secretary of Agriculture Ann Veneman. Cato Institute economist Ian Vásquez also highlights the property rights issue, as well as the correlation of economic freedom with poverty reduction (US Department of State, 2002). From the perspective of the US Department of State, poverty alleviation will only beaccomplished by addressing not only ‘food security’ but on ‘economic freedom’. Such a state inthe social setting of the poor must come from access to quality and higher education. Povertyreduction, therefore, does not rest with the provision of food to the poor or to poor countries, asthis will not go to destroy the economic livelihood of farmers and other institutions within therecipient country. The issue can only be address from a multidimensional approach whichincludes the provision and access of education to all peoples within the country. By provideaccess to quality education, the poor is given an opportunity to gain financial independence.This seemingly simplistic approach holds the key to financial freedom, hunger eradication,opportunities, plethora of choices and social harmony. Another aspect that is hidden in the foodinsecurity is the nutritional deficiencies, and the direct association between poverty and illness,unemployment and crime, unemployment and poverty and unemployment and illness. 17
  27. 27. In ‘They cry ‘respect’: Urban violence and poverty in Jamaica’, Horace Levy, a seniorlecturer in the department of Sociology, Psychology and Social Work at the University of theWest Indies, Mona, in his research, finds that there is a relationship between unemployment andcrime. He says that “along with people from other areas they point to a direct link betweenunemployment and crime.” (Levy, 2001, p.10). Despite the qualitative methodology that he usesto acquire data for his findings, Levy’s findings provide a basis, upon which an understandingmay be had of the importance of financial independence, violence and crime, unemployment andpoverty. From Levy’s study, chief among the characteristics of youth involvement in gangs is“parents not educated”. It is clearly from Levy’s study, that the poor experience a high rate ofnon-school attendance because of in affordability. With such a setting, the ability to transformtheir lives is high improbable as they lack the financial resources, and their human capital israther low making their labour cost low, and this explain the high degree of unemployment orinvolvement in menial work or ‘hustling’. Lipton and Litchfield (2001) forward an explanationfor setting above. They say that “One of the main conclusions from Lipton (1998) is that higherlevels of resources are associated with lower levels of poverty” (Lipton & Litchfield, 2001, p.3). Access to tertiary education is a difficult option for the poor. Based on studies, educationis a vehicle in the socio-economic mobility (development) (Nie, et al., 1972) to which if can beaccess by the poor will transform their social-environment (Barr, 2005). Poverty preventseconomic freedom and choice, and so despite ones willingness, this circumvents many realitiesof their experience. The poor is held in the vicious cycle of continuous poverty. The Inter-American Development Bank in highlighting the social conditions of the poor says, “Who arethe poor? They are likely to be less educated and to work in the informal sector” (Inter-AmericanDevelopment Bank, 1998, p. 12). One writer forwards a perspective that converges with that of 18
  28. 28. the Inter-American Development Bank that access to higher education is the most basicingredient in the reduction of poverty (NetAid, 2005). NetAid asks the question ‘Why iseducation key to ending global poverty?’ Illiterate adults tend to be poor (Younger, 2002 p.98) Poverty is correlated with adults’ educational level: 66 percent of illiterate are adults poor,…64 percent of adults who did not graduate for primary school are poor, …22 percent of secondary school graduates are poor (Younger, 2002, p. 100) From Younger’s findings, an underline principle of poverty is illiteracy and how it affectsthe adult age cohorts. With such a finding, poverty directly affects the quality of the labourstock. The situation emphasizes how access to tertiary level education is inversely related to theadult poor as those who can access post-secondary education; only 22 percent of secondarygraduands are poor. Embedded within this finding is how increase in age of the poor willinversely relate to accessing post-secondary level education, and the low probability of the pooraccessing post-secondary education.ABOUT THIS BOOK Poverty is essentially the lack of means to live. At the heart of any consideration of poverty lies the issue of what is needed to live “a decent life” and, more fundamentally, what it is to be human (Senate Community Affairs References Committee, 2004, p.5). The existence of so many poor people in the capitals of the Caribbean has transformed those cities into large slums with here and there pockets of the upper and middle classes. …The poor, having been exploited over and over again by the elite, now live in large numbers in the cities and share the facilities developed earlier to meet chiefly the needs of the urban middle and upper classes (Languerre, 1990, p.6) The author believes that poverty erodes lives – including health, empowerment,opportunities, cognitive skills, and what it means to be human. With the aforementioned matters, 19
  29. 29. the interconnectivity among poverty education, empowerment, opportunities, cognitive skills andhealth cannot be denied. However, there was never a book which examines different aspect ofinterrelation between poverty and health, particularly among Jamaicans using cross-sectionaldata. This book is an introduction of poverty and health, and the topics are selected in keepingwith the general theme.REFERENCESBarr, N. (2005). Financing higher education. Retrieved on February 23, 2006, from http://www.imf.org/external/pubs/ft/fandd/2005/06/barr.htm.Barrow C, & Reddock R, (eds). (2001). Caribbean sociology: Introductory Readings. Kingston: Ian Randle, markus Wiener, & James Currey.Blake J. (1961). Family structure in Jamaica: the Social Context of Reproduction. New York: Free Press.Bourne PA, McGrowder DA, & Beckford OW. (in print). Unemployment, Illness and Poverty in Jamaica. Submitted for publication.Buhmann, B., Rainwater, L., Schmaus, G. and T. Smeeding (1988), “Equivalence Scales, Well- Being, Inequality and Poverty: Sensitivity Across Ten Countries Using the Luxembourg Income Study (LIS) Database”, Review of Income and Wealth, 94, 115-142.Callender, J. 2000. Lifestyle management in the hypertensive diabetic. Cajanus, 33:67-70.Clarke E. (1970). My Mother who Fathered me. London: George Allen and Unwin.Coser, Lewis and Rosenberg, Bernard. (1957). Sociological Theory: A Book of Readings. Second Edition. The McMillan Company, New York.Costa, D. 2000. Understanding the twentieth-century decline in chronic conditions among older men. Demography 37:53-72.Costa, D. L. 2002. Chronic diseases rates and declines in functional limitation. Demography 39:119-138.Coulter, F.A.E., Cowell, F.A. and S.P. Jenkins (1992), “Equivalence Scale Relativities and the Extent of Inequality and Poverty”, Economic Journal, 102, 1067-82.Eldemire D. 1995. A situational analysis of the Jamaican elderly, 1992. Kingston: Planning Institute of Jamaica.Elmstahl, S, Malmberg B, Annerstedt L. (1996). Caregiver’s Burden of Patients 3 Years After Stroke Assessed by a Novel Caregiver Burden Scale. Arch Phys Med Rehabil 77: 177-82.Fields, G. S. (1980). Poverty, inequality, and development. Cambridge, England: Cambridge University Press.Gibbison, G., & Murthy, N. (2003). An assessment of the problem of irregular school attendance among primary school children in Jamaica. Social and Economic Studies, 52 (1)119-160.Giddens, A. (1982). Contemporary Social Theory. Basingstoke, London: Macmillan Press.Giddens, A. (1986). Sociology – A brief but critical introduction. London: Macmillan Press.Giddens, A. (1993). Sociology. London: Polity Press. 20
  30. 30. Gordon, D. (1987). Class, Status and Social Mobility in Jamaica. Kingston: Institute of Social and Economic Research, UWI, Jamaica.Gosling, R. A., Hill, M., Free, L,K., & Taylor, S. (2003). Introduction to sociology, (7th ed.). London: University of London Press.Greenfield S. (1966). English Rustics in Black Skin: A Study of Modern family forms in a Pre- Industrial Society. New Haven, Conn., College and University Press.Haralambus, M and Holborn, M (2002), Sociology: Themes and Perspective; London; University Tutorial PressInkeles, A. (1964). What is sociology? An introduction to the discipline and profession. Englewood Cliff, New Jersey, U.S.A.: Prentice-Hall.Inter-American Development Bank. (1998). The path out of poverty. Brazil: Inter-American Development bank.Laguerre, Michel S. (1990). Urban Poverty in the Caribbean. New York, United States: St. Martin’s Press.Jamaica Gleaner. (Thursday , October 20, 2005). Deregistration of UWI Students. Retrieved on February 26, 2006, from http://www.jamaica- gleaner.com/gleaner/20051020/cleisure/cleisure1.html.Jessop, Williams et al. (1998). Key Sociological Thinkers. R. Stones ed. New York, New York University PressJoseph Rowntree Foundation. (2000). Ethnic diversity, neighbourhoods and housing. Retrieved on March 17, 2006 fromKurasha, P. (2003). Access to tertiary education as a national strategy for development: The Zimbabwe Open University case. Zimbabwe: Zimbabwe Open University.Lanjouw, P. & Ravallion, M. (1995). Poverty and household size. The Economic Journal, 105, 1415-1434. UK: Blackwell Publishers.Levy, Horace. (1996). They cry ‘Respect’! Urban violence and poverty in Jamaica. Kingston, Jamaica: The Centre for Population, Community and Social Change, University of the West Indies, Mona.Lipton, M., & Litchfield, J. (2001). Successes in anti-poverty: National-level poverty performance. Geneva, Switzerland: International Labour OrganizationMacionis, JJ. & Plummer, K. (1998). Sociology. New York: Prentice Hall, New YorkMajid, N. (2003). Globalization and poverty. Geneva, Switzerland: International Labour Office.McCarney, J. (1990). Social Theory and the crisis of Marxism. United Kingdom. 6 Meard St. London WIV 3HR.McCarthy, F. M. 2000. Diagnosing and treating psychological problems in patients with diabetes and hypertension. Cajanus 33:77-83.McIntosh, Ian. (1997). Classical Sociological Theory. Section 1, Washington Square, New York, New York University PressMcKenzie H, & McKenzie H. (1971). The Caribbean Family. Workshop – Family Life Education July 19-31, 1971. Kingston; Bureau of Health Education, Ministry of Health, Kingston, Jamaica.Meenakshi, J.V. & Ray, R. (2000). Impact of Household Size and Family CompositionMorgan O, ed. (2005). Health Issues in the Caribbean. Kingston: Ian Randle.Morrison, E. 2000. Diabetes and hypertension: Twin trouble. Cajanus 33:61-63. 21
  31. 31. NetAid. (2005). Access to Education. February 25, 2006 from http://www.netaid.org/global_poverty/education/.Nie, N. H., Powell, G. B. Jnr., & Prewitt, K. (1972). Quoted in J.Finkel & Gable, R. (eds). Political development and social change. New York: John Wiley. on Poverty in Rural India. Retrieved on March 10, 2006, from http://rspas.anu.edu.au/papers/asarc/meenakshi.pdfOxaal, Z. (1997). Education and Poverty: A Gender Analysis. Retrieved on February 26, 2006, from http://www.bridge.ids.ac.uk/reports/re53.pdf.Planning Institute of Jamaica (PIOJ), & Statistical Institute of Jamaica (STATIN). (1994-2003). Jamaica Survey of Living Conditions, various years. Kingston, Jamaica: PIOJ & STATIN.Post, K. (1996). Regaining Marxism. The Macmillan Press Limited. Great BritainPowell, L., Bourne, P., & Waller, L. (2007). Probing Jamaica’s Political Culture, vol. 1. Main Trends in the July-August 2006 Leadership and Governance Survey. Kingston: Centre of Leadership and Governance, the University of the West Indies at Mona.Public Relations Office. (2004). Press statement on the deregistration of students owing fees. Retrieved on February 26, 2006, fromQuddus, M. (1999). Access to Higher Education in Bangladesh: The Case of Dhaka University. Retrieved on February 08, 2006 from Retrieved on February 08, 2006 fromRadiojamaica.com. (2006). Some UWI students again facing deregistration. Retrieved on February 26, 2006 fromRitzer, G. (1992). Contemporary Sociological Theory. New York, McGraw-Hill, USA.Rodman H. (1971). Lower class families: The cultures of Poverty in Negro Trinidad. London: Oxford University press.Sen, A. (1979). Poverty: An ordinal approach to measurement. Econometricia 44, 219-231. Retrieved on March 1, 2006 from http://links,jstor.org/sici?sici=0012- 9682%28197603%2944%3A2%3c219%3APAOATM%3E2.0.CO%3B2-Z.Senate Community Affairs Reference Committee. (2004). A hand up not a hand out: Renewing the fight against poverty. Report on poverty and financial hardship. Retrieved on February 25, 2006, from http://www.aph.gov.au/Senate/committee/clac_ctte/completed_inquiries/2002- 04/poverty/report/report.pdf.Smith MG. (1962). West Indian Family Structure. Seattle and London, University of Washington Press.Smith RT. (1973). The Matrifocal Family in J. Goody The Character of Kinship. Cambridge: Cambridge University Press.Statistical Institute of Jamaica. (1990-2004). Demographic Statistics, various years. Kingston, Jamaica: Statistical Institute of Jamaica.Statistical Institute of Jamaica. (2001). Census, 2001, Country Report. Kingston, Jamaica: Statistical Institute of Jamaica.United States Information Service. (1996). Wireless file. Retrieved on February 21, 2006, from http://www.mtholyoke.edu/acad/intrel/incomgap.htm.University of California. (2009). Jamaica. Available from: http://hivinsite.ucsf.edu/global?page=cr02-jm-00 [dated May 21, 2009]. 22
  32. 32. US Department of State. (2002). Addressing global poverty. Economic perspective, 6 (3). Retrieved on February 23, 2006, from http://usinfo.state.gov/journals/ites/0901/ijee/ijee0901.pdf.Wallace, R.A., & Wolf, A. (1999). Contemporary sociological theory, expanding the classical tradition, (5th ed.). Upper Saddle River, New Jersey, U.S.A.: Prentice Hall.World Bank. (2006). Mexico: World Bank Approves $420 Million For Education. Washington, United States: World Bank. Retrieved on March 13, 2006 from http://web.worldbank.org/WBSITE/EXTERNAL/COUNTRIES/LACEXT/MEXICOEXT N/0,,contentMDK:20754583~menuPK:338403~pagePK:141137~piPK:141127~theSiteP K:338397,00.html.World Bank. (2002). Constructing Knowledge Societies: New Challenges for Tertiary Education. Retrieved on February 25, 2006, fromWorld Health Organization. (2005). Preventing Chronic Diseases a vital investment. Geneva: WHO.Younger, S.D. (2002). Public social sector expenditure and poverty in Peru. Morrison, C. (ed). Education and health expenditure, and development: The cases of Indonesia and Peru. Retrieved on February 23, 2006, from http://www.lloydwaller.com/. 23
  33. 33. Chapter 2Poverty, Unemployment, Illness, Health Insurance and Health-care SeekingBehaviour in Jamaica: A Multivariate AnalysisUsing approximately two decades of statistical data (1988-2007) on poverty, unemployment,self-reported illness (or dysfunctions), health insurance coverage, and health seeking behaviourfor Jamaicans, the current study seeks to model the social determinants of 1) self-reported healthconditions, as well as the medical predictor of 2) health seeking behaviour, 3) poverty, 4)unemployment, 5) health insurance coverage. The data for the study were published by theStatistical Institute of Jamaica, Bank of Jamaica, and the Planning Institute of Jamaica and theStatistical Institute of Jamaica. The data were analyzed using ordinary least square; and the levelof significance was 5%. The findings revealed that the social determinants of health care-seeking behaviour were prevalence of poverty and health insurance with a biological variable -illness. Health insurance coverage was the significant predictor of health care-seeking behaviourof Jamaica (beta = 0.504, 95% CI = 0.563 – 1.525). Illness was found to be negatively correlatedto health care-seeking behaviour and the same was found for poverty. The determinants thatexplain illness in Jamaica were poverty (beta = -527, 95% CI = -0.230-0.093); rate of growth inGDP at constant prices (beta = 0.877, 95% CI = 0.787-1.109); health care seeking behaviour(beta = -0.544, 95%CI = -0.235-0.106). Illness (beta = -0.432, 95%CI = 0.464-0.851); medicalcare-seeking behaviour (beta = 0.466, 95%CI =0.136-0.314) and unemployment (beta = -0.604,95% CI = -11.557-6.523) were found to be significant predictors of health insurance coverage.The significant non-medical predictors of unemployment rate in Jamaica were poverty (beta =0.195, 95% CI = -0.001-0.013); medical care-seeking behaviour (beta = 0.328, 95% CI = 0.002-0.019) and health insurance coverage (beta = -0.881, 95% CI=-0.075-0.042) and a medicalpredictor (illness – beta = 0.496, 0.034-0.067). The social predictors of poverty wereunemployment (beta = 0.411, 95% CI = 5.843-20.353) and medical care-seeking behaviour (-0.575, 95% CI = -0.825-0.357) and a medical predictor (illness – beta = -0.237, 95% CI = -1.358-0.176). The challenges for public health practitioners is address health, deprivation,material inadequacies and poor sanitation conditions and poor water quality of the poor becauseof their the direct association between those social variables and poor health. The current workre-ashes those realities; but also highlight the health challenges of wealthy and wealthiest 20% inthe nation. Public health practitioner therefore can only focus on the poor and unemployed, asthe wealthy’s unhealthy lifestyle choices are eroding some of the benefits associated with incomeand wealth. 24
  34. 34. IntroductionLife expectancy is among the indicators of health of an individual, a society, or a nation.Statistics from the United Nations (2002) revealed that life expectancy at birth in the Caribbean(for 2000-2005) was 68.1 years; 70.4 years in Latin America and the Caribbean; 78.5 years inWestern Europe; 81.5 years in Japan; 78.2 years in United Kingdom and Northern Ireland; 77.5years in the United States; 75.6 years in the more developed nations and 75.7 years for Jamaica.Using life expectancy as a measure of health, the health status of Jamaicans is comparablyequivalent to that in developed nations such as Japan and the United States. According to theWorld Health Organization (1948), health is more than the mere absence of diseases or infirmity;it includes the state of complete physical, social and psychological wellbeing, suggesting thatany study of health must include social, economic and psychological determinants as well asbiological variables. This demands an expansion of using life expectancy to assess health status.Life expectancy which is computed from mortality data places emphasis on death and so thisjustifies why the WHO argued for healthy life expectancy or disability free health as this is morein keeping with the multi-dimensional tenets of health. Hence, only using life expectancy toevaluate health of a people, society or nation is insufficient as WHO argued that the 21stcentury’s focus is on superior quality of life and not the number of lived years. Health demand is needed because people want to live longer and experience a goodquality of life. Good health is desired by all for the very reasons that were aforementioned andaccounts for health demand. Good health is more than experiencing the absence of ill-health; it isa state of harmony of the mind, body and the socio-physical environment. It contributes to virilelabour force, the creation of wealth for an individual and a nation, and accounts a happier person; 25
  35. 35. optimistic behaviour; high self-esteem and an individual who is more satisfied with life(Hutchinson et al., 2004; Diener, 1984; Wilson, 1967). It is this desire to live, be happy, enjoylife and live well that at a signal of unhealthiness some people and for others a degree of severityis needed that will see them seeking medical care (Rosenstock, 1966; Strecher & Rosenstock,1997). Strecher & Rosenstock (1997) attributed the willingness to seek medical care based onperceived severity of the illness as an issue found in black men. Approximately 90 percentage ofthe Jamaican population are blacks and close to 50 percent are men and so Strecher &Rosenstock argument could provide some explanation of the low medical care-seeking behaviourof Jamaican men. Statistics from the Jamaica Ministry of Health showed that most of the healthcare-seekers were females (Jamaica Ministry of health, 2006) except in cases of injuries.According to the Planning Institute of Jamaica and the Statistical Institute of Jamaica (2008),66% of Jamaicans sought medical care in 2007. Of this figure, 68.1% was females compared to62.8% males. Males did not only seek less health care than females, they bought less medical(70.8% males, 75% females) as well as holding less health insurance coverage (20.1%)compared to females (22.2%). Culturally, Jamaicans men do not seek medical care because it is interpreted as feminine,weak and such a reality prevents them from seeking medical care, which was also found outsideof Jamaica (Doyal, 2000). The low responsiveness of men than women to health care treatmentwas also the case in Zambia (Stekelenburg et al., 2005); Kenya (Taff & Chepngeno, 2005); andUganda (Lawson, 2004). A study done in Chekaria, Bangladesh, by (Future Health Systems ResearchProgramme Consortium (2007) found that more females reported an illness; but more men (58.2%)sought medical care than females (40.9%) which contradicts the other aforementioned studies. 26
  36. 36. Despite the preponderance of studies that have established that more females seek medical carethan men, in Jamaica, the mean number of days spent receiving curative care is more for malesthan for females which was also the case in Zambia (Stekelenburg et al. 2005). For males,medical care is acceptable when there is severity of a health condition. Medical care therefore, will always be sought by humans in an effort to live without theseverity of illness as this affects their employment status; family life; wealth; socialrelationships; happiness, and harmony with themselves (Akande & Owoyemi, 2009). Healthwhich is a multidimensional construct (WHO, 1948) means that human will seek health-careservices not only at the onset of diseases (dysfunctions, illness or symptoms) but it has socio-cultural influences such as income level; education; distance; cost and quality of care; perceptionof ill-health and its severity; and life satisfaction. It is the need to protect the mechanism of thebody with the socio-physical milieu that dictates the demand for health care services; but this isstill guided by culture (Hausmann-Muela et al. 1998; Caldwell, 1993) and the interpretation ofthe health condition(s) as well as what is happen inside the body. It is well established in health literature that poverty influences health (WHO, 2005;Marmot, 2002; Wooden & Headey, 2004). According to the WHO (2005), 80% of the deathsfrom chronic diseases occur in low-to-middle income countries and that 60% of global mortalityis caused by chronic illness. This indicates that a proportion of mortality that is occurring in thedeveloping nations is resulting in premature deaths. Poverty is more than income deprivation; itincludes material and social deprivation of resources (Marmot, 2002). Sen (1979) encapsulatedthis well when he forwarded that low levels of unemployment in the economy is associated withhigher levels of incapability. 27
  37. 37. Poverty means therefore the inability to have good nutrition; proper water and foodsupply; quality physical environment; quality education and choices. Education is a vehicle forthe socio-economic mobility (Nie, et al., 1972) to which continues to elude the poor and accountsfor their inability to transform the social-economic environment (Barr, 2005). Poverty preventseconomic freedom and choice, and so despite ones willingness, this circumvents many realities.The poor is held in the vicious cycle of continuous poverty, and on the onset of health conditionspoverty could extend to the family. The Inter-American Development Bank in highlighting thesocial conditions of the poor says, “Who are the poor? They are likely to be less educated and towork in the informal sector” (Inter-American Development Bank, 1998, p. 12) and so with lessaccess to social and material resources, they are highly like to face premature death withoutassistance from the wider society or the government. One writer forwards a perspective thatconverged with that of the Inter-American Development Bank that access to higher education isthe most basic ingredient in the reduction of poverty (Net Aid, 2005). Poverty also influences many of the other social determinants of health such as income,education, employment status (WHO, 2008; Kelly et al. 2007; Marmot, 2003) as well asbiological conditions. Money is need in health care services, and so its non-access affects thetreatment of care that the poor are likely to receive. A study by Lee & Kim (2003) found thatexisting illness and ‘new health event’ were significantly correlated with the diminution of thewealth of elderly in United States. Therefore, the awareness of ill-health is not a sufficientdriving force for people to seek medical care as they must balance the perception of severity withthe affordability of health care. It is this fact that explains why purchase health insurancecoverage allows the increase of health care demand. 28
  38. 38. Health insurance which reduces the cost of medical care is possessed less by the poor,and this is apart of the social deprivation which aids their poor health compared to the wealthy.Another aspect to the reality of health insurance in particular to Jamaica is that is primarily aprivate good. It is substantially offered to the employed, and within this context and the fact thatthe poor are substantially in the informal sector, they are therefore greatly removed fromaccessing this product and by extension health care-services. Prior to 2007, health insurance wastotally a private good in Jamaica. Such an arrangement and the fact that 21 percent of Jamaicanshad health insurance coverage in the same period; it means that health care service costs weresubstantially out-of pocket payment for many Jamaicans. Hence, faced with the choice ofspending on food and health care, many people delay medical care to their detriment, and this iseven more complex for the poor who have less income in the first instance. Income deprivationtherefore, influences health insurance coverage, nutrition, timing in seeking medical care, illnessand further complicate the precipitous fall between poverty, illness and deeper poverty. Whilethe wealthy and the middle class experience the same typology of health conditions like the poor,they are more ability to afford medical care than the poor. In 2007, statistics on self-reported illness in Jamaica was 15.5%: 15% for those in thepoorest 20%, 14.5% of the poor; 15.8% of the middle income categorization; 16.1% and 16% ofthe wealth and wealthiest income quintiles, respectively (PIOJ & STATIN, 2007).Concomitantly, arthritis was the highest among the poorest 20% (12.9% compared to thenational average of 8.8%). Eleven percent of the poorest 20% had asthma which was the highestfor all the income quintiles and the nation (8.7%). Fifty-one percent of those in poorest 20%indicated that they did not seek medical care owing to inafffordability. Continuing, the statisticsrevealed only 6.6% of the poorest 20% had health insurance coverage compared to 12% of the 29
  39. 39. poor; 18% of the middle class and 22.7% of the wealthy and 43.5% of the wealthiest 20%. Thegreatest percentage of Jamaican reporting a recurring illness was in the poorest 20% (58.7%compared to 47.9% in the poor; 51.5% in the middle class; 47.8% in the wealthy and 53.6% inthe wealthiest 20%) and this cohort sought the least medical care (54.3% compared to 62.9% inof the poor; 67.7% of the middle class; 68.7% of the wealthy and 73.5% of the wealthiest 20%).The poorest 20% reported the most mean days in illness (11.3 days) compared to the poor (11.1days); 9.7 days for the middle class; 9.6 days for the wealthy and 8.1 days for the wealthiest20%. Health statistics in the Caribbean and in particular Jamaica continue to overemphasizemortality, morbidity, or biomedical factors (Ministry of Health, 2007; PIOJ & STATIN, 2007;STATIN, 2008), and although these are critical to the planning process and social development,more research is needed in regard to the social determinants of health. An extensive review ofthe health literature for the Caribbean in particular Jamaica found no study that has sought tomodel the relationship between unemployment, illness, health care-seeking behaviour andpoverty. Hence this study will examine five hypotheses: (1) health care-seeking behaviour ofJamaicans can be determined by social determinants (poverty and health insurance) and by abiological factor (illness); (2) Self-reported illness can be predicted by social determinants(poverty, health insurance; medical care-seeking behaviour; and rate of growth in GDP); (3)Health insurance coverage can be determined by social variables (poverty, unemployment andmedical care-seeking behaviour) and a biological variable (illness); (4) Unemployment can bepredicted by social factors (poverty, health insurance coverage; and medical care-seekingbehaviour) and a biological factor (illness) and (5) Poverty is determined by social factors(medical care-seeking behaviour and unemployment) and a biological factor (illness). The 30
  40. 40. purpose of the research is to aid public health practitioners with health research literature andfindings that can be used to inform policy decisions.MethodDESIGN AND METHODSThe current study used two decades (1988-2007) of data which is published by the PlanningInstitute of Jamaica, and the Planning Institute of Jamaica and Statistical Institute. The statisticaldata was provided by the Jamaica Survey of Living Conditions (JSLC). The Survey is anadaptation of the World Bank’s Living Standard Measurement Study (LSMS) household survey,with some modifications as the JSLC (survey) focuses and emphasizes policy impacts. Since,1988, the Statistical Institute of Jamaica in collaboration with the Planning Institute of Jamaicahas been conducting annual studies of living conditions of Jamaicans. The survey design is thatof a multi-topic household survey including a section on health, consumption, education, house,anthropometric measurements and immunization data for all children 0-59 months, anddemographic variables. Each survey year was drawn using stratified random sampling. This design was a two-stage stratified 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 of a minimum of 100 dwellings 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 of 31
  41. 41. dwelling was compiled, which in turn provided the sampling frame for the labour force. Thesurvey is weighted in order to present the population of Jamaica. The survey is carried out with a self-administered questionnaire by trained interviewers toresponsible household members. Participations are asked to recall specific and detailedconsumption patterns over the last 30 days of the survey period as well as their health careexpenditure. The basic structure of the questionnaire has remained the same over the years withinclusive of social safety net, crime and victimization, physical environment, remittances andother components as modules at different survey periods. For this study, data used were onunemployment, health insurance coverage, poverty, health care-seeking behaviour, illness andutilization. A self-administered questionnaire was used to collect the data, which were stored andanalyzed using SPSS for Windows 16.0 (SPSS Inc; Chicago, IL, USA). Multiple regressionswere used to examine the relationship between the dependent variable and some predisposedindependent (explanatory) variables. Models will be established for (i) health care-seekingbehaviour; (ii) illness; (iii) health insurance; (iv) unemployment; and (v) poverty. The resultswere presented using unstandardized B-coefficients, beta value, and confidence interval (95%CI). The correlation matrix was examined in order to ascertain whether autocorrelation (ormulticollinearity) existed between variables. Based on Cohen & Holliday [36] correlation can below (weak) - from 0 to 0.39; moderate – 0.4-0.69, and strong – 0.7-1.0; and this was used toexclude (or allow) a variable in the model as well as the p < 0.05. For the model, tolerances lessthan 0.2 were excluded as these indicate high multicollinearity. Multicollinearity is a relationship 32
  42. 42. between two or more explanatory variables (Mamingi, 2005:49). Hence, this study did not usehighly collinear variables as the estimators lose precision and therefore are difficult to interpret.ModelsThe use of multivariate analysis is well established in health literature to examine many socio-economic and biological factors which simultaneously influence health, wellbeing or healthconditions (Grossman, 1972; Smith & Kington, 1997; Hambleton et al., 2005; Bourne, 2009;Bourne & McGrowder, 2009). The current study will employ multivariate analyses in the studyof health and medical care seeking behaviour of Jamaicans. The use of this approach is betterthan bivariate analyses as many variables can be tested simultaneously for their impact (if any)on a dependent variable. Scholars like Grossman (1972), Smith & Kingston (1997), Hambleton et al. (2005),Kashdan (2004), Yi & Vaupel [40], the World Health Organization pilot work a 100-questionquality of life survey (WHOQOL) (Murphy & Murphy, 2006) and Diener (1984) have both usedand argued that self-reported health status can be used to evaluate health status instead ofobjective health status measurement. Other scholars, on the other hand, employed self-reportedhealth conditions to operationalize health of individual [30]. Embedded in the works of thoseresearchers is the similarity of self-reported health status and self-reported dysfunction inassessing health. 33
  43. 43. The current study will examine the social determinants (i) and biological determinants ofhealth care-seeking behaviour, (ii) poverty, (iii) unemployment, (iv) health insurance, (v) healthconditions of Jamaicans. Using multivariate analysis, this research will seek to model fivefunctions for the previously stated areas: HSBt = f(Pt, It,HIt,lnUt, GDPt, εt) t = 1,2,3, ….,20 [1] It = f(Pt, GDPt,HIt,lnUt, HSBt, εt) t = 1,2,3, ….,20 [2] HIpop = f(Pt, It,GDPt,lnUt, HSBt, εt) t = 1,2,3, ….,20 [3] lnUt = f(Pt, It,HIt,HSBt, GDPt, εt) t = 1,2,3, ….,20 [4] Pt = f(HSBt, It,HIt,lnUt, GDPt, εt) t = 1,2,3, ….,20 [5] Where HSBt = health care-seeking behaviour (in %); Pt = prevalence of poverty (in %) It = self-reported illness (in %) HIt = health insurance coverage (in %) lnUt = logged unemployment rate (in %) GDPt = Rate of growth of Gross Domestic Product (GDP) at constant prices εt = error term t = time index 34
  44. 44. ResultsUsing 2 decades of data, the respective models below were based on p value < 0.05, and nomulticollinearity. Ordinary least square (OLS) was used to model each equation from the data.The OLS estimations lead to the results shown below:Health care-seeking behaviour:HSBt = α + β1Pt + β2It + β3HIt + εt t = 1,2,3, ….,20 [1.1]Self-reported illness:It = α + β1Pt + β2GDPt +β3HSBt + εt t = 1,2,3, ….,20 [2.1]Health Insurance coverage:HIt = α + β1lnUt + β2It + β3HSBt + εt t = 1,2,3, ….,20 [3.1]Log-lin:lnUt = α + β1Pt + β2It + β3HSBt + β4HIt + εt t = 1,2,3, ….,20 [4.1] (α + β1P + β2I + β3HSB + β4HI + ε )Ut = e t t t t t t = 1,2,3, ….,20 [4.2]Poverty:Pt = α +, β1It + β2HSBt + β3lnUt + ε) t = 1,2,3, ….,20 [5.1]Poverty and unemployment are highly corrected, and so both variables cannot be used in asestimators as the same time. The correlation between poverty and unemployment was 0.707. 35
  45. 45. PredictorsThe predictive functions with their different explanatory variables are presented below. Theexplanatory power of each model are [1.2] r-squared of 0.735 (see Table 2.1); [2.2] r-squared of0.853 (see Table 2.2); [3.2] r-squared of 0.870 (see Table 2.3); [4.3] r-squared of 0.811 and [5.1]with a r-squared of 0.688 (Table 2.5).Health care-seeking behaviour:HŜBt = 65.86 – 0.305Pt – 1.100It + 1.044HIt t = 1,2,3, ….,20 [1.2]Self-reported illness:It = 23.09 – 0.161Pt + 0.948GDPt – 0.171HSBt t = 1,2,3, ….,20 [2.2]Health Insurance coverage:ĤIt = 12.836 – 90.40lnUt + 0.657It + 0.225HSBt t = 1,2,3, ….,20 [3.2]Unemployment:Ût = e(1.677 + 0.006Pt + 0.050It + 0.011HSBt - 0.059HI ) t t = 1,2,3, ….,20 [4.3]Poverty:Pt = 36.106 – 0.737It – 0.591HSBt + 13.098lnUt t = 1,2,3, ….,20 [5.1] 36
  46. 46. DiscussionMany studies that have examined social determinants of health have established that income,poverty, illness, health care-seeking behaviour, health insurance and unemployment aresignificantly correlated to health status (Marmot, 2002; Hambleton et al. 2005; Grossman, 1972;Smith & Kington, 1997; Kelly et al., 2007; Marmot, 2008; WHO, 2008; Bourne, 2008a, 2008b,2009; Bourne & Beckford, 2009). Those research conducted in the Caribbean on health(Hambleton et al. 2005; Bourne, 2008a, 2008b, 2009; Bourne & McGrowder, 2009; Asnani, etal., 2008; Hutchinson et al., 2004; Morgan, 2005) or the Americas (PAHO, 2001) have neverused national data on poverty, illness, unemployment, health care-seeking behaviour and healthinsurance coverage in order to examine how those phenomena correlate. The current research isnot like the others in the Caribbean in particular Jamaica that used national cross-sectionalsurvey data to model health determinants of the individual, or other health related phenomenafrom an individual perspective. In this paper, national figures were used for health care-seekingbehaviour, health insurance coverage, poverty, illness, unemployment and rate of growth of GDPin order to model the type and degree of particular social determinants and medical factorinfluence on each model. The current work went further than its predecessors as it found that with all other thingsbeing held constant, 66 out of every 100 Jamaicans are likely to seek medical care. Poverty wasfound to significant corrected with health care-seeking behaviour which Marmot (2002) opinedthat this was owing to inafffordability. Poverty being a negative predictor of health care-seekingbehaviour within the context of low nutrition, poor quality milieu and low access to medical careservices justifies the greater probability of this cohort have chronic illness (WHO, 2005) andexperience premature death than the middle class or the wealthy in the same population. Hence, 37
  47. 47. the poor delay seeking medical care services, which contradicts studies by Okolo (1988) andAkande & Owoyemi (2009) that found no correlation between income levels and delay inseeking health care. Although those studies did not identify income levels as affecting waitingtime in selecting care, inafffordability of health care does affect the poor’s delay time in seekingcare and this is accounted in this study. In 2007, the poorest 20% sought the least medical careand had the longest mean number of days spent in illness, suggesting that poverty influence onhealth care seeking behaviour in Jamaica is not surprising and does further increase the healthexpenditure of the nation when they do seek health care. Another important finding of the study is the direct correlation between health insuranceand health care-seeking behaviour. The costs of health care are such that out-of pocketexpenditure may ruin an individual wealth, create unemployment, reduce income, and furtherdeepens ill-health. Those realities are among reasons for people to purchase health insurancecoverage. Hence, health insurance allows the individual to seek as against delay care becausehe/she is cognizant that the out-of pocket expenditure for health care costs will be lower than ifhe/she did not have the product. This study found that health insurance coverage was the mostsignificant predictor of health care-seeking behaviour of Jamaicans, which concur with otherstudies that showed that health insurance was a good indicator of health care demand (Geisler etal. 2006; Schoen et al, 2000; Kasper et al, 2000). With 7 out of every 100 Jamaicans who areclassified in the poorest 20% having health insurance coverage in 2007, it is not surprising thatthey have the lower demand for health care services. Again, this is again highlighting theimportance of social determinants in health care-seeking and providing an understanding of whyWHO (2005) forward the perspective on premature death of poor. Hence health insurance 38
  48. 48. coverage does not only influence health care-seeking behaviour, it also reduces wellbeing of theindividual and the family, and the timing of health care. Studies have shown that there is positive correlation between illness and health care-seeking behaviour; but this research found the contrary. This appears contradicting to theargument that people will seek care in order to protect life and sustain life; but this is theoreticaltrue but why is this not the reality in Jamaica. Statistics for the last 2-decades in Jamaica revealedthat poor sent the least on medical expenditure; attended medical care the least; substantiallymore of them reported that they were unable to seek medical care owing to inafffordability; hadthe least health insurance coverage; reported a high probability of illness and so would explainan aspect to this negative correlation. Another interesting explanation is embedded in the culture.For men, health care-seeking behaviour is a signal of weakness and frequency of visits formedical care is cultural interpreted as feminine. Boys are socialized to be strong, macho, and notdisplay sign of weakness (Chevannes, 2001) indicating an explanation for their low utilization ofmedical care services. While the same rigidity does not hold true for girls, females (or women),socio-cultural, there is a high unwillingness to seek more care than less care. Reporting illness therefore, does not symbolize more demand for medical care services.There is a tendency for Jamaicans in particular men to seek health care on the first sign ofseverity, indicating the psyche to delay care which is keeping with another study on black men inUnited States (Strecher & Rosenstock, 1997). In 1989, 17 out of every 100 Jamaicans reported atleast one illness and in 2007, with a large population, the number of people reporting illness was15 out of every 100. The media, internet, and more public health programmes are accounting forthe increase awareness and reporting of ill-health; but this has not translated into willingness toseek medical care. 39
  49. 49. According to Marmot (2002), income affords choices in foods, nutrition, medical careand better quality physical environment and therefore justifies the direct association betweenitself and health. This study contradicts the findings of Marmot, as it found a positive correlationbetween income (measures by rate of change GDP per capita) and illness. Studies have agreedwith Marmot, there is a direct correlation between income and health (UNDP 2006; Roos et al.2004; Case 2001: Kawachi et at 1997; Smith & Kington 1997). One researcher went as far as tosay that income buy health (Sen, 1998). There is fallacious aspect to type of reason as it assumesthat health can be purchased, health can be transferred from medical practitioners to their clientson demand; income comes with better choices, and that poor health can be reversed when wewant. A survey conducted by Diener, Sandvik, Seidlitz and Diener (1993), in Diener (1984),stated that correlation between income and subjective wellbeing was small in most countries.According to Diener (1984, 11), “…, there is a mixed pattern of evidence regarding the effects ofincome on SWB [subjective wellbeing]”. Benzeval, Judge and Shouls (2001) study concur withDiener that income is associated with health status. Benzeval et al went further as their researchrevealed that a strong negative correlation exists between increasing income and poor health,which concurs with this study. Furthermore, from a study, it was found that people from thebottom 25 percent of the income distribution self-reported poorer subjective health by 2.4 timesthan people in the wealthiest 20% (Benzeval et al., 2001). Like Benzeval et al. (2001), this studyhighlights that lack of income and wealth for the poor is a disadvantage; but it is also adisadvantage for the wealthiest 20%. Embedded in this finding is an unhealthy lifestyle practiceof the wealthy which erodes the merits of income to purchase quality food and water; nutritionand its ability to secure good physical environment. 40
  50. 50. Two economists studying the ‘impact of wealth and income on subjective wellbeing andill-being’ found that employed people had a higher life and financial satisfaction than theirunemployed counterparts. Using linear regression analysis, they found that the employed had acoefficient of 0.77 in life satisfaction compared to unemployed -3.00; and in the case of financialsatisfaction it was 5.52 to -11.52 respectively (Wooden & Headey, 2003, 16). Despite thatfinding, it should be noted that the adjusted R2 for all the explanatory variables was 8.3% and20.8% for life satisfaction and financial satisfaction respectively. The current researchestablished an association between poverty and health care-seeking, and unemployment andpoverty. The correlation between unemployment and poverty was a strong one indicating thatunemployment fuels more poverty and embodied in this reality is the psychological trauma ofjob separation for the employed and material deprivation for the unemployed and poor. Withpersistent unemployment comes the socio-cultural challenges of this experience, and this furtherwidens the gaps in the inability of the poor to seek medical care along with the unemployedreality of recognizing and reporting ill-health but the difficulty of demanding care for thenegative health. Milstein & Smith (2006) has found the high cost of medical care is resulting insome Americans seeking care abroad, as the current cost of health care is such they some themhave become pauper by their illnesses. While some Americans are able to go overseas formedical care, the uninsured, poor, unemployed, self-employed on become ill is faced with thechoice of delaying care which can become fatal for them (Kaiser Commission on Medicaid andthe Uninsured, 2004), which is also the case in Jamaica.ConclusionThe challenges for public health practitioners is address health, deprivation, materialinadequacies and poor sanitation conditions and poor water quality of the poor because of their 41
  51. 51. the direct association between those social variables and poor health. The current work re-ashesthose realities; but also highlight the health challenges of wealthy and wealthiest 20% in thenation. Public health practitioner therefore can only focus on the poor and unemployed, as thewealthy’s unhealthy lifestyle choices are eroding some of the benefits associated with incomeand wealth.ReferencesAkande TM, & Owoyemi J. (2009). Healthcare-seeking behaviour in Anyigba, North-Central, Nigeria. Research Journal of Medical Sciences, 3: 47-51.Asnani MR, Reid ME, Ali SB, Lipps G, Williams-Green P. (2008). Quality of life in patients with sickle cell disease in Jamaica: rural-urban differences Rural and Remote Health 8: 890. (Online).Barr, N. (2005). Financing higher education. Retrieved on February 23, 2006, from http://www.imf.org/external/pubs/ft/fandd/2005/06/barr.htm.Benzeval, M., Judge, K., and Shouls, S. (2001). Understanding the relationship between income and health: How much can be gleamed from cross-sectional data? Social policy and Administration. Quoted in Benzeval, Michaela, and Judge, Ken. 2001. Income and health: the time dimension. Social Science and Medicine 52:1371-1390.Bourne PA. (2008). Health Determinants: Using Secondary Data to Model Predictors of Well- being of Jamaicans. West Indian Medical J. 57:476-481.Bourne, P. (2007a). Determinants of well-being of the Jamaican Elderly. Unpublished thesis, The University of the West Indies, Mona Campus.Bourne, P. (2007b). Using the biopsychosocial model to evaluate the wellbeing of the Jamaican elderly. West Indian Medical J, 56: (suppl 3), 39-40.Bourne PA. (2009). Good health status of older and oldest elderly in Jamaica. Are there differences between rural and urban areas? Open Geriatric Medicine Journal:2:18-27.Bourne PA, & Beckford OW. (2009). Unemployment, Illness and Health Seeking Behaviour in Jamaica: Using A Cross-Sectional Survey. Paper presented at 34th Annual Conference, Caribbean Studies Association Conference June 1-5, 2009, Hilton Kingston, Jamaica.Bourne, PA & McGrowder DA. (2009). Rural health in Jamaica: examining and refining the predictive factors of good health status of rural residents. Rural and Remote Health 9 (2), 1116. [PubMed]. ISSN 1445 – 6354.Caldwell JC. Health transition: The cultural, social and behavioural determinants of health in the Third World. Soc. Sci. Med, 36:125-135.Case, A. (2001). Health, Income and economic development. Prepared for the ABCDE Conference, World Bank, May 1-2, 2001. http://www.princeton.edu/~rpds/downloads/case_economic_development_abcde.pdf (accessed 6 June 2001). 42