Socio-demographic determinants of health status of elderly with self-reported diagnosed chronic medical conditions in Jamaica

doi:10.4236/health.2010.22017

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Vol.2, No.2, 101-111 (2010) Health

doi:10.4236/health.2010.22017

Socio-demographic determinants of health status of

elderly with self-reported diagnosed chronic medical

conditions in Jamaica

Paul. A. Bourne1*, Donovan. A. McGrowder2

1Departments of Community Health and Psychiatry, The University of the West Indies, Kingston, Jamaica; paulbourne1@yahoo.com

2Pathology, Faculty of Medical Sciences, the University of the West Indies, Kingston, Jamaica

Received 29 October 2009; revised 9 December 2009; accepted 14 December 2009.

ABSTRACT

Objectives: The aim of the current study is to

examine the health status of elderly in rural,

peri-urban and urban areas of residence in Ja-

maica, and to propose a model to predict the

social determinants of poor health status of

elderly Jamaicans with at least one chronic

disease. Methods: A sub-sample of 287 re-

spondents 60 years and older was extracted

from a larger nationally cross-sectional survey

of 6783 respondents. The stratified multistage

probability sampling technique was used to

draw the survey respondents. A self-adminis-

tered questionnaire was used to collect the data

from the sample. Descriptive statistics were

used to examine the demographic characteris-

tics of the sample; chi-square was used to in-

vestigate non-metric variables, and logistic re-

gression was the multivariate technique chosen

to determine predictors of poor health status.

Results: Almost thirty six percent of the sam-

ples had poor health status. Majority (43.2%) of

the sample reported hypertension, 25.4% dia-

betes mellitus and 13.2% rheumatoid arthritis.

Only 35.4% of those who indicated that they had

at least one chronic illness reported poor health

status and there was a statistical relation be-

tween health status and area of residence [χ2 (df

= 4) = 11.569, P = 0.021, n = 287]. Rural residents

reported the highest poor health status (44.2%)

compared to other town (27.3%) and urban area

residents (23.7%). Conclusions: Majority of the

respondents in the sample had good health, and

those with poor health status were more likely

to report having hypertension followed by dia-

betes mellitus and rheumatoid arthritis. Poor

health status was more prevalent among those

of lower economic status in rural areas who re-

ported greater medical health care expenditure.

The prevalence of chronic diseases and levels

of disability in older people can be reduced with

appropriate health promotion and strategies to

prevent non-communicable diseases.

Keywords: Older; Chronic Illness; Social Determi-

nants; Jamaica

1. INTRODUCTION

The Caribbean has been identified as the most rapidly

ageing region of the world. Between 1960 and 1995,

there was a 76.8% increase in the elderly population [1].

Among its regional island states, the average growth rate

in the elderly population was approximately 5.3% for the

1995-2000 periods. The elderly as a percentage of total

population was 4.3% in 1950 and is estimated to reach

about 15% by 2020 [1]. In Jamaica, a similar pattern has

been observed with a clear and rapidly rising trend in the

elderly as a proportion of the population [2]. By 2025 as

much as 1 in 7 persons will be elderly. Moreover, char-

acterizing this pattern of increasing elderly is the differ-

ential growth rates within the various sub-age groups

over age 60, with the 75 years and above age group ex-

pected to double moving from 2.8% currently to 4.0 %

in 2025 [3]. Eldemire [4] noted that the elderly in Ja-

maica represents 10% of the population, and that they

were for the most part mentally competent and physi-

cally independent. With a calculated life expectancy of

75.5 years [5], the burden on the healthcare system can

be expected to increase.

The epidemiologic transition in the Caribbean over

the last 40 years has produced an epidemic of life-

style-related chronic non-communicable diseases [6].

Among these are obesity, diabetes mellitus, and hyper-

tension, along with such complications as stroke, heart

disease, and amputations [6]. Cardiovascular disease is

by far the leading cause of death at older ages in devel-

oping countries, although the impact of communicable

P. A. Bourne et al. / HEALTH 2 (2010) 101-111

102

diseases remains considerable [7]. One comprehensive

analysis attributes nearly 46 percent of all deaths among

women aged 60 and over in developing countries in the

early 1990s to cardiovascular disease; the corresponding

figure for older men was 42 percent [7]. Older people

with diabetes mellitus are at particularly high risk for

heart disease, stroke, eye damage, kidney disease, limb

amputation and depression. In the Survey on Health and

Well-Being of Elders (SABE), among those reporting

diabetes, at least 60% reported visual problems with or

without eye glasses. Among those reporting at least two

chronic diseases, 25% had symptoms of depression [8].

Furthermore, SABE indicates that an average of 70% of

women aged 60 years and older have at least one poten-

tially disabling condition, such as low vision, rheuma-

toid arthritis, or urinary incontinence [8].

In developed countries, the health and social status of

the elderly has received a fair amount of attention [9].

Within the Caribbean, some progress has been made in

terms of research on the elderly. Braithwaite [10] noted

that data on the Caribbean elderly were extremely lim-

ited. With the continuing aging of the population in the

Caribbean, gerontological research has devoted increas-

ing attention to those at very advanced ages [11] and in

recent years, there has been increasing interest in issues

relating to health of the elderly in the Caribbean. Pat-

terns of mortality at the most advanced ages are of inter-

est in their own right, indicating variation in health status

and well-being among this group. Moreover, differences

in mortality and trends in them may give clues about the

likelihood of a further extension of life expectancy [12].

Rural populations in Caribbean countries generally

experience excessive deficiencies in health care access,

social services, and other goods and services needed for

healthy living. Rural residence has significantly influ-

enced health care access and health status. Urban resi-

dents consistently reported better health status than rural

residents and greater satisfaction with their health care

[13]. Rural residents are more often uninsured [14], have

greater distance to travel for their health care needs [13],

and are more often plagued by resource inaccessibility

[15]. Using poverty to proxy resource inadequacies wh-

ich increased inaccessibility, in 2007; rural poverty was

2.5 times more than urban poverty (i.e. 6.2%) and 3.8

times more than urban poverty (i.e. 4.0%) [16,17]. Rural

residents in Jamaica are poor and a greater proportion of

them reported having chronic illnesses, with an even

smaller population having insurance of any kind (7.6%

in rural areas versus 25.0% in urban areas) [16].

While national averages provide insights into the ine-

qualities in the nation, the current study on a sub-popu-

lation provides health policy practitioners with a com-

prehensive understanding of the issues experienced by

elderly Jamaicans particularly public health problems

that presently exist in this population. Among these is the

fact that rural and peri-urban residents spent 11 and 14

times more days experiencing illnesses than urban resi-

dents. Another public health problem is the percentage of

elderly population with chronic illness compared to the

general population. Statistics revealed that 12% of Ja-

maicans had diabetes mellitus; 22.4% had hypertension

and 8.8% had rheumatoid arthritis [17]. However, the

prevalence of diabetes mellitus in the elderly was 2.1

times more than the general population. Similarly, the

prevalence of hypertension and rheumatoid arthritis in

elderly Jamaicans were 1.9 and 2.1 times respectively

more than in the general population. The public health

problem also includes reasons why some elderly are un-

able to seek care despite health care being free for this

group (since 2006). Of those who did not seek medical

care, 18% indicated that they could not afford it and 38%

reported that they were not ill enough (i.e. after self-as-

sessment of health and image of health care). Hence, the

aims of the study were to 1) examine the health status of

elderly Jamaicans in rural, peri-urban and urban areas of

residence; 2) establish a model to predict the social de-

terminants of poor health status of elderly Jamaicans who

have reported at least one chronic disease, and 3) provide

information that could assist health care professionals to

specifically and adequately address the health needs of

the elderly in Jamaica.

2. MATERIALS AND METHODS

The current study used cross-sectional survey data col-

lected by the Planning Institute of Jamaica (PIOJ) and

the Statistical Institute of Jamaica (STATIN) [17] be-

tween May and August 2007. The sample for this study

was 287 individuals who indicated having being diag-

nosed with a chronic illness and who are older than 60

years. The study was extracted from a larger nationally

representative cross-sectional survey of 6,783 Jamaicans.

The survey 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 a selection of dwellings from the primary units. The

PSU is an Enumeration District (ED), which constitutes

of a minimum of 100 dwellings in rural areas and 150 in

urban areas. An ED is an independent geographic unit

that shares a common boundary. This means that the

country was grouped into strata of equal size based on

dwellings (EDs). Based on the PSUs, a listing of all the

dwellings was made, and this became the sampling

frame from which a Master Sample of dwelling was

compiled, which in turn provided the sampling frame for

the labour force. One third of the 2007 Labour Force

Survey (LFS) was selected for the Jamaican Survey of

Living Conditions (JSLC, 2007) [17]. The sample was

weighted to reflect the population of the nation.

The researchers chose this survey based on the fact

that it is the latest survey on the national population and

P. A. Bourne et al. / HEALTH 2 (2010) 101-111

103

that it has data on the health status of Jamaicans. A

self-administered questionnaire was used to collect the

data, which were stored and analyzed using SPSS for

Windows 16.0 (SPSS Inc; Chicago, IL, USA). The ques-

tionnaire was modeled from the World Bank’s Living

Standards Measurement Study (LSMS) household sur-

vey. There are some modifications to the LSMS, as

JSLC is more focused on policy impacts. The question-

naire covered areas such as socio-demographic, eco-

nomic and health variables. The non-response rate for

the survey was 26.2%.

Descriptive statistics such as mean, standard deviation

(SD), frequency and percentage were used to analyze the

socio-demographic characteristics of the sample. Chi-

square was used to examine the association between

non-metric variables, and an Analysis of Variance (AN-

OVA) was used to test the relationships between metric

and non-dichotomous categorical variables. Logistic

regression examined the relationship between the de-

pendent variable and some predisposed independent

(explanatory) variables, because the dependent variable

was a binary one (health status: 1 if reported poor health

status and 0 if otherwise).

The results were presented using unstandardized

B-coefficients, Wald statistics, Odds ratio and confi-

dence interval (95% CI). The predictive power of the

model was tested using the Omnibus Test of Model and

Hosmer and Lemeshow [18] was used to examine

goodness of fit of the model. The correlation matrix was

examined in order to ascertain whether autocorrelation

(or multicollinearity) existed between variables. Based

on Cohen and Holliday [19] correlation can be low

(weak)—from 0 to 0.39, moderate—0.4-0.69, and strong

—0.7-1.0. This was used to exclude (or allow) a variable

in the model. Wald statistics were used to determine the

magnitude (or contribution) of each statistically signifi-

cant variable in comparison with the others, and the Od-

ds Ratio (OR) for the interpreting of each significant va-

riable.

Multivariate regression framework was utilized to as-

sess the relative importance of various demographic,

socio-economic characteristics, physical environment

and psychological characteristics, in determining the

health status of Jamaicans; and this has also been em-

ployed outside of Jamaica. This approach allowed for

the analysis of a number of variables simultaneously.

Secondly, the dependent variable is a binary dichoto-

mous one and this statistic technique has been utilized in

the past to do similar studies. Having identified the de-

terminants of health status from previous studies, using

logistic regression techniques, final models were built

for Jamaicans as well as for each of the geographical

sub-regions (rural, peri-urban and urban areas) and sex

of respondents using only those predictors that inde-

pendently predict the outcome. A p-value of 0.05 was

used to for all tests of significance.

2.1. Model

The use of multivariate analysis in the study of health

and subjective wellbeing (i.e. self-reported health or

happiness) is well established [20,21] and this is equally

the case in Jamaica and Barbados [22,23]. The current

study will employ multivariate analyses in the study of

health status of elderly Jamaicans with diagnosed

chronic medical conditions. The use of this approach is

better than bivariate analyses as many variables can be

tested simultaneously for their impact (if any) on a de-

pendent variable.

The current study seeks to examine the social deter-

minants of poor health status of old Jamaicans who re-

ported having at least one chronic medical condition

(Eq.1):

Ht = f(Ai, Gi, ARi, FCi, NFCi, MRi, Si, HIi, CRi, MCt, SAi,

εi) (1)

where Ht

(self-rated current health status in time t) is a

function of age of respondents, Ai ; sex of individual i,

Gi; area of residence, ARi; food consumption per person

per household member, FCi; non-food consumption per

person per household member, NFCi; marital status of

person i, MRi; social class of person i, Si

; health insur-

ance coverage of person i, HIi; crowding of individual i,

CRi; medical expenditure of individual i in time period t,

MCt; social assistance of individual i, SAi and an error

term (ie. residual error).

2.2. Measure

Age is a continuous variable which is the number of

years alive since birth (using last birthday). Age group is

a non-binary measure: young-old (ages 60 to 74 years);

old-old (ages 75 to 84 years) and oldest-old (ages 85

years and older).

Elderly denotes the chronological age of 60 years and

beyond. Self-reported illness (or self-reported dysfunc-

tion): The question was asked: “Is this a diagnosed re-

curring illness?” The answering options were: Yes, cold;

Yes, diarrhoea; Yes, asthma; Yes, diabetes mellitus; Yes,

hypertension; Yes, arthritis; Yes, Other; and No. A binary

vari- able was later created from this construct (1 = yes,

0 = otherwise) in order to use in the logistic regression.

Health status: “How is your health in general?” And

the options were very good; good; fair; poor and very

poor. For this study the construct was categorized into 3

groups with (i) good; (ii) fair, and (iii) poor. A binary

variable was later created from this variable (1 = good

and fair 0 = otherwise).

Social class: This variable was measured based on in-

come quintile: The upper classes were those in the weal-

P. A. Bourne et al. / HEALTH 2 (2010) 101-111

104

Table 1. Socio-demographic characteristics of sample.

Variable Frequency Percent

Sex

Men 110 38.3

Women 177 61.7

Diagnosed chronic medical condition

Diabetes mellitus 73 25.4

Hypertension 124 43.2

Arthritis 38 13.2

Other (unspecified) 52 18.2

Health care-seeking behavior

Sought care 201 70.8

Did not seek care 83 29.2

Why didn’t you seek care

Could not afford it 14 17.7

Was not ill enough 29 36.7

Preferred home remedies 11 13.9

Didn’t have time to go 6 7.6

Unspecified 19 24.1

Purchased medication

Prescribed medicine 198 72.0

Partial prescription 8 2.9

Prescribed/over the counter 6 2.2

Over counter 6 2.2

Prescribed, but did not buy 9 3.3

No 48 17.4

Health insurance coverage

Private 23 8.0

Public 72 25.2

No 191 66.8

Health status

Good 49 17.1

Fair 136 47.4

Poor 102 35.5

Area of residence

Urban 76 26.5

Other town 55 19.1

Rural 156 54.4

Social class

Poor 114 39.7

Middle 62 21.6

Wealthy 111 38.7

Household head

No 85 29.6

Yes 202 70.2

thy quintiles (quintiles 4 and 5); middle class was quintile

3 and poor those in lower quintiles (quintiles 1 and 2).

3. RESULTS

3.1. Socio-Demographic Characteristics

The sample was 287 elderly respondents (38.3% of men

and 61.7% of women), with 57.1% young-old; 33.1%

old-old and 9.8% oldest-old. Seventy percent of the

sample was head of household; 35.5% had poor health

status; 70.8% sought health care; 72.0% purchased the

prescribed medication; 33.2% had public health insur-

ance coverage; 39.7% were poor; 26.5% lived in urban

areas, 19.2% in other towns and 54.4% in rural areas

(Table 1). Majority (43.2%) of the sample reported hy-

pertension; 25.4% diabetes mellitus; 13.2% rheumatoid

arthritis and 18.2% unspecified the type of chronic ill-

ness that they were diagnosed with (Table 1). Approxi-

mately eighteen percent of those who indicated that they

did not seek care indicated that they could not afford it;

36.7% indicated that they were not ill enough; 13.9%

reported that they use home remedy.

3.2. Bivariate Analyses

There was no statistical correlation between health status

and self-reported dysfunction (χ2 = 1.810, P = 0.404, n=

286) (Table 2). Based on Table 2, only 35.4% of those

who indicated that they had at least one chronic medical

condition reported poor health status. Table 3 revealed a

statistical relation between health status and area of

Table 2. Health status by self-reported dysfunction.

P. A. Bourne et al. / HEALTH 2 (2010) 101-111

105

Self-reported Dysfunction

Health status

n (%) Yes

n (%)

Total

n (%)

Good 0 (0.0) 49 (17.2) 49 (17.1)

Fair 0 (0.0) 135 (47.4) 135 (47.2)

Poor 1 (100.0)

101 (35.4) 102 (35.7)

Total 1 285 286

χ2 (df = 2) = 1.810, P = 0.404, n = 286

Table 3. Health status by area of residence.

Area of residence Total

Health

status Urban

Other

town Rural

Good 16

(21.1) 11 (20.0)

(14.1) 49 (17.1)

Fair 42

(55.3) 29 (52.7)

(41.7) 136 (47.4)

Poor 18

(23.7) 15 (27.3)

(44.2) 102 (35.5)

Total 76 55 156 287

χ2 (df = 4) = 11.569, P = 0.021, n=287

Table 4. Diagnosed chronic medical condition by area of residence.

Area of residence Total

Diagnosed chronic medical condition Urban Other town Rural

Diabetes mellitus 25 (32.9) 17 (30.9) 31 (19.9) 73 (25.4)

Hypertension 25 (32.9) 22 (40.0) 77 (49.4) 124 (43.2)

Rheumatoid arthritis 9 (11.8) 5 (9.1) 24 (15.4) 38 (13.2)

Other (unspecified) 17 (22.4) 11 (20.0) 24 (15.4) 52 (18.1)

Total 76 55 156 287

χ2 (df = 6) = 10.455, P = 0.107, n=287

Table 5. Self-reported chronic medical condition by social class.

Social Class

Self-reported chronic medical condition Poor Middle class

Upper class Total

Diabetes mellitus 21 (18.4) 11(17.7) 41 (36.9) 73 (25.4)

Hypertension 55 (48.2) 32 (51.6) 37 (33.3) 124(43.2)

Rheumatoid arthritis 19 (16.7) 8 (12.9) 11 (9.9) 38 (13.2)

Other (unspecified) 19 (16.7) 11 (17.7) 22 (19.8) 52 (18.1)

Total 114 62 111 287

χ2 (df = 6) = 15.870, P = 0.014, n=287

residence [χ2 (df = 4) = 11.569, P = 0.021, n = 287]. Ru-

ral residents reported the highest poor health status

(44.2%) compared to other town (27.3%) and urban area

residents (23.7%). On the other hand, greatest good heal-

th status was reported by urban residents (21.1%), com-

pared with other town (20.0%) and rural area residents

(14.1%) (Table 3). No statistical association was found

between diagnosed chronic medical condition and area

of residence [χ2 (df = 6) = 10.455, P = 0.107, n = 287]

(Table 4).

A statistical correlation was found between self-re-

ported chronic medical condition and social class [χ2 (df

= 6) = 15.870, P = 0.014, n = 287]. The wealthy was

most likely to have diabetes mellitus (36.9%) while the

poor (48.2%) and the middle class (51.6%) were mostly

likely to indicated hypertension. Approximately ten per-

cent of the wealthy had arthritis compared to 12.9% of

middle class and 16.7% of poor (Table 5).

The mean number of day reported to have illness was

71.6 days (SD = 185.1, 95% CI = 49.1 – 94.2 days). Ur-

ban dwellers reported the least number of days in illness

(mean = 7.5 days, SD=10.96, 95% CI = 4.7 – 10.2 days)

compared to other town residents (mean = 98 days, SD =

216.4, 95% CI = 38.3 – 157.6 days) and rural residents

P. A. Bourne et al. / HEALTH 2 (2010) 101-111

106

Table 6. Annual consumption expenditure, length of illness, total medical expenditure, public medical expenditure, private

medical expenditure by area of residence.

Variable Area of residence n Mean Std. Deviation 95% Confidence

Interval

†Annual consump-

tion expenditure* Urban 76 8711.95 6761.20 716695 - 10256.95

Other Town 55 7388.90 5271.25 5963.88 - 8813.91

Rural 156 5445.09 4470.72 4738.01 - 6152.17

Total 287 6682.69 5485.63 6045.34 - 7320.03

††Length of illness

Urban 64 7.45 10.96 4.72 - 10.19

(days) Other Town 53 97.98 216.44 38.32 - 157.64

Rural 143 90.55 206.90 56.35 - 124.76

Total 260 71.61 185.10 49.01 - 94.22

†††Number of visit

to health care practi-

tioner Urban 55 1.65 1.58 1.23 - 2.08

Other town 39 1.21 .61 1.01 - 1.40

Rural 101 1.42 .85 1.25 - 1.58

Total 195 1.44 1.08 1.29 - 1.59

††††Medical expen-

diture* Urban 57 1481.58 1988.75 953.89 - 2009.27

Other town 39 1817.95 2377.57 1047.23 - 2588.67

Rural 103 1805.34 5154.02 798.04 - 2812.64

Total 199 1715.07 3988.73 1157.48 - 2272.67

† F statistic [2,284] = 10.248, P < 0.001; †† F statistic [2,257] = 5.031, P = 0.006; ††† F statistic [2,192] = 2.057, P = 0.131; †††† F statistic

[2,196] = 0.136, P = 0.001

Table 7. Logistic regression: Predictors of poor health status of those diagnosed with chronic medical condition.

Variable Coefficient Std. Error

Wald statistic

Odds ratio 95.0% C.I.

Middle class 0.647 0.527 1.507 1.909 0.680 - 5.360

Upper class 0.427 0.639 0.446 1.533 0.438 - 5.366

†Poor

Man 0.765 0.386 3.937* 1.000

2.150 1.009 - 4.578

Urban areas -0.314 0.439 0.512 0.730 0.309 - 1.727

Other towns -0.449 0.466 0.931 0.638 0.256 - 1.589

†rural areas

Social assistance (1=yes) -0.112 0.461 0.059 1.000

0.894 0.362 - 2.207

Crowding 0.173 0.119 2.124 1.189 0.942 - 1.499

Age 0.033 0.022 2.182 1.033 0.989 - 1.079

Married 0.257 0.403 0.406 1.293 0.587 - 2.847

Divorced, separated or widowed 0.629 0.461 1.858 1.875 0.759 - 4.628

†Never married

Non-food consumption 0.000 0.000 0.017 1.000

1.000 1.000 - 1.000

Food consumption 0.000 0.000 4.088* 1.000 1.000 - 1.000

Health insurance (1=yes) 0.390 0.382 1.039 1.476 0.698 - 3.123

χ2 (df = 13) = 20.249, P < 0.001; n = 285

-2 Log likelihood = 238.17

Nagelkerke R2 =0.115

Hosmer and Lemeshow goodness of fit χ2=7.565, P = 0.477

Overall correct classification = 83.5%

Correct classification of cases of self-rated poor health status = 99.2%

Correct classification of cases of self-rated good health status = 6.3%

†Reference group

*P < 0.05, **P < 0.01, ***P < 0.001

P. A. Bourne et al. / HEALTH 2 (2010) 101-111

107

(mean = 90.6 days, SD = 206.9, 95% CI = 56.4 – 124.8

days) - F statistic [2,257] = 5.031, p = 0.006. This was

similar for medical health care expenditure - F statistic

[2,196] = 0.136, P = 0.001. The mean amount spent on

medical care for urban residents was US $21.85 com-

pared to US $26.12 for other town residents and US

$26.81 for rural respondents. On the other hand, there

was a statistical difference between annual consumption

expenditure and area of residence - F statistic [2,284] =

10.248, P < 0.001. The mean annual amount spent by

urban dwellers was US $8, 711.95 than other town

dwellers US $7, 388.90 and rural residents US $5,

445.09 (Table 6).

3.3. Multivariate Analyses

The socio-demographic determinants of poor health sta-

tus of those who indicated being diagnosed with chronic

illness were sex of respondents (OR = 2.15, 95% CI =

1.009 – 4.578) and food consumption (OR = 1.00, 95%

CI = 1.00 – 1.00) (Table 7). Elderly men who revealed

that they were diagnosed with chronic illness were 2.15

times more likely to indicated poor health than elderly

women (Table 7).

4. DISCUSSION

The current revealed that 43 out of every 100 elderly

Jamaican who reported chronic illness had hypertension,

25 in every 100 had diabetes mellitus and 13 in every

100 had rheumatoid arthritis. Thirty-five in every 100

indicated poor self-reported health status; 70 out of

every 100 were household heads; 29 out of every 100

did not seek care and of those who did not seek care

37% indicated that they were not ill enough to visit a

medical practitioner or health facility. Rural residents

had greatest percentage with hypertension (49.4%) and

rheumatoid arthritis (15.4%) compared to other area of

residents. However, urban residents had the greatest

percent of diabetes mellitus (32.9%) compared to

peri-urban (30.9%) and rural residents (19.9%). Upper

class people recorded the most diabetes mellitus cases

(37%) compared to the poor (18%) and the middle class

(18%). Middle class however recorded the most hyper-

tensive cases (52%) compared to the poor (48%) and the

wealthy (33%). Concurrently, the poor recorded the most

rheumatoid arthritis cases (17%) compared to the middle

class (13%) and the wealthy (10%). Only sex and food

consumption were found to be correlated with

self-reported health status. Older men self-reported

health status was almost 2.2 times more than that for

older women, and those who consumed more food re-

corded better health status. Furthermore, the duration of

illness (in days) for rural residents was 12 times more

than that for urban residents and their medical expendi-

ture was 1.2 times more than that of those in urban areas.

Concurrently, periurban residents spent 13 times more

days in illness than urban residents and spent 1.2 times

more on medical expenditure.

Self-reported health status has been widely used in

censuses, surveys, and observational studies and there is

evidence suggesting that self-reported health is an indi-

cator of general health with good construct validity [24]

and is a respectably powerful predictor of mortality risks

[25], disability [26] and morbidity [27]. The results of

this study showed that the majority of those sampled re-

ported themselves to be experiencing good or fair health,

while approximately one-third indicated poor health. Th-

ese results concur with those by other researchers from

Dominica [28] and Trinidad [29]. In a recent island wide

survey of persons aged 65 years and older conducted in

Trinidad in 2002, 44% reported their health as fairly good

or good. In reviews of the literature, Benyamini & Idler

[30] and Idler & Benyamini [25], showed that in most

studies conducted since the 1980s, the elderly people

who self-rated their health as bad presented greater inci-

dence of death than did those who considered it to be

excellent. Among elderly people, self-rated health may

present greater sensitivity for men than for women. Since

women live longer than men and experience more years

with diseases and incapacities, they tend to rate their

health more negatively than do men, but do not necessar-

ily die because of this, over the short term. Thus, negative

self-rated health expressed by women may be more asso-

ciated with quality of life. On the other hand, when men

rate their health negatively, they present a greater risk of

succumbing to a fatal event [31].

There has been a general epidemiological shift from

infectious to chronic diseases and the elderly are one of

the main at risk groups. In this study, just over one-third

of the respondents who reported poor health indicated

that they had at least one chronic disease. This is less

than the 80% reported in a study in Trinidad [29]. The

main chronic illnesses reported by the respondents in

this study were hypertension, diabetes mellitus and

rheumatoid arthritis. This is in keeping with the study by

Rawlins et al. [29] and other Caribbean studies on this

age group [32,33]. Furthermore, a study conducted on

elderly Jamaicans showed that this age cohort was

mainly affected by chronic non-communicable diseases

[34]. The most common chronic diseases identified

among the elderly in Jamaica are hypertension, arthritis,

diabetes mellitus, cardiovascular arrest, stroke and can-

cer. Patients in the 60 and over age groups accounted for

37.2% and 41.1%, respectively, of new hypertensive and

diabetic cases [35]. Some gender differences have been

reported in respect of chronic illnesses with women at

greater risk for hypertension and men cardiovascular

P. A. Bourne et al. / HEALTH 2 (2010) 101-111

108

diseases [36]. Furthermore, in 1991, cardiovascular dis-

eases followed by diabetes mellitus and neoplasms were

the diseases for which Jamaicans 65 years older were

most often hospitalized [37].

Data for the Caribbean showed that hypertension and

rheumatoid arthritis are morbidities that significantly

affect both men and women [38]. The current study re-

vealed that hypertension was the leading cause of illness

among older and oldest elderly in Jamaica, followed by

diabetes mellitus, and rheumatoid arthritis, which concurs

somewhat with a past study [39] that had hypertension as

the leading cause of morbidity of the elderly, followed by

rheumatoid arthritis and diabetes mellitus. In another

reported study, the most common chronic diseases identi-

fied among the elderly were hypertension, rheumatoid

arthritis, diabetes mellitus, cardiovascular arrest, stroke

and cancer [35]. Some gender differences have been re-

ported in respect of chronic illnesses with women at

greater risk for hypertension and men cardiovascular

diseases [36]. In a recent study by Bourne, 1.4 times

more women had diabetes mellitus than men and this was

the same for hypertensive older and oldest elderly Ja-

maicans [39]. On the other hand, there were 1.6 times

more old and oldest elderly Jamaican men with

self-reported rheumatoid arthritis than women [39]. Th-

ese chronic non-communicable diseases continue to in-

terface within the functional lives of the elderly, which

means that they are indeed living longer but are faced

with lower levels of good health than young adults (ages

15 to 29 years) and middle-aged adults (ages 30 to 59

years). According to the JSLC there has been significant

increase in illness/injury among older persons since 1997

[40]. Data from the 2002 survey indicate that 34.6 per-

cent of the elderly population surveyed, reported an ill-

ness or injury during the four-week reference period [41].

Hypertension is one of the most important treatable

causes of morbidity and mortality and accounts for a

large proportion of cardiovascular diseases in elderly in

Jamaica [42]. It is known to be a major risk factor for the

development of diabetic renal disease, and hyperglycae-

mia also has a role in the development of diabetic neph-

ropathy [43]. Studies from developed countries have

reported prevalence of raised blood pressure among eld-

erly to vary from 60% to 80% [44]. Furthermore, diabe-

tes mellitus is one of the leading causes of morbidity and

mortality among persons aged 65 and older [45]. About

20% of persons in this age group are estimated to have

diabetes mellitus, with another 25% in pre-diabetic

stages [46]. Moreover, because diabetes can be asymp-

tomatic for many years, about 50% of older individuals

with diabetes are thought to be undiagnosed [47]. In

Jamaica, diabetes-related deaths in 1994 had increased

147% over the 1980 level and represented the third

leading cause of loss of years of potential life among

women and tenth among men [48]. There is evidence

that this is due to the low rates of awareness, treatment

and control among patients with hypertension and dia-

betes [49,50].

One of the silent illnesses which emerged from the

current study is unspecified health conditions. Eight out

of every 100 elderly Jamaicans who reported a chronic

illness stipulated unspecified conditions. Based on cau-

ses of mortality and morbidity statistics in Jamaica, the

other includes heart diseases; malignant neoplasm of the

prostate; malignant neoplasm of the breast; and malig-

nant neoplasm of the trachea, bronchus [51,52]. Statis-

tics revealed that other heart diseases, malignant neo-

plasm of the breast, malignant neoplasm of the prostate

and malignant neoplasm of the trachea and bronchus are

among the 10 leading causes of mortality for males

and/or females [51]. The prevalence of diseases in this

category (i.e. unspecified condition) is greater than those

with rheumatoid arthritis, and statistics have showed

malignant neoplasm of the prostate is the 5

th leading

cause of mortality of male 50 years and older [52]. Heart

diseases and malignant neoplasm of the breast were the

6th and 7

th leading cause of death respectively among

females 50 years and older [52]. The unspecified health

conditions are therefore silent killer among the elderly

with chronic diseases.

Seventy-two percent of poverty lies in rural are com-

pared to 20% in urban and 9% in peri-urban area [17],

indicating that poverty is accounting for illnesses ex-

perienced by rural residents as well as the length of time

they spent in illness. The current study showed that

length of time spent in illnesses by rural residents was 12

times more than that for those in urban area, and so jus-

tifying why they spend 1.2 times more on medical care

compared to urban dwellers. The typology of illness that

is experienced by rural residents (i.e. hypertension) is

such that they require frequent visits to health care pro-

viders (i.e. doctors, nurses, pharmacists). Seemingly the

afore-mentioned should be the case, but we found that

there was no significant statistical difference between the

number of visits made to health care providers and area

of residents. Like those who were unable to attend health

care during the time of illness, they were either unable to

afford it (18%) or diagnosed themselves as being not ill

enough (37%). Inspite of this fact, 48% of the poor eld-

erly with chronic illnesses had hypertension and 18%

had diabetes mellitus, which are illness which require

treatment and cannot be left to prayer, faith or abstinence

from medical care.

Rural populations generally experience excessive de-

ficiencies in healthcare access, social services and other

goods and services needed for healthy living. Further-

more, 23% of people from rural Jamaica who reported

having a chronic medical condition were not actively

engaged in seeking health care because of affordability

issues, compared with 9.4% from urban areas. Urban

residents consistently reported better health status than

rural residents, and greater satisfaction with their health

P. A. Bourne et al. / HEALTH 2 (2010) 101-111

109

care [53]. There was a statistical correlation between

good health status and area of residence, or self-reported

(chronic) recurring illness and age cohort. Furthermore,

the data showed that elderly Jamaicans who dwelled in

rural area had the lowest self-reported good health com-

pared to those who resided in other towns and urban

areas. Continuing, those who resided in urban residence

reported the greatest good health status. In 1997, statis-

tics from PIOJ and STATIN [54] revealed that 54.3 per-

cent of elderly (ages 60 years and over) lived in rural

areas. A study by Bourne [39] showed that approxi-

mately 7 out of every 10 old and oldest elderly in Ja-

maica lived in rural areas, compared to 6 out of 10 for

those 60 years and older of the population. In addition,

20 out of every 100 Jamaicans were below the poverty

line, compared to 25 out of every 100 in rural Jamaica.

Given that the elderly substantially lived in rural areas

and that poverty for this group was 10.2 percent [55], it

is not surprising that the elderly in this area of residence

had a lower level of good health status than the urban

elderly in Jamaica.

The wealthiest in the society are expected to experi-

ence better health due to their knowledge of health risks

and their access to the resources necessary to avoid such

risks and treat emerging health conditions [56]. But with

increasing wealth and development these has been an

increase in chronic disease as lifestyle changes have had a

negative impact. The studies found that there were large

gaps between the mean amounts of money spend by ur-

ban residents compared with their rural counterparts.

Furthermore, the elderly who are wealthy were more

likely to have diabetes mellitus while the poor and the

middle class were more likely to report hypertension.

This suggests the consumption patterns of the wealthy

contribute to ill-health. Thus whereas the poor become ill

due to their inability to access their basic human rights,

the rich become ill as a result of their harmful consump-

tion patterns. According to Sobal and Stunkard [57], in

developing societies there is a higher likelihood of obe-

sity among men in higher socioeconomic strata. These

men are at increased risk of developing type 2 diabetes

mellitus [58] which is increasing in the adult population.

Among the demographic correlates of health is the cost

of medical care. It is established that medical care [20]

and cost of medical care [21] are among the social de-

terminants of health.

5. CONCLUSIONS

The general epidemiological shift from infectious to

chronic non-communicable diseases in Jamaica puts the

elderly at risk. Majority of the respondents in the sample

had good or fair health, and those with poor health status

were more likely to report having hypertension followed

by diabetes mellitus and rheumatoid arthritis. Poor health

status was more prevalent among those of lower eco-

nomic status in rural areas who reported the greatest

number of sick days of illness and medical health care

expenditure. The prevalence of chronic diseases and lev-

els of disability in older people can be reduced with ap-

propriate health promotion and strategies to prevent

non-communicable diseases. This research provides

valuable information on health status and the non-comm-

unicable diseases which affect the elderly in Jamaica, and

particular socioeconomic group respond being diagnosed

with particular chronic illnesses. These findings can as-

sist health care professionals to specifically and adequ-

ately address the health needs of the elderly in Jamaica.

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