Health measurement

doi:10.4236/health.2010.25070

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Vol.2, No.5, 465-476 (2010)

doi:10.4236/health.2010.25070

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;

paulbourne1@yahoo.com

Received 21 December 2009; revised 14 January 2010; accepted 17 January 2010.

ABSTRACT

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

1. INTRODUCTION

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

P. A. Bourne / HEALTH 2 (2010) 465-476

466

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

health.

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

diseases.

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,

P. A. Bourne / HEALTH 2 (2010) 465-476

467

Openly accessible at

Health Policy

Determinants of

Health –

Biological

conditions

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.

2. PHYSICAL FUNCTIONING

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-

P. A. Bourne / HEALTH 2 (2010) 465-476

468

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

P. A. Bourne / HEALTH 2 (2010) 465-476

469

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

P. A. Bourne / HEALTH 2 (2010) 465-476

470

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-

tion.

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].

3. EXPANSION OF THE BIOMEDICAL

MODEL

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

471

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

non-smokers.

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.

4. EVIDENCE OF USE FOR

BIOPSYCHOSOCIAL MODEL

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

472

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

indicators

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

factors

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

473

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.

5. CONCLUSIONS

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

474

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

society.

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