Vol.2, No.5, 465-476 (2010)
Copyright © 2010 SciRes http://www.scirp.org/journal/HEALTH/
Openly accessible at
Health measurement
Paul Andrew Bourne
Department of Community Health and Psychiatry, The University of the West Indies at Mona, Kingston, Jamaica;
Received 21 December 2009; revised 14 January 2010; accepted 17 January 2010.
Jamaicans are not atypical in how they con-
ceptualize health and/or how they address pa-
tient care as the antithesis of diseases or dys-
functions (i.e. health conditions). In the 1900s
and earlier, Western Societies were using the
biomedical model in the measurement and trea-
tment of health, health attitudes and the utiliza-
tion of health services. This approach empha-
sizes sickness, dysfunction, and the identifica-
tion of symptomology or medical disorders to
evaluate health and health care. Such an ap-
proach places significance on the end (i.e. ge-
netic and physical conditions), instead of the
multiplicity of factors that are likely to result in
the existing state, or issues outside of the space
of dysfunctions. Notwithstanding the limitations
of the biomedical approach, it is still practiced
by many Caribbean societies, and this is fun-
damentally the case in Jamaica. The current
paper is an examination of health measurement,
and provides at the same time a rationale for the
need to have a more representative model as
opposed to the one-dimensional approach of
using pathogens in measuring health. Owing to
the importance of health in development, patient
care and its significance for other areas in so-
ciety, this paper seeks to broaden more than
just the construct, as it goes to the core of
modern societies in helping them to understand
the constitution of health and how patient care
should be treated. Thus, it provides a platform
for the adoption of the biopsychosocial model,
which integrates biological, social, cultural, psy-
chological and environmental conditions in the
assessment of health and the outcome of re-
search, by using observational survey data.
Keywords: Health; Biomedical Model;
Biopsychosocial Model; Determinants; Antithesis of
Diseases; Health Measurement; Jamaica
The construct of health is more than a concept. It is a
“leading characteristic of the members of a popula-
tion...” [1] and, ergo, it plays a direct role in the images
of health and health care. Among the plethora of reasons
for the importance of health are not merely the images
created by the construct, but also its contribution to the
production of different tenets of human existence—ill-
ness, morbidity, comorbidity, disability, mortality, life
expectancy, wellbeing, and so on, as well as the guide
that it affords for health interactions and interventions.
In addition to the aforementioned issues, it is of germane
significance in aiding us to understand many of the
things that we see. The definition of this single term
“health” is important, as a precise use of the construct
fashions and connects other important applications such
as growth and development, productivity, health care
and people’s expectations of health care professionals.
One scholar, in helping us to understand the meaning of
a construct, says that “without a well-defined construct,
it is difficult to write good terms and to derive hypothe-
ses for validation purposes” [2]. Embedded in Spector’s
argument is the “theoretical abstraction” of the construct,
and how we may use it for outcome research. In this
paper, the author will review the existing literature and
identify particular measures of health, examining how
these differ from the WHO’s conceptual definition of
health [3]. At the same time, within the limitations of the
biomedical model, the study will evaluate the usefulness
of the biopsychosocial model in health and how the im-
age of health influences the health care of people.
1.1. Image of Health
Health, however, is more than a “theoretical abstraction”.
There is an “objective reality” to this construct. It ex-
plains life, and life is an objective reality. Furthermore,
health is a valuable tool that “drives” health policies and
influences the determinants of health care. Then there is
the issue of health care and how this is planned for, as
well as the role that health plays in the development of a
society. Health, wellbeing and poverty are well docum-
ented in developmental economics by scholars such as
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Amartya Sen, Paul Streeten and Martin Ravallion as
having critical roles in understanding human develop-
ment (or the lack of it). The fascination with health and
wellbeing in developmental studies is primarily because
of the direct association between development and
Jamaica is not atypical in how its people conceptual-
ize health and/or how they address patient care. In the
1900s and earlier, western societies used the biomedical
approach in the measurement and treatment of health [5].
The biomedical approach emphasizes sickness, dysfunc-
tion, pathogens, and disability and medical disorders in
the construction of health. This approach places impor-
tance on the outcome (or the end) instead of the multi-
dimensional conditions that are likely to result in the
existing state. Notwithstanding the limitations of the
biomedical approach, it is still practiced by many Carib-
bean societies, and this is fundamentally the case in Ja-
maica. This is atypical in many Western nations, as con-
temporary demographers still use the antithesis of illness
and disability to write about health [6-8]. Rowland wrote
that “Measures of population health are of general inter-
est to demographers, sociologists, geographers and epi-
demiologists. Interdisciplinary concerns here include
comparing national progress through the epidemiologic
transition, and identifying social and spatial variations
within countries in patterns of disease and mortality [5].
The United States has left many Caribbean societies
behind in how they conceptualize health and treat health
care. As early as the commencement of the 20th century
[4], the United States shifted their focus from negative
wellbeing (i.e. antithesis of diseases) to positive wellbe-
ing. The antithesis of diseases assumes a bipolar oppo-
site between health and diseases. Embedded in this bi-
polar thinking is that for one to be healthy, he/she must
not be experiencing any symptomology of dysfunctions.
Hence, the health of people is measured by mortality or
morbidity statistics. Health, however, is more than just
the antithesis of diseases to positive psychology, inclu-
sive of socio-cultural conditions and the environment.
Positive wellbeing encapsulates the biomedical model in
addition to psychological, socio-cultural and environ-
mental conditions. The name that Engel gave to this new
approach is the biopsychosocial model. The current pa-
per is a discourse on the limitation of the biomedical
model, which will provide a rationale for the need to
have a more representative model as against this one-
dimensional approach to the measurement of health.
Traditionally, health was conceptualised as the “an-
tithesis of diseases” [4]. Using the antithesis of diseases,
this construct utilizes a minimization approach or a
negative perspective, adopted by western societies,
which saw health as the absence of dysfunctions, mor-
bidity conditions or comorbidity. “This definition of
health has been largely the result of the domination of
the biomedical sciences by a mechanistic conception of
man. Man is viewed by physicians primarily as a physio-
chemical system” [9]. With this thinking, health profes-
sionals’ evaluation of patient care and diagnostic treat-
ments is based primarily on the identification of any
symptomology of dysfunctions. Hence the standard that
is used in the evaluation of health is the established norm
of any deviation from diseases. Rather than conceptual-
izing health and stating its determinants, this approach
uses the identification of symptomology to measure
health. Therefore, life expectancy is used here as a
measure of health. This assumes that once an individual
is alive, it is because there are no dysfunctions to cause
death. Embedded in this association is the influence of
dysfunctions on health, but there are no other determi-
nants of health except the various symptomologies of
Outside of diseases, there are other determinants of
health. Based on the biopsychosocial model that George
Engel [10,11] developed, he proposed an approach to the
treatment of the health care of psychiatric patients that
included biological, social and psychological conditions.
Such a conceptual framework, unlike the biomedical
sciences, introduces and identifies factors that are re-
sponsible for the health, and by extension the wellbeing,
of a population. One scholar cites that “the states of
health and disease are the expressions of the success or
failure experienced by the organism in its efforts to re-
spond adaptively to environmental changes” [12]. Again,
when health is defined as the antithesis of diseases its
determinant is solely biological, but this is clearly one
-dimensional, and many scholars have shown that health
is, in fact, multidimensional, and composed of biopsy-
chosocial and environmental conditions.
Another aspect to health is the positive association
between the determinants of health and health care poli-
cies. Health care policy makers use the determinants of
health as the benchmark that directs their planning.
Therefore, when health policies are too narrow, the
health determinants which fashion a population’s health
care will take a minimal approach, as this is based on the
image of health. One scholar puts it succinctly, “…health
policies affect health through their effects on health de-
terminants” [13], which speaks to the importance of
“good” hypotheses in the schema of things. It should be
noted that the hypotheses allow us to derive the possible
determinants of health, which would be used to evaluate
the effectiveness of the health policy, and so show how
they affect health (see Figure 1).
The goal of the policy is to decrease the incidence of
chronic diseases, high risk sexual behaviour/violence
and injury through the adaptation of appropriate behav-
iours by the population and particularly young children,
adolescents and young adults [14].
The general conceptualization of health in Jamaica is
the “antithesis of diseases”. This explains why many
people emphasize health care for morbidity conditions,
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Health Policy
Determinants of
Health –
Figure 1. The relation between health policy and health, and
the roles of health determinants.
genetics, or physical functioning (i.e. their biology). An-
other indicator of the usage of this perspective can be
seen in how data are collected on health in Jamaica
and/or in the wider Caribbean. Such a situation high-
lights the minimization or substantially negative ap-
proach in the construct of health. Despite the title of the
Ministry of Health’s “National Policy for the Promotion
of Healthy Lifestyle in Jamaica”, throughout the paper
the MOH [14] emphasizes mortality, diseases, dysfunc-
tions and reproductive health, which highlights Jamai-
cans’ perspective on health. This is also evident in the
Planning Institute of Jamaica which is responsible for
policy, along with the Statistical Institute of Jamaica,
collecting information on health by way of 1) preventa-
tive (i.e. behaviour modification), curative (surgical
procedures, visits to health practitioners), restorative
(physical rehabilitation), and palliative (i.e. pain man-
agement) measures, and ownership of health insurance.
Thus, the hypotheses that arise from the collected data
are in keeping with the narrowed definition for which
the data was initially gathered by the research design
exercise. The hypothesis of the presence of pathogens
such as poor air being the cause of diseases, or classifi-
cation of ill-health, is ancient, within the context that
health has been expanding from mere physical function-
ing for some time. This hypothesis assumes that a person
who does not have an ailment (or disease condition) is
healthy, which is categorically false, as health psycholo-
gists have shown that psychological conditions do in-
fluence wellbeing [4]. This perspective dates back to
Galen in Ancient Rome (i.e. 130 CE-200 CE). A point is
even more forcefully made in a study by two economists,
which found a strong direct relationship between happi-
ness and wellbeing [15]. Other researchers found an as-
sociation between “positive and/or negative” mood(s)
and wellbeing [16]. This paper is in two parts, designed:
1) to provide detailed evidence that will support the ra-
tionale for an expanded concept which looks at health
and wellbeing; and 2) to illustrate the purpose and sig-
nificance of the expanded model that Engel termed the
biopsychosocial model. This paper however is not argu-
ing for a biopsychosocial hybrid model, which would
include biological, economic, social, cultural, psycho-
logical and ecological conditions.
Caring for patients suffering from ill-health has a long
history, which dates back to the Agrarian societies. Dur-
ing those earlier periods, man in his quest to address
health conditions did so primarily from the standpoint of
physical functionality. Based on the annals of time, the
literature showed that people would treat biological
dysfunctions and sometimes the “spirit” in their pursuit
of making man healthier. This approach dates back as far
as ancient Rome (i.e. 130 CE-200 CE). Despite the
WHO offering us a better way in the pursuit of happi-
ness and wellness, man continues to return to the bio-
medical model of health. One of the reasons for the con-
tinued acceptance of the use of the biomedical model is
the dominance of technology in this process. As tech-
nology is still primarily intended to address physical
dysfunctions and the absence of pathogens, many studies
conducted in early societies have not only linked the
concept of health to medical conditions and by extension
health care, but have served as another important indi-
cator in determining lifespan.
In 1884, an Englishman named Francis Galton who
was both a mathematician and medical doctor researched
the “physical and mental functioning” of some 9,000
people between the ages of 5 and 80 years [17]. Galton
wanted to measure the human life span in relation to the
physical and mental functioning of people, so he spon-
sored a health exhibition that would allow him to collect
data for analysis. Health was traditionally defined as the
“antithesis of diseases”, which explains the predomi-
nance of physical functioning in policy making and
health care, and justifies Galton’s wanting data on the
physical functioning of people.
The 20th century has brought with it massive changes
in the typologies of dysfunctions, where deaths have
shifted from infectious diseases such as tuberculosis,
pneumonia, yellow fever, Black Death (i.e. Bubonic
Plague), smallpox and “diphtheria” to illnesses such as
cancer, heart disease and diabetes [14]. Although dis-
eases have shifted from infectious to degenerate, chronic
non-communicable illnesses and science, medicine and
technology have expanded since then, and the image of
health in contemporary Jamaica still lags behind many
developed nations. Morrison [18] titled an article “Dia-
betes and Hypertension: Twin Trouble” in which he es-
tablishes that diabetes mellitus and hypertension have
now become problems in Jamaicans and in the wider
Caribbean. This situation was equally corroborated by
Callender [19] and Steingo [20] at the 6th International
Diabetes and Hypertension Conference, which was held
in Jamaica in March 2000. They found that there is a
positive association between diabetic and hypertensive
patients—50% of individuals with diabetes had a history
of hypertension [19,20]. Prior to those scholars’ work,
Eldemire [21] found that 34.8% of new cases of diabetes
and 39.6% of hypertension were associated with senior
citizens (i.e. ages 60 and over). Accompanying this pe-
riod of the “age of degenerative and man-made ill-
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nesses” are life expectancies that now exceed 50 years.
Before the establishment of the American Gerontol-
ogy Association in the 1930s and their many scientific
studies on the ageing process [17], many studies were
done based on the biomedical model, i.e. physical func-
tioning or illness and/or disease-causing organisms [4].
Many official publications used either reported illnesses
or the prevalence of seeking medical care for measuring
sicknesses. Some scholars have still not moved to the
post biomedical predictors of health status. The domi-
nance of this approach is so strong and present within
the twenty-first century, that many doctors are still treat-
ing illnesses and sicknesses without an understanding of
the psychosocial and economic conditions of their pa-
tients. To illustrate this more vividly, the researcher will
quote a sentiment expressed by a medical doctor in The
Caribbean Food and Nutrition Institute’s Quarterly [22].
A public health nutritionist, Dr. Kornelia Buzina [23],
says, “When used appropriately, drugs may be the single
most important intervention in the care of an older pa-
tient … and may even endanger the health of an older
patient …” This proposition highlights the paradox in
biomedical sciences as well as showing the need to ex-
pand the image of health beyond this negative approach
to it.
Within the context of the WHO’s definition and
growing numbers of studies that have concluded that
health should be a multidimensional construct, in 2007 a
group of medical practitioners used physical functional-
ity and dysfunctions to treat an elderly patient who was
suffering from a particular health condition [24]. The
researchers put forward an examination of a 74-year old
man who with “...a long history of ischaemic heart dis-
ease, presented with increasingly prolonged episodes of
altered consciousness” [24]. The physicians cite the ar-
gument that “many elderly patients may have more than
one cause for this symptom” [24], which summarizes
their perspective and reliance on understanding medical
disorders in the dispensing of patient care. Throughout
the study, the scholars and medical practitioners did not
seek to evaluate the psychological, social, and environ-
mental conditions and their possible influence on the
current state of dysfunction of the elderly patient. De-
spite the seeming complexity of the result of the detailed
inquiry into the neurological conditions of the patient,
and the keen medical examination of the patient, his
medical condition continued for years unabated. This
emphasises the dominance of the biomedical model, and
it goes beyond this single study, as a review of publica-
tions in the West Indian Medical Journal—a medical
journal in Jamaica—from 1960-2009 revealed a few
studies that have gone beyond the use of the biomedical
approach to the examination of patient care.
In seeking to treat the 74-year old patient, the medical
practitioners examined and re-evaluated various medical
problems. Thus, owing to the thinking of this group of
researchers, they used “multiple medications” in the
treatment of the patient’s condition. It was clear from the
perspective of the scholars that what guided their inter-
vention were the biomedical sciences (i.e. physical func-
tionality or dysfunctions). In this case, health is the “an-
tithesis of diseases”. It is the narrow definition of health
—negative health (i.e. biomedical approach) —which
explains the image of health and health care for those
scholars and researchers. Apart from the reasons for the
use of diagnosed conditions, life expectancy and other
physical issues are utilized in examining health, because
of the precision in using them to evaluate health as
against other approaches that are more holistic and
broader in scope.
2.1. Health Measurement
The narrow definition of health is the “antithesis of dis-
eases” which Longest [13] says is the “…absence of
infection or the shrinking of a tumour” which can be
called dysfunctions (see [1,4]. As we mentioned earlier,
the “antithesis of diseases” idea dates back to Galen in
Ancient Rome. It was widespread in the 1900s, and so
medical professionals used this operational definition in
patient care. Another fact during this time was that
technology was fashioned in this regard, addressing
solely physical dysfunctions. This definitional limitation
may be a rationale for the World Health Organization,
nearing the mid-1900s, declaring that health is the “state
of complete physical, mental, and social wellbeing, and
not merely the absence of diseases or infirmity” [3]. It
should be noted that this conceptual definition which is
in the Preamble to the constitution of the WHO which
was signed in July 1946 and became functional in 1948,
according to one scholar, from the Centre of Population
and Development studies at Harvard University, is a
mouthful of sweeping generalizations. According to Bok
[25], the definition offered by the WHO is too broad and
difficult to measure, and at best it is a phantom. Other
intelligentsia point to the WHO’s definition as a diffi-
culty for policy formulation, because its scope is “too
broad” [26]. The question is “Is the conceptual definition
formulated by WHO so broad that those policies faced
difficulty in formation”, and by extension should we
regress to a pre-1946 conceptualization of health be-
cause a construct is difficult to operationalize today?
Undoubtedly, health extends beyond diseases and is tied
to cultural and psychological elements, personal respon-
sibility, lifestyle, environmental and economic influ-
ences as well as quality nutrition [27-41]. Those condi-
tions are termed determinants of health [26].
The WHO’s perspective must have stimulated Dr.
George Engel to pursue a modification of the narrow
approach to the health and health care debate. Dr. Engel
was a psychiatrist who formulated the construct called
the biopyschosocial model in the 1950s. He believed that
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when a patient comes to a doctor, for example for a
mental disorder, the problem is a symptom not only of
actual sickness (biomedical), but also of social and psy-
chological conditions [10,11]. He therefore campaigned
for years for physicians to use the biopsychosocial
model for the treatment of patients’ complaints, as there
is an interrelationship between the mind, the body and
the environment. He believed so deeply in the model,
convinced that it would help in understanding sickness
and providing healing, that he introduced it into the cur-
riculum of Rochester medical school [42,43]. Medical
psychology and psychopathology was the course that
Engel introduced into the curriculum for first year
medical students at the University of Rochester. This
approach to the study and practice of medicine was a
paradigm shift from the biomedical model that was
popular in the 1980s and 1990s.
The Planning Institute of Jamaica and the Statistical
Institute of Jamaica employ the biomedical model in
capturing the health status and/or wellbeing of the popu-
lace. This approach was obsolete by the late 20th century,
as in 1939 Cowdy, E.V. a cytologist in the United States;
expanded on how ageing and health status should be
studied in the future. Cowdy broadened the biomedical
model in the measurement of the health status of older
adults by including social, psychological and psychiatric
information in his study entitled the “Problem of Age-
ing” [17]. The Ministry of Health [MOH] [14], however,
has published a document in which it shows that health
interfaces with biomedical, social and environmental
conditions. One of the reasons put forward by the MOH
to help in understanding why they arrived at the afore-
mentioned position, was the rationale behind the expla-
nation for the changes in the typology of diseases – that
is, from infectious and communicable diseases to
chronic conditions. The institution cites that this is sub-
stantially because of the lifestyle practices of Jamaicans.
One of the ironies within the document was in the “main
components of the policy for the promotion of a healthy
lifestyle in Jamaica”, which cites that the goal of the
policy was to reduce the incidence of communicable and
infectious diseases, which speaks to society’s subcon-
scious emphasis on the biomedical model in conceptual-
izing health and its treatment. Embedded within the
MOH’s 2004 publication are repetition and the focus on
seeking to reduce physiological conditions that affect the
individual. The MOH admits, however, that health inter-
faces with body and environment, which is an expansion
of the biomedical model, but all indications in their
document point to the biomedical science approach in
the application of the policy. The institution recognized
that psychological factors (for example, self-esteem, and
resilience) play a role in influencing health, so much so
that it included these within its “goal of the strategic
approach”, but they were not supported in the “broad
objectives of the strategic approach”.
Critical to all of this is the acceptance that the defini-
tion of health is fundamental to the construction of those
hypotheses that are used to formulate health policies.
According to Longest [13], the conceptualization of health
is indeed critical to all the things that rely on its defini-
tion. Longest writes:
The way in which health is conceptualized or defined
in any society is important because it reflects the soci-
ety’s values regarding health and how far the society
might be willing to go in aiding and supporting the pur-
suit of health among its members [13].
In Jamaica health policies are still driven by physical
functioning, which is an obsolete approach to addressing
health and by extension wellbeing. This limited ap-
proach to health and wellbeing means that little consid-
eration is given to other factors such as lifestyle, psy-
chological state, the environment, crime and violence,
among others. This of course implies that Jamaica’s
health policy is limited in its orientation, as it is largely
driven by hypotheses that support physical functioning.
2.2. Biopsychosocial Approach
Dr. Buzina admits that wellbeing is fundamentally a
biomedical process [23]. This conceptual framework
derives from the Newtonian approach of basic science as
the only mechanism that could garner information, and
empiricism being the only apparatus to establish truth or
fact. It is still a practice and social construction that nu-
merous scholars and medical practitioners [24] continue
to advocate despite new findings. Simply put, many
scholarships still put forward a perspective that the ab-
sence of physical dysfunction is synonymous with well-
being (or health, or wellness). Such a viewpoint appears
to hold some dominance in contemporary societies, and
this is a widespread image held in Jamaica. Then there
are issues such as the death of an elderly person’s
life-long partner; a senior citizen taking care of his/her
son/daughter who has HIV/AIDS; an aged person not
being able to afford his/her material needs; someone
older than 64 years who has been a victim of crime and
violence and continues to be a victim; seniors who reside
in volatile areas who live with a fear of the worst hap-
pening, the inactive aged, and generally those who have
retired with no social support, are equally sharing the
same health status as the elderly who have not been on
medication because they are not suffering from bio-
medical conditions to the extent that they need to be
given drugs.
Two medical doctors writing in Kaplan and Saddock’s
Synopsis of Psychiatry noted that physicians are fre-
quently caught in theorizing that normality is a state of
health [44]. They argued that doctors’ definition of nor-
mality correlates with a traditional model (biomedical)
that emphasizes observable signs and symptoms. Using
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psychoanalytic theories, Saddock and Saddock [44] re-
marked that the absence of symptoms as a single factor
is not sufficient for a comprehensive outlook on normal-
ity. They stated, “Accordingly, most psychoanalysts
view a capacity for work and enjoyment as indicating
normality…” [44]. Among the challenges associated
with this method (biomedical model), is its emphasis
only on curative care. Such an approach discounts the
importance of lifestyle and preventative care. In that,
health is measured based on experiences with illnesses
and/or ailments, with limited recognition being placed
on approaches that militate against sickness and/or dis-
eases. The biomedical approach is somewhat biased
against an understanding of multi-dimensional man,
which is not in keeping with the holistic conceptualiza-
tion of health as offered by the WHO.
2.3. Biopsychosocial Approach
In the 1950s, George Engel, a physician, teamed with
John Romano, a young psychiatrist, to develop a bio-
psychosocial model for inclusion in the curriculum of
the University of Cincinnati College of Medicine, which
measured the health status of people. It is referred to as
Engel’s biopsychosocial model. Engel’s biopsychosocial
model [10,11,43], recognized that psychological and
social factors coexisted along with biological factors. It
was a general theory of illness and healing, a synergy
between medicine, psychiatry and the behavioural sci-
ences [42]. Therefore, from Engel’s model, wellbeing
must include factors such as motivation, depression (or
the lack thereof), biological conditions (such as illnesses
and diseases), social systems, cultural, environmental
and familial influences on the appearance and occur-
rence of illness.
Some scholars may argue that this paper appears to
believe that only quantitative studies may provide an-
swers to the examination of the determinants of health.
This is absolutely not so, and we use a qualitative study
to show people’s perception of what contributes to a
particular medical condition. In a qualitative study that
uses in-depth interviews with some 17 Malaysian men
aged between 40 and 75 years old, some scholars exam-
ined the perception of these men in relation to erectile
dysfunction (ED) —the sample was a convenient one of
men who were suffering from ED and who were willing
to speak about their condition. When the interviewers
asked the participants about the possible causes of ED,
many of them outlined biomedical conditions such as
diabetes, hypertension, medications, past injuries, ageing
and then came lifestyle practices (i.e. smoking) and
psychosocial factors [45]. Embedded in this perception
is the respondents’ emphasis on pathophysiological con-
ditions in health measurement and intervention. Al-
though the sampled respondents do believe that psycho-
social factors play a role in health status, it should be
noted here that they did not itemize those conditions.
This speaks to the conceptualization of health that these
respondents have come to accept, and the fact that they
believe that health is not limited to biomedical sciences.
Using their definition of health, the study shows how
culture plays a pivotal role in determining how men will
seek health care irrespective of the nature of their condi-
According to a number of demographers [46,47],
health has been conceptualized as “functioning ability”.
These pundits categorized “functioning ability” as 1)
being able to provide both personal care and independent
living but having some difficulty in performing these
tasks or in getting about outside the home, 2) having no
functioning difficulties, 3) being unable to independently
provide personal care, and finally 4) being able to pro-
vide personal care but not able to manage life in the
home independently” [46].
Studies reveal that positive moods and emotions are as-
sociated with wellbeing [48] as the individual is able to
think, feel and act in ways that foster resource building
and involvement with particular goal materialization
[49]. This situation is later internalized, causing the in-
dividual to be self-confident, from which follow a series
of positive attitudes that guide further actions [50]. Posi-
tive mood is not limited to active responses by individu-
als, but a study showed that “counting one’s blessings,”
“committing acts of kindness”, recognizing and using
signature strengths, “remembering oneself at one’s best”,
and “working on personal goals” all positively influence
wellbeing [50,51]. Happiness is not a mood that does not
change with time or situation; hence, happy people can
experience negative moods [52].
Human emotions are the coalescence of not only posi-
tive conditions but also negative factors [53]. Hence,
depression, anxiety, neuroticism and pessimism are seen
as a measure of the negative psychological conditions
that affect subjective wellbeing [54-56]. From Evans and
colleague [54], Harris et al. [55] and Kashdon’s mono-
graphs [56], negative psychological conditions affect
subjective wellbeing in a negative manner (i.e. guilt, fear,
anger, disgust); and the positive factors influence self-
reported wellbeing in a direct way—this was corrobo-
rated in a study conducted by Fromson [57]; and by
other scholars [53,58,59]. Acton and Zodda [60] aptly
summarized the negative affective of subjective wellbe-
ing in the sentence that reads “expressed emotion is det-
rimental to the patient's recovery; it has a high correla-
tion with relapse to many psychiatric disorders.”
From the theologians’ perspective, spirituality and re-
ligiosity are critical components in the lifespan of people.
They believe that man (including woman) cannot be
P. A. Bourne / HEALTH 2 (2010) 465-476
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whole without religion. With this fundamental concept,
theologians theorize that man cannot be happy, or feel
comfortable without a balance between spirit and body
[62]. In order to achieve a state of personal happiness, or
self-reported subjective wellbeing, some pundits put
forward a construct that people are fashioned in the im-
age of God, which requires some religiosity before man
can be happy or less stressed. Religion is, therefore, as-
sociation with wellbeing [63-65] as well as low mortality
[66]. Religion is seen as the opiate of the people from
Karl Marx’ perspective, but theologians, on the other
hand, hypothesize that religion is a coping mechanism
against unhappiness and stress. According to Kart [67],
religious guidelines aid wellbeing through restrictive
behavioural habits which are health risks, such as smok-
ing, drinking alcohol, and even diet.
The discourse of religiosity and spirituality influenc-
ing wellbeing is well-documented [68,69]. Researchers
have sought to concretize this issue by studying the in-
fluence of religiosity on quality of life, and they have
found that a positive association exists between those
two phenomena [70]. They found that the relationship
was even stronger for men than for women, and that this
association was influenced by denominational affiliation.
Graham et al.’s [71] study found that blood pressure for
highly religious male heads of households in Evans
County was low. The findings of this research did not
dissipate when controlled for age, obesity, cigarette
smoking, and socioeconomic status. A study of the
Mormons in Utah revealed that cancer rates were lower
(by 80%) for those who adhered to Church doctrine
[72,73] than those with weaker adherence.
In a study of 147 volunteer Australian males between
18 and 83 years old, Jurkovic and Walker [65] found a
high stress level in non-religious as compared to reli-
gious men. The researchers in constructing a contextual
literature quoted many studies that have made a link
between non-spirituality and “dryness”, which results in
suicide. Even though Jurkovic and Walker’s research
was primarily on spiritual wellbeing, it provides a plat-
form that can be used in understanding the linkages be-
tween the psychological status of people and their gen-
eral wellbeing. In a study which looked at young adult
women, the researchers found that spirituality affects the
physical wellbeing of a populace [69]. Embedded within
that study is the positive influence of spirituality and
religion on the health status of women. Edmondson et
al.’s work constituted of 42 female college students of
which 78.8 percent were Caucasian, 13.5 percent Afri-
can-American, 5.8 percent Asian and 92 percent were
Health psychologists concurred with theologians and
Christians that religion influences psychological wellbe-
ing [74,75]. Taylor [74] argued that religious people are
more likely to cope with stressors than non-religious
individuals, which explains the former’s better health
status. She put forward the position that this may be
done through avoidance or vigilant strategies. This re-
sponse is an aversive coping mechanism in addressing
serious monologue or confrontational and traumatic
events. Coping strategies, therefore, are psychological
tools used by individuals to problem-solve issues, with-
out which they are likely to construct stressors and
threaten their own health status. Taylor [74] said that
“some religious beliefs also lead to better health prac-
tices”, producing lower mortality rates from all cancers
in Orthodox Christians.
Even though policy makers are cognizant of the impor-
tance of healthy lifestyle practices and their influence on
wellbeing [76], we continue to sideline them in under-
standing health status, and using this concept in the for-
mulating of hypotheses that will drive a broader policy
focus of health care for the populace. This is evident in
our neglect to expand studies for policy purposes that
collect data on health using the biopsychological model,
meaning that policy formulators are emphasizing physi-
cal vulnerability or dysfunction to measure health status.
Is there a study that has sought to use a maximization
definition of health that will be able to better evaluate
and plan for the wellbeing of Jamaicans?
A study conducted in Barbados reveals that there is a
statistical causal relationship between socioeconomic
conditions and health status. The findings revealed that
5.2% of the variation in reported health status was ex-
plained by the traditional determinants of health (disease
indicators–See Table 1). Furthermore, when this was
controlled for current experiences, the percentage fell to
3.2% (falling by 2%). When the current set of socioeco-
nomic conditions were used they accounted for some
4.1% of the variations in health status, while 7.1% were
due to lifestyle practices, compared to 33.5% that were
as a result of current diseases [34]. It holds that the im-
portance placed by medical practitioners on the current
illnesses—as an indicator of health status—is not un-
founded as people place more value on biomedical con-
ditions as being responsible for their current health status.
Despite this fact, it is obvious from the data—using
33.5%—that there are other indicators that explain some
67.5% of the reason why health status should be as it is.
Furthermore, with an odds ratio of 0.55 for number of
illnesses, there is a clear suggestion that the more people
reporting illnesses, the lower will be their health status
[34]; and this was equally so for more disease symp-
toms—odds ratio was 0.71).
Figure 1 above is a depiction of the use of the bi-
opsychosocial model in the study of health status. This
P. A. Bourne / HEALTH 2 (2010) 465-476
Copyright © 2010 SciRes http://www.scirp.org/journal/HEALTH/Openly accessible at
Table 1. Potential determinants of self-reported health status,
study of historical and current predictors of self-reported health
status in elderly persons, Barbados, 1999-2000.
Predictor group Individual predictor in each predictor group
Historical socioeco-
nomic indictors
Education, occupation, childhood economic
situation, childhood nutrition, childhood
health, number of childhood diseases
Current socioeconomic
Income, financial means, household crowd-
ing, living alone, currently married, number
of people in household, number of siblings
living outside household, number of other
family and friends living outside household
Current lifestyle risk
Body mass index, waist circumference,
categories of disease risk, nutrition, smok-
ing, exercise
Disease indicators
Number of illnesses,a number of symptoms,b
geriatric depression scale score, number of
nights in hospitals in 4-month period, num-
ber of medical contacts in 4-month period
aIllnesses included hypertension, diabetes, cancer, chronic lung disease,
coronary heart disease, cerebrovascular accident, and arthritis
bSymptoms included chest pain, shortness of breath, back pain, severe
fatigue or tiredness, joint problems, persistent swelling in the feet or
ankles, persistent dizziness, persistent headaches, persistent wheezing,
cough or phlegm, persistent nausea or vomiting and persistent thirst or
excessive sweating.
Source: Hambleton et al. [34]
research was conducted in Barbados between 1999 and
2000, in which health status was predicted by a compos-
ite function of five general typologies of variables. The
model shows that health status is not primarily limited to
biomedical conditions—such as diseases and ailments—
as has been the custom of many scholars. While different
indicators as used by these researchers may not be pos-
sible in this paper because of the limitation of the sec-
ondary dataset—for example “current lifestyle risk fac-
tors”, “childhood nutrition”, “childhood diseases”, “en-
vironmental factors”, to name a few—despite the data’s
shortcomings, the study emphasizes the use of a multi-
dimensional approach in the study of wellbeing.
Bourne [27], using secondary data, encapsulates Geor-
ge Engel’s conceptual idea of a multidimensional model
which incorporates biological, social, psychological,
environmental and social conditions in examining well-
being. Wellbeing is operationally defined as material
resources, illness and total expenditure of households.
The sample is drawn from a nationally representative
survey of 25,018 Jamaicans, some 9.3% of the sample
being elderly. From a sample of 2,320 elderly Jamaicans
(ages 65 + years), Bourne [27] found that 10 of the 14
predisposing variables explain 36.8% of the variance in
wellbeing. Of the 10 statistically significant variables,
the five most important ones, in descending order, are 1)
area of residence (β = 0.227); 2) cost of medical care (β
= 0.184); 3) psychological conditions [total positive af-
fective conditions] (β = 0.138); 4) ownership of property
(β = 0.135); and 5) crime (β = 0.111). Among the other
factors, which are the 5 least important conditions, are
negative affective conditions, marital status, educational
level, average occupancy per room, age of residents, and
the environment. Thus, whether or not we use Gross-
man’s model [77], Hambleton et al.’s model [34] or
Bourne’s models [27-33] it is clear from them that well-
being extends beyond biological conditions to include
psychological, environmental, and social conditions.
Another study was conducted by Bourne [30] of some
3,009 elderly Jamaicans (60 years and older), with an
average age of 71 years and 10 months ± 8 years and 6
months, of which 67% (n = 2,010) resided in rural areas,
21% (n = 634) dwelled in Other Towns and 12% (n =
365) lived in the Kingston Metropolitan Area. The mean
General Wellbeing of elderly Jamaicans was low (3.9 out
of 14 ± 2.3). Bourne’s model [30] identified 10 explana-
tory variables which explain 40.1% (adjusted R-squared)
of the variance in general wellbeing. In this study he
deconstructed the general model into 1) economic well-
being and 2) physical wellbeing (proxy by health condi-
tions). Using the same set of explanatory variables, the
latter model explains 3.2% of the variability in wellbeing
(proxy by health conditions) compared to 41.3% for the
former model (i.e. economic wellbeing using material
economic resources). General Wellbeing was operational
as material resources and functional limitation (or health
conditions). Material economic resources constitute
ownership of durable goods (such as motor vehicles,
stereo, washing machines, et cetera); income (proxy by
income quintile); and financial support (e.g. social secu-
rity and other pensions). Hence, it follows that the bi-
opsychosocial model is a better proxy for wellbeing; and
that functional limitation is still not a good proxy for
wellbeing as used by Hambleton et al. Grossman and
even Smith and Kington [78].
Globally, regionally and especially domestically, the
most popular space in research concerning wellbeing is
the biomedical approach; its popularity is fuelled by the
combination of the traditional operational definition of
health (good physical health) and the dominance of the
medical sciences in this field of enquiry. The number of
studies on mortality, structural alterations and functional
declines in body systems, genetic alterations induced by
exogenous and endogenous factors, prevalence and in-
cidence of diseases, and certain diseases as determinants
of health, clearly justifies establishing leniency towards
medical science in the study of health and health care.
Engel [10,11] accredited the biomedical model that gov-
erns health care to the practice of pundits over the last
300 years. This model assumes that psychosocial proc-
esses are independent of the disease process. Engel ar-
gued for the bio-psychosocial model that it includes
biological, psychological, and social factors, which is a
close match to the multi-dimensional aspect of man.
P. A. Bourne / HEALTH 2 (2010) 465-476
Copyright © 2010 SciRes http://www.scirp.org/journal/HEALTH/Openly accessible at
With this as the base, it can be construed from Engel’s
thrust behind the biopsychosocial model that the previ-
ous model is a reductionistic model. Engel’s biopsycho-
social model in analyzing health emphasizes both health
and illness, and maintains that health and illnesses are
caused by a multiplicity of factors. Engel’s theorizing,
therefore, is better fitted for the definition of health
coined by the World Health Organization.
In Jamaica, only a miniscule number of studies have
sought to analyze the effect of the death of a family
member or close friend, violence, joblessness, psycho-
logical disorders and sexual abuse, on wellbeing, or so-
cial change on health, area of residence on quality of life
and the perception of ageing and its influence on health
conditions. Morrison [18] alluded to a transitory shift
from infectious communicable diseases to chronic non-
communicable diseases as a rationale for the longevity
of the Anglophone Caribbean populace. This was
equally endorsed by Peña [79], the PAHO/WHO repre-
sentative in Jamaica. They argued that this was not the
only reason for the changing life expectancy. Morrison
summarized this adequately, when he said that:
Aiding this transition is not only the increased longev-
ity being enjoyed by our islanders but also the changing
lifestyle associated with improved socioeconomic condi-
tions [18].
With the post-1994 widened definition of health as put
forward by the WHO, people are becoming increasingly
cognizant of the fact that socio-cultural factors such as
geographical location, income, household size and so on,
as well as several psychological factors, explain wellbe-
ing; hence the new definition of health has coalesced
biomedical variables and socio-cultural and psychologi-
cal variables in the new discourse on wellbeing.
Stressors may arise from within the individual or out-
side his/her environment. One such external stressor that
may affect the individual is the death of loved ones. Re-
sponse to the mortality of close family members may be
more traumatic, depending on expectancy or non-exp-
ectancy. Bereavement influences the incidence of mor-
tality. This may result in exhaustion of the individual’s
“adaptive reserve”. The person’s body wears down and
becomes highly vulnerable to morbidity and even death.
Rice put forward a study that contradicted an association
between bereavement and mortality. He wrote that “Fa-
thers who lost sons in war had lower mortality rates than
those who lost son in accidents” [75]. Despite that study,
Rice quoted other studies [80] that showed the impact of
stress on human physiology. He argued that it is sup-
pression during and after bereavement that creates the
stressors, which become potent devices for mortality and
morbidity. Lusyne, Page and Lievens’ [81] study finds
that there is an association between bereavement and
mortality. However, this is more likely to occur in the
short-run (i.e. during the first 6 months after the death of
the spouse). As there are a number of confounding situa-
tions which in the long-run could offset the likelihood of
mortality, such as remarriage, social support from other
family members, grandchildren and so on, bereavement
may not necessarily be a constant in one’s life. Never-
theless, Lusyne, Page and Lievens affirm with other
studies that the loss of a long-time partner may result in
the death of the living spouse. The explanations given
for this eventuality are 1) role theory as the surviving
partner may find the role played by the other partner too
stressful and so 2) may not be able to adapt to the new
role alone; this is more a male phenomenon [81].
The Planning Institute of Jamaica and Statistical In-
stitute of Jamaica collect data on ill-health, and ques-
tions are asked based on visits to health practitioners,
healers and pharmacies, injuries, ailments, ownership of
health insurance, duration of the disease or illness, cost
of treatment for ailments and injuries, and mental dis-
ability. Those questions are clearly derivatives from the
biomedical model, as they seek to address physical func-
tioning without equally emphasizing culture, lifestyle
behaviour, depression, stress, fatigue, trust for others,
perception of one’s position in current society and the
likelihood of one’s place in the future, religiosity, time
periods, HIV/AIDS of family members or the individual
and how it is likely to influence the his/her health and
wellbeing, social involvement in various institutions, and
issues on positive affective conditions.
In sum, any definition of the construct of health must be
multidimensional in nature. Such a definition must in-
clude 1) personal and environmental conditions; 2) so-
cial factors; 3) psychological conditions; 4) diagnosed
illness; and 5) self-determination of wellbeing. If health
is solely based on illnesses (i. e. biomedical model), we
would have failed in our bid to operationally define a
construct that is comprehensive enough to encapsulate
all the tenets that would capture man in his complex
milieu. Health is not simply a construct. It plays a criti-
cal role in the formulation of policy for health care, and
in the development of the society. Thus, if we emphasize
only the biomedical approach to the study of health, its
underpinnings could only be symptomology. This ap-
proach fails to capture issues outside of the mechanistic
structure of man’s conception of biomedical sciences.
Concurringly if health care professionals were to use as
their premise dysfunctions to indicate health, which is
the deviation from the norm, this image of health would
affect policy formulation and intervention programmes
which are geared towards this narrow conceptualization.
But this approach lacks are clear characteristics outside
of illnesses that will encapsulate wellness, wellbeing,
and healthy life expectancy in a multidimensional hu-
P. A. Bourne / HEALTH 2 (2010) 465-476
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Openly accessible at
man. Thus, the biomedical model relies on illness identi-
fication to capture health and this fashions the health
care system, which also limits health coverage outside of
this negative view of health. This is undoubtedly subop-
timal, and does not account for health. The health ser-
vices in the Caribbean, and in particular Jamaica, are
best described as medical services, as they are still fun-
damentally structured around the biomedical model
which is embedded as the image of health, and not psy-
chosocial, economic and ecological wellbeing. Although
the WHO as early as the 1940s provides a definition of
health that is comprehensive and complex, some schol-
ars believe that it is elusive and by extension immeasur-
able. There are merits to the argument of those academ-
ics, but the emphasis should not be the difficulty of how
operationalizing the construct labels it “elusive”. Instead
the goal should have been for researchers and academics
alike to formulate a working definition of the conceptual
framework created by the WHO. Thus, when Grossman
in the 1970s moved away from the difficulty posed by
the WHO’s conceptual framework, he developed an
econometric framework that laid the foundation for the
measure of this seemingly “elusive” construct. Other
scholars have built on the initial theoretical model in-
troduced by Grossman, and Bourne in particular has
added psychological and environmental conditions to the
already established factors of the health model. The con-
stitution of the World Health Organization (WHO) states
that “Health is a state of complete physical, mental and
social well-being and not merely the absence of diseases
or infirmity” [3]. Hence, any use of morbidity statistics,
dysfunctions, sickness, diseases or ill-health to concep-
tualize health is limited, and by extension is a negative
approach to the treatment of this construct. Health,
health care, and patient care are critical components in
development, as unhealthy people will not be able to
offer to the society their maximum, neither will they be
able to comparatively contribute the same to productiv-
ity and production as their healthy counterparts. There-
fore, the conceptualization of health is not merely a
concept but a working product that affects all aspects of
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