J. Biomedical Science and Engineering, 2010, 3, 700-710 JBiSE
doi:10.4236/jbise.2010.37094 Published Online July 2010 (http://www.SciRP.org/journal/jbise/).
Published Online July 2010 in SciRes. http://www.scirp.org/journal/jbise
Modelling social determinants of self-evaluated health of poor
older people in a middle-income developing nation
Paul A. Bourne
Department of Community Health and Psychiatry Faculty of Medical Science University of the West Indies, Mona.
Received 15 March 2010; revised 6 April 2010; accepted 8 April 2010.
ABSTRACT
Over the last 2 decades (1988-2007), poverty in Ja-
maica has fallen by 67.5%, and this is within the
context of a 194.7% increase in inflation for 2007
over 2006. It does not abate there, as Jamaicans are
reporting more health conditions in a 4-week period
(15.5% in 2007) and at the same time this corre-
sponds to a decline in the percentage of people seek-
ing medical care. Older people’s health status is of
increasing concern, given the high rates of prostate
cancer, genitourinary disorders, hypertension, diabe-
tes mellitus and the presence of risk factors such as
smoking. Yet, there is a dearth of studies on the
health status of older people in the two poor quintiles.
This study examined 1) the health status of those
elderly Jamaicans who were in the two poor quintiles
and 2) factors that are associated with their health
status. A sample of 1,149 elderly respondents, with an
average age of 72.6 years (SD = 8.7 years) were ex-
tracted from a total survey of 25,018 Jamaicans. The
initial survey sample was selected from a stratified
probability sampling frame of Jamaicans. An admin-
istered questionnaire was used to collect the data.
Descriptive statistics were used to examine back-
ground information on the sample, and stepwise lo-
gistic regression was used to ascertain the factors
which are associated with health status. The health
status of older poor people was influenced by 6 fac-
tors, and those factors accounted for 26.6% of the
variability in health status: Health insurance cover-
age (OR = 13.90; 95% CI: 7.98-24.19), age of re-
spondents (OR = 7.98; 95% CI: 1.02-1.06), and sec-
ondary level education (OR=1.82; 95% CI: 1.35-2.45).
Males are less likely to report good health status than
females (OR = 0.56; 95% CI: 0.42-0.75). Older people
in Jamaica do not purchase health insurance cover-
age as a preventative measure but as a curative
measure. Health insurance coverage in this study
does not indicate good health but is a proxy of poor
health status. The demand of the health services in
Jamaica in the future must be geared towards a par-
ticular age cohort and certain health conditions, and
not only to the general population, as the social de-
terminants which give rise to inequities are not the
same, even among the same age cohort.
Keywords: Health Status; Self-Evaluated Health; Older
Poor; Socioeconomic Factors; Jamaica
1. INTRODUCTION
Factors determining the poor health status of the elderly
in Jamaica can be viewed from the perspective of a
socio-medical dichotomy. Such factors include poverty
(resulting in one’s inability to access loans, quality edu-
cation and health care), lifestyle (e.g. smoking, sedentary
habits, sexual and dietary practices and physical inac-
tiveity), resulting in prostate cancer, genitourinary dis-
orders, hypertension, diabetes mellitus and premature
death. In 2005, the World Health Organization began a
thrust in examining the social determinants of health,
and despite that reality there is a lack of literature in this
regard on the elderly poor people in Jamaica. These pa-
rameters were explored in the current research by using
a sample of 1,149 elderly poor Jamaicans.
The findings of this paper reveal that the cost of
medical care is positively correlated with health condi-
tions, and that economic constraints account for the de-
cline in the elderly seeking medical care. Older people in
Jamaica do not purchase health insurance coverage as a
preventative measure but as a curative measure. Health
insurance coverage in this study does not indicate good
health, but on the contrary, it is a proxy of poor health
status. It is also noted that income is positively corre-
lated with a higher standard of living and life expectancy.
In support of this claim, studies have shown that life
expectancy in many developing countries [1], in par-
ticular the Caribbean (Barbados, Guadeloupe, Jamaica,
Martinique, Trinidad and Tobago) has exceeded 70 years,

P. A Bourne et al. / J. Biomedical Science and Engineering 3 (2010) 700-710 701
and they are now experiencing between 8-10% of their
population living to 60+ years old. Life expectancy,
which is a good indicator of the health status of a popu-
lace, is higher in countries with high GDP per capita.
This means that income is able to purchase better quality
products [2], and indirectly affects the length of years
lived by people. GDP per capita is used as an objective
valuation of standard of living [3-12]. While a country’s
GDP per capita may be low, life expectancy is high be-
cause health care is free for the population. Despite this
fact, material living standards undoubtedly affect the
health status and wellbeing of people, as well as the
level of females’ educational attainment [6] and the nu-
trition intake of the poor. On the other hand, when there
is economic growth, the society has more to spend on
nutrition, health care, better physical milieu, better qual-
ity food, safer sanitation and education.
Good health is, therefore, linked to economic growth,
something which is established in a plethora of studies
by economists. Developing countries (a term synony-
mous with poverty) do not only constitute low levels of
democracy, civil unrest, corruption [13], high mortality
and crude birth rates, but one must also include nutria-
tional deficiency [14]. The WHO in 1998 put forward
the position that 20% of the population in developing
countries do not have access to enough food to meet
their basic needs and provide vital nutrients for survival.
In the Caribbean, and in particular Jamaica, poverty is
typical, and many of the ills that affect other developing
nations outside of this region are the same. The poor in
this society are facing insurmountable challenges in buy-
ing the necessary health care. In 2007, between 51 and
53% of those in the poor quintiles in Jamaica sought
medical care, compared to 61-68% of those in the mid-
dle-to-wealthiest quintiles. When those who had re-
ported that they were ill were asked why they had not
sought medical care, 51% of those in the poorest quintile
indicated that they ‘could not afford it’, with 36.7% of
those in the poor quintile giving the same response, and
the percentage declines as the wealth of the person in-
creases to the wealthiest quintile (7.7% of those in the
wealthiest quintile).
Over the last 2 decades (1988-2007), poverty in Ja-
maica has fallen by 67.5% and this is in the context of a
194.7% increase in inflation for 2007 over 2006. Jamai-
cans are reporting more health status in a 4-week period
(15.5% in 2007) and at the same time this is associated
with a decline in the percentage of people seeking
medical care. Older people’s health status is of increase-
ing concern, given the high rates of prostate cancer,
genitourinary disorders, hypertension, diabetes mellitus
and the presence of risk factors such as smoking in ear-
lier life. Yet, there is a dearth of studies on the health
status of older people in the two poor quintiles.
Works which have examined the social determinants
of health have used data for the population [2,3], but
none emerged from a literature research using data for
poor old people. This study examined 1) the health status
of those elderly Jamaicans who were in the two poor
quintiles, and 2) factors that are associated with their
health status.
2. MATERIALS AND METHODS
2.1. Sample
A sample of 1,149 elderly respondents was extracted
from a larger survey of 25,018 Jamaicans. The sample
was based on being 60 + years old, and being classified
in the two poorest income categorizations. The initial
survey sample (n = 25, 018) was across the 14 parishes,
and was conducted between June and October 2002. The
sample (n = 25,018 or 6,976 households out of a planned
9,656 households) was drawn using a stratified random
sampling technique. This design was a two-stage strati-
fied random sampling design, where there was a Primary
Sampling Unit (PSU) and a selection of dwellings from
the primary units. The PSU is an Enumeration District
(ED), which constitutes of a minimum of 100 dwellings
in rural areas and 150 in urban zones. An ED is an inde-
pendent geographic unit that shares a common boundary.
This means that the country was grouped into strata of
equal size based on dwellings (EDs). Based on the PSUs,
a listing of all the dwellings was made, and this became
the sampling frame from which a Master Sample of
dwellings was compiled, and which provided the frame
for the labour force. The survey adopted was the same
design as that of the labour force, and it was weighted to
represent the population of the country.
The survey was a joint collaboration between the
Planning Institute of Jamaica and the Statistical Institute
of Jamaica. The data were collected by a comprehensive
administered questionnaire, which was primarily com-
pleted by heads of households for all household mem-
bers. The questionnaire was adapted from the World
Bank’s Living Standards Measurement Study (LSMS)
household surveys, and was modified by the Statistical
Institute of Jamaica with a narrower focus, to reflect
policy impacts as well. The instrument assessed: 1) the
general health of all household members; 2) social wel-
fare; 3) housing quality; 4) household expenditure and
consumption; 5) poverty and coping strategies, 6) crime
and victimization, 7) education, 8) physical environment,
9) anthropometrics measurement and immunization data
for all children 0-59 months old, 10) stock of durable
goods, and 11) demographic questions.

P. A Bourne et al. / J. Biomedical Science and Engineering 3 (2010) 700-710 702
Data were stored and retrieved in SPSS for Windows,
version 16.0 (SPSS Inc; Chicago, IL, USA). The current
study is explanatory in nature. Descriptive statistics were
presented to provide background information on the
sampled population. Following the provision of the
aforementioned demographic characteristics of the sub-
sample, chi-square analyses were used to test the statis-
tical association between some variables, t-test statistics
and analysis of variance (i.e. ANOVA) were also used to
examine the association between a metric dependent
variable and either a dichotomous variable or non-
dichotomous variable respectively. Logistic regression
was used to examine the statistical association between a
single dichotomous dependent variable and a number of
metric or other variables (Empirical Model). The logistic
regression was used because in order to test the associa-
tion between a single dichotomous dependent variable
and a number of explanatory factors simultaneously,
it was the best available technique. A p-value < 0.05
(two-tailed) was selected to indicate statistical signifi-
cance in this study. Where collinearity existed (r > 0.7),
variables were entered independently into the model to
determine those that should be retained during the final
model construction. To derive accurate tests of statistical
significance, SUDDAN statistical software was used
(Research Triangle Institute, Research Triangle Park,
NC), and this was adjusted for the survey’s complex
sampling design.
2.2. Measure
Social determinants. These denote the conditions under
which people are born, grow, live, work and age, in-
cluding the health system.
Crowding: This is the total number of persons living
in a room with a particular household.
1
Crowding = ni
i
h
r

, where i
h is each person in the
household and r is the number of rooms excluding
kitchen, bathroom and verandah.
Age: This is a continuous variable in years, ranging
from 15 to 99 years.
Old/Aged/Elderly: An individual who has celebrated
his/her 60th birthday or beyond.
Negative Affective Psychological Condition: Number
of responses from a person on having lost a breadwinner
and/or family member, loss of property, having been
made redundant, failure to meet household and other
obligations.
Private Health Insurance Coverage (or Health Insur-
ance Coverage) proxy Health-Seeking Behaviour, is a
dummy variable which speaks to 1 for self-reported
ownership of private health insurance coverage, and 0
for not reporting ownership of private health insurance
coverage.
Gender: Gender is a social construct which speaks to
the roles that male and female perform in a society. This
variable is a dummy variable, 1 if male and 0 if other-
wise.
Health conditions: The report of having had an ail-
ment, injury or illness in the last four weeks, which was
the survey period. This variable is a binary measure,
where 1 = self-reported health status or illnesses, and 0 =
otherwise (not reporting an illness, injured or dysfunc-
tions).
Poverty: In this study, the definition of poverty is the
same as that used to estimate poverty in Jamaica. It is
established from the basis of a poverty line. In order to
compute the per capita poverty line in each geographical
area (Kingston Metropolitan Area, Other Towns and
Rural Areas), the cost of living for a basket of goods is
divided by an average family of five. The basket of
goods is established by the Ministry of Health based on
the normal nutrients of the average family. Based on a
per capita approach, there are five per capita income
quintiles, with the poorest being below the poverty line
(quintile 1) and the wealthiest being in quintile 5.
Elderly, aged or old persons: Using the same defini-
tion offered by the United Nations in the Report of the
World Assembly on Ageing, July 26-August 6, 1982 in
Vienna, that the elderly are persons who are 60+ years
old.
Older-poor (elderly-poor, aged-poor): All aged per-
sons below and just above the poverty line (quintiles 1 &
2) in Jamaica.
3. RESULTS
3.1. Demographic Characteristics of Sample
Consistent with the demographic characteristics of the
ageing population, the sample was 1,149 of which there
were 45% males (N = 517) compared to 55% females (N
= 632). The mean age of the sample was 72.6 years (SD
= 8.7 years). Most of the sample were married (40%, N
= 452), 50.5% (N=580) of the sample were in the poor-
est 20% of per capita income quintile, 95% (N = 1,087)
were not receiving retirement income; those who were
heads of households (98.3%, N = 1,129), those who had
at most primary education (65.2%, N = 700) and those
who did not have health insurance coverage (86.0%, N =
973) (Table 1).
Thirty-seven percent (37.2%) of the sample indicated
having had an illness in the last 4-week period. Ap-
proximately 64% of the respondents indicated that they
sought health care for their health conditions. When the
respondents were asked if they had visited a health prac-
titioner for any other reason during the last 12 months,
57.1% reported yes and 30.3% reported going for ‘regu-
lar checkups’. Of those who indicated yes, 37.2% visited

P. A Bourne et al. / J. Biomedical Science and Engineering 3 (2010) 700-710 703
Table 1. Socio-demographic characteristics of sample.
Description N Percent
Gender
Male 517 45.0
Female 632 55.0
Marital status
Married 452 40.0
Never married 357 31.6
Divorced 10 0.9
Separated 22 1.9
Widowed 290 25.6
Per capita Income quintile
Poorest 580 50.5
Poor 569 49.5
Retirement Income
No 1087 95.0
Yes 57 5.0
Household head
No 20 1.7
Yes 1129 98.3
Health Insurance coverage
No 973 86.0
Yes 158 14.0
Educational Level
Primary and below 700 65.2
Secondary 363 33.8
Tertiary 10 0.9
Age 72.63 years (SD = 8.7 years)
Total Medical Care Expenditure $1,067.64 (SD = $2,000.00)
Per capita consumption $30,998.07 (SD = $9,833.00)
US $1.00 = JA$50.9

P. A Bourne et al. / J. Biomedical Science and Engineering 3 (2010) 700-710 704
public health care institutions, and 18.7% went to private
clinics, compared to 5.7% who claimed that they at-
tended both health care facilities. The typologies of ill-
ness included colds (1.4%), diabetes mellitus (5.7%),
hypertension (42.9%) and arthritis (31.4%), while 18.6%
did not specify their health condition(s). Only 2% of the
respondents had health insurance coverage; 61% pur-
chased the prescribed medication; and 81.8% of those
who indicated having not bought their medication re-
ported that they could not afford it.
The median number of days for how long an illness
lasted was 7 days, with a median medical expenditure of
US $7.85 (US $1.00 = Ja. $50.97).
3.2. Bivariate Correlation of Health Status and
Age Cohort
Of the 1,149 sample respondents for this study, 98.8% (N
= 1,135) were used for the statistical correlation between
health status and gender. Of the 1,135 respondents, there
were 688 young-old, 327 old-old and 120 oldest-old poor
Jamaicans. There was a correlation between the two
above-mentioned variables – χ2 (df = 2) = 22.863,
p-value < 0.001. On an average, 46% of the aged-poor (N
= 523) reported that they had at least one illness/injury in
the survey period. The most health status was reported by
the oldest-old poor (59.2%, N = 71), 52.9% (N = 173)
and the least by the young-old (40.6%, N = 279). Em-
bedded in these findings is that for every 1 young-old
poor who indicated that he/she had an illness/injury, there
are 1.5 oldest-old and 1.3 old-old poor.
3.3. Multivariate Analysis
The results of the multiple logistic regression model (in
Table 2), were statistically significant [Model χ2 (df =
18) = 229.47; –2Log likelihood = 1130.37; p-value <
0.001]. Table 2 showed that 26.6% of the variances in
the health status of older people in Jamaica were ac-
counted for by the independent variables used in the
multiple logistic regressions. The mold revealed that
there were 6 statistically significant factors that deter-
mined health conditions. These predictors are age (OR =
1.04, 95% CI = 1.02-1.06), health insurance coverage
(OR = 13.90, 95% CI = 7.98-24.19), physical environ-
ment (OR = 1.42, 95% CI = 1.06-1.89), cost of medical
care (OR = 1.00, 95% CI = 1.00-1.00), secondary level
education (OR = 1.82, 95% CI = 1.35-2.45) with refer-
ence to primary and below education, and gender of re-
spondents (OR = 0.56, 95% CI = 0.42-0.75). Controlling
for the effect of other variables, the average likelihood of
reporting illness/injury in a 4-week reference period de-
clined by 17 times for those who had dysfunctions.
The model had statistically significant predictor power
(Model χ2 (df = 18) = 229.47; -Homer and Lemeshow
goodness of fit χ2 = 3.739, P = 0.880), and correctly
classified 70% of the sample (correctly classified 55.4%
of those with dysfunctions and 82.3% of those without
dysfunctions) (Table 2). The logistic regression model
can be written as: Log (probability of dysfunctions/
probability of not reporting dysfunctions) = –4.185 +
0.039 (Age) + 2.632 (Health Insurance coverage, 1 =
yes, 0 = no) + 0.348 (Physical Environment, 1 = yes, 0
= no) + 0.000 (Cost of Medical Care) + 0.598 (Secon-
dary level education = 1, 0 = primary and below) –
0.581 (Sex).
4. DISCUSSION
People are living longer [15], which means that on av-
erage the elderly are living 15-20 years after retirement.
Demographic ageing at the micro and macro levels im-
plies a demand for certain services such as geriatric care.
In addition to preventative care, there will be a need for
particular equipment and products (i.e. wheelchairs,
walkers etc.). Then there are future preparations for pen-
sion and labour force changes, along with the social and
economic costs associated with ageing, as well as the
policy based research to better plan for the reality of
these age groups. The World Health Organization
(WHO), in explaining the ‘problems’ that are likely to
occur because of population ageing, argues that the 21st
Century will not be easy for policy makers as it is piv-
otal in the preparation process to postpone ailments and
disabilities, and the challenge of providing a particular
standard of health for the populace [16]. What consti-
tutes population ageing? Some demographers have put
forward the benchmark of 8-10% as an indicator of
population ageing [17]. Within the construct of Gavrilov
and Heuveline’s perspective, the Jamaican population
began experiencing this significant population ageing as
of 1975 (using 60+ years for ageing) or 2001 (if ageing
is 65+ years). The issue of population ageing will double
come 2050, irrespective of the chronological definition
of ageing, but what about the elderly poor health condi-
tions?
Let us examine the disparity between long life and
quality of lived years. Ali, Christian & Chung [18] who
is medical doctors, cite the case of a 74 year-old man
who had epilepsy, and presented the findings in the West
Indian Medical Journal. They write that “Elderly patients
are frequently afflicted with paroxysmal impairments of
consciousness, because they frequently have chronic
medical disorders such as diabetes mellitus and hyper-
tension, and can also be on many medications….Many
elderly patients may have more than one cause for this
symptom” [18].
The case presented by the medical doctors emphasizes
the point we have been arguing that long life does not

P. A Bourne et al. / J. Biomedical Science and Engineering 3 (2010) 700-710 705
Table 2. Logistic Regression: Socio-demographic correlates of health status of poor older people in Jamaica, N = 1,033.
Va ri a bl e OR 95.0% C.I.
Age 1.04 1.02-1.06***
Retirement income 0.75 0.38-1.49
Per capita consumption 1.00 1.00-1.00
Separated, divorced or widowed 1.07 0.74-1.55
Married 1.11 0.77-1.58
Never married (reference group) 1.00
Health insurance 13.90 7.98-24.19***
Environment 1.42 1.06-1.89*
Household head 3.34 0.37-30.01
Cost of medical care 1.00 1.00-1.00**
Secondary 1.82 1.35-2.45***
Tertiary 0.43 0.07-2.63
Primary and below (reference group) 1.00
Semi-urban 0.78 0.51-1.19
Urban areas 0.86 0.50-1.49
Rural areas (reference group) 1.00
Sex 0.56 0.42-.75***
Living arrangement 1.20 0.77-1.88
Crowding 0.89 0.78-1.02
Crime index 1.00 0.98-1.03
Positive affective 0.96 0.90-1.01
Model Chi-square (df =18) = 229.47, p-value < 0.0001; -2Log likelihood = 1130.37; Nagelkerke R-square = 0.266; Hosmer and Le-
meshow test P = 0.880; *P < 0.05, **P < 0.01, ***P < 0.001
imply quality of lived years. Although the case study
cited here does not constitute a general perspective on all
the elderly, other quantitative studies have concurred
with Ali, Christian and Chung’s general findings. Scien-
tists agree that biological ageing means degeneration of
the human body, and such a reality means that longer life
will not mean quality years. Population ageing is going
to be a socioeconomic, psychological and political chal-
lenge today, tomorrow and in the future of developing
countries and nations like Jamaica. This reinforces the
position postulated by the WHO that healthy life expec-
tancy [19] is where we ought to be going, as the new
thrust is not living longer but how many of those years
are lived without dysfunctions. Within the context of
healthy life expectancy, studies that will be used to guide
policy are those that incorporate many determinants, and
not only biological conditions [20-25]. But none of those
studies examined poor old people. Hambleton [20] and
Bourne [23-25] are Caribbean scholars who have re-
searched social determinants using the population of the
poor, and this gap to date in the literature needs to be
addressed, as the elderly constitute a vulnerable group,
and the poor elderly group is even more vulnerable. Any
policy which seeks to reduce poverty must take into ac-
count the poor elderly.
‘Ageing in poverty’ implies that persons remain in their
local environments with the ability to live in their own
home - wherever that might be - for as long as confidently

P. A Bourne et al. / J. Biomedical Science and Engineering 3 (2010) 700-710 706
and comfortably possible. It inherently includes not hav-
ing to move from one's current residence in order to se-
cure the necessary support services in response to chang-
ing needs. The ageing of Caribbean populations has been
accompanied by a shift to chronic non-communicable
diseases as major causes of morbidity. While overall na-
tional trends have been reported, examination of local
patterns of morbidity are increasingly important, as they
have implications for the services to be provided, the
mix of human resources, and the maintenance of health
and functional status that facilitate ageing in place.
Research has shown that crowding is strongly corre-
lated with the wellbeing of the elderly (ages 60+ years)
[23]; however this phenomenon, which is synonymous
with poverty, does not influence the health status of poor
elderly Jamaicans. Embedded in this finding is the fact
that older people, in particular those in poor quintiles,
interpret people around not as a negative force but as
good social networking and interaction. What, then, in-
fluences their health conditions?
Poverty speaks to a particular environment; Pacione
[26] showed that one’s physical environment affects
one’s quality of life, and other scholars have agreed with
this finding. The current study concurs with Pacione and
others, in that the physical milieu is positively correlated
with health conditions. Although Michael Pacione’s
work was on the general population, Bourne’s works [23,
24] examined the elderly population (ages 60+ years)
and found a negative association between physical envi-
ronment and wellbeing, and this study concurred with
that of the aforementioned researcher on the correlation
between physical environment and health conditions. In
this study, an important finding is to refine the correla-
tion.
Health insurance coverage is among the many indica-
tors of the health-seeking behaviour of a populace. For
the poor elderly, it is the most significant predictor of
health conditions. The correlation is a strong positive
one, indicating that health insurance coverage is a good
proxy for more ill-health than good health. The current
research found that those elderly poor who owned health
insurance were 14 times more likely to report dysfunc-
tions (or injuries) than those who did not. Health insur-
ance is, therefore, a cost reducer for those who are aware
that they are ill, and it is not in demand as a preventative
measure. Arising from this fact is the role played by the
costs of medical and curative care. Health is influenced
by more than disease-causing pathogens. [27]
The cost of medical care is positively correlated with
health conditions, suggesting that the more dysfunctions
(or injuries) that the elderly poor report, the more they
are likely to spend on medical care. The elderly poor are
prevented from seeking preventative care as against
curative care. The latest data published by the Planning
Institute of Jamaica and the Statistical Institute of Ja-
maica [28] showed that 37.3% of elderly people are at
least poor, with 20.6% falling in the poorest quintile.
This further explains the rationale for the reduction in
the demand for medical care within the context of a pre-
cipitous increase in inflation in 2007 over 2006 (194%).
With the steady rise in the cost of health care, as well as
the increase in general food and non-alcoholic beverage
prices in Jamaica, coupled with the fact that illness in
older age requires care, the elderly poor are facing in-
creasingly difficult times. The severity of the economic
situation has seen a dramatic increase in the number of
Jamaicans not seeking medical care for illness/injury.
Although there is a decline in the general population
seeking medical care (66%), more of the elderly do seek
health care (72.3%) and this is owing to recurrent
chronic illness which was shown to affect 74.2% of them
[28]. Illnesses/injuries are precipitously affecting the
elderly, and the data showed that self-reported illness for
the elderly was 2.3 times more (36.6%) than in the gen-
eral population (15.5%) [28]. In 2007, the elderly poor
who constitute 38% of the poor-to-poorest in the popula-
tion are mostly household heads (67.3%) and often un-
employed, and within this context they must provide for
their own health needs and those of their family, despite
the harsh economic challenges and increased cost of
health care.
In 2002, 12.9% of Jamaicans were unable to afford
medical care, and approximately 4 years later, the figure
had risen by 162.8% to 33.9% in 2007. This is within the
context of a 26.3% decline in poverty for the same pe-
riod. Generally poverty has been falling over the last 2
decades in Jamaica, and inflation has fluctuated, justify-
ing the increased amount spent on food and beverages
[28], and the corresponding reduction in health care ex-
penditure. In Jamaica remittances, which subsidize in-
come for many households, have fallen by 7.7% and the
reduction is 33% for those in the poor-to-the-poorest
income quintiles. If the cost of medical care is positively
correlated with the health status of the elderly poor, then
can it be said that the poor elderly have more ill-health
within the context of biological ageing and lowered ac-
cess to employment income? Marmot [2] opined that
there is a direct association between income and poor
health, and this further helps us to understand the em-
bedded health challenge of the elderly poor, as they must
meet the increasing costs of medical care, cost of living,
lower income, illnesses and severity of health conditions.
On examining the health statistics for 2007 [28], the
indication was that 50.8% of those in the poorest income
quintile were unable to afford to seek medical care, and

P. A Bourne et al. / J. Biomedical Science and Engineering 3 (2010) 700-710 707
the figure was 36.7% of those in the poor quintile. In
order to understand the severity of the situation regard-
ing the aged-poor people in Jamaica, let us analyze the
aforementioned within the context of the aged-poor. The
official statistical publication for Jamaica for 2007 [28]
showed that 20.6% percent of the elderly people are in
the poorest quintile and 17.7% in the poor quintile which
means that a little over half of the aged-poorest in Ja-
maica (10.4%) were unable to afford medical care, and
6.5% of the aged-poor had financial difficulty affording
medical care expenditure. One of the choices that must
be made by the aged-poor in Jamaica is a switch from
the formal medical care service to utilizing home reme-
dies and over-the-counter medications, instead of visit-
ing their personal physicians or health care facilities.
Since 1988 when the Jamaican authorities began col-
lecting data on self-reported health conditions, men have
been reporting less health status than women [28]. The
reporting of less illness does not mean that men are
healthier than women, as the same statistical report [28]
shows that women seek more medical care than men.
Morbidity data for the sexes in Jamaica is typical, as in
Mexico City, Havana and Santiago-Chile at least 60% of
females compared to 50% of males aged 60+ years old
reported fair-to-poor health [29]. Continuing, Buenos
Aires, Montevideo and Bridgetown-Barbados had twice
the figures of the aforementioned geo-political zones
[29]. This is in keeping with women’s protective role of
self, and their willingness to have a regard for their fu-
ture health status accounts for a higher health status and
not a lower one, although they report more dysfunctions
than men. If life expectancy were to be used to proxy
good health status, females are healthier than men given
that they outlive them by 6 years in Jamaica and 8 years
in the world. Furthermore, in 2000-2005, life expectancy
for men was 69.5 years and 74.7 years for women, and
come 2045-2050 they both would have gained an addi-
tional 2 and one-quarter years more to their life span.
The equal and constant rate of change in the life expec-
tancy of both sexes in Jamaica highlights the fact that
men do not enjoy better overall health status than their
female counterparts. More years of life for both sexes
means that the life course opens itself to coronary heart
disease, stroke and diabetes mellitus, and so morbidity
must be examined in this discourse.
Studies done by the Ministry of Health reveal that of
the five leading causes of mortality in Jamaica, which
are malignant neoplasm, heart disease, diabetes mellitus,
homicide and cerebrovascular diseases [30], more men
die from more of the aforementioned conditions than
women. Malignant neoplasms are 39% greater for men
than women; cerebrovascular diseases are 14% higher
for females than males; heart disease was 71.2 per 100,
000 for men and 66.1 per 100,000 for women; and dia-
betes mellitus was 64% more for females than males
[30]. The greater vulnerability of men to particular mor-
tality than women is typical across Latin America and
the Caribbean [29], pointing to gender bias (that is fem-
inization) in visits to health care facilities, which are
embedded in the life expectancy rates and visits to health
care institutions. The matter of reporting less health
status, once again, does not imply a healthier person, as
health is not on a continuum, with ill-health on one ex-
treme and good health on the other. Health is more in
keeping with cyclical flow, and changes over the life
course with time, experiences and socio-physical envi-
ronmental conditions. Hence, asking about ill-health is
not a good proxy for health status, as in 2007 a group of
Caribbean scholars conducted a national representative
prevalence survey of some 1,338 Jamaicans, and found
that those who indicated themselves to be of the lower
class had the least self-reported health status [13].
The discipline of gerontology – scientific inquiry into
the biological, psychological, and social aspects of age-
ing - has shown that ageing is not necessarily without
increased health conditions; it is natural for aged people
to complain and die more of dysfunctions than other age
cohorts [31,32] and that is directly related to their basal
metabolic rate [33] and the nature of the life course of
the aged [34]. Here functional ageing is an explanation
for the image of ageing, and it can be measured by nor-
mal physical changes, diminished short-term memory,
reduced skin elasticity and a decline in aerobic capacity.
It is well established in the research literature that age is
directly correlated with health status for the elderly, and
in this study the finding concurs with the literature. The
current research shows that age is the second most sig-
nificant predictor of health status for the elderly poor,
and explains why the disparity in poor health in Latin
and America and the Caribbean is higher for older per-
sons than younger people [29]. Population ageing is
synonymous with more disability and more non-commu-
nicable diseases such as malignant neoplasms, hyperten-
sion, diabetes, and heart diseases than younger ages.
Donald Bogue [35] noted that health problems increase
with ageing, and that one’s health issues intensify with
ageing. Therefore, an unhealthy lifestyle – tobacco con-
sumption, physical inactivity, unprotected sex, and un-
healthy diet - over the life course will affect the elderly
in latter life, and the declining health of the elderly poor
is the same within the sub-categories of the elderly –
young-old, old-old and oldest old.
Issues of the elderly cannot be discussed without an
examination of area of residence. This study found no
correlation between the aged-poor’s health status and
area of residence. Using data since 1989 (from various

P. A Bourne et al. / J. Biomedical Science and Engineering 3 (2010) 700-710 708
issues of the Jamaica Survey of Living Conditions),
population ageing is biased by gender as well as by spe-
cific area of residence. Over the last decade (1997-2007),
the number of elderly Jamaicans living in rural areas has
declined from 54.3% to 46.6% (a rate of 14.1%). For the
same period, the rate of increase of the aged populace in
the Kingston Metropolitan Area (100% cities) was
19.5%, down from 27.2% (in 1997) while the increase in
the aged population over the same period in Other
Towns was 12.9% over 18.5% in 1997. Regarding the
prevalence of poverty for the region (2007), rural pov-
erty was 3.8 times more than that in Other Towns, and
2.5 times more than that in the Kingston Metropolitan
Area. Despite the compounding economic challenges of
poverty coupled with ageing, the poor-elderly in Jamaica
do not experience a difference in their health status ow-
ing to area of residence. Here the health issues of the
aged poor are independent of their area of residence,
suggesting that in the population the poor are age-
residence insensitive. This contradicts research literature
on the health status of the elderly which has shown a
correlation between the aged and their areas of residence
[23,24,48], indicating that the physical characteristics of
the aged poor are the same in different areas of residence,
and therefore do not account for any poor health, dis-
ability, functional inability or psychological conditions.
Like the WHO [35,36], the researcher believes that
although ageing is a biological phenomenon, it cannot be
due only to biological conditions, as ageing relates to
bio-psycho-social [20,25,37-49] and environmental con-
ditions [23-26], since people – biological organisms –
must operate in a socio-physical milieu throughout their
life span, and this demands an expansion of biological
conditions in the ageing discourse. The very nature of
gerontology must coalesce biopsychosocial and envi-
ronmental conditions in assessing ageing and the health
of the aged, which are in keeping with the WHO’s Con-
stitution of 1948, and this has also been established in
many Caribbean scholarships [20,23-25,42-49]. Within
the context of the above-mentioned challenges for eld-
erly people, when this is coupled with poverty which
affects 10.2% of elderly Jamaicans (N = 29,794) in 2007,
it intensifies the challenges experienced by elderly peo-
ple. With the increased cost of food and non-alcoholic
beverages, fuel and household supplies, housing and
household operational expenses, the health status of the
older-poor will continue to deteriorate, as they will not
be able to afford health care services. The decline in
medical care-seeking behaviour of Jamaicans speaks to
the challenges of older people and the rise in instances of
switching to alternative medicine. This is further intensi-
fied by poverty; and rural poverty, which is more severe
than that found in urban areas, [50] will further com-
pound the challenges of the health status of the aged
populace. Older people who are poor must operate
within the same biopsychosocial and physical environ-
ment during their lifetimes as other persons.
Even among the WHO commissioned studies [51-53],
as well as other studies on the social determinants of
health [2,3,20-25], the population of the poor elderly
were not examined. Likewise in the Caribbean, scholars
have examined the social determinants of the population
or the elderly population, with poverty being an inde-
pendent variable [20,23-25]. Any policy that seeks to
address the health status of the elderly poor must take
into consideration, or concentrate and/or rely on, not
only the population in general, but the cohort of the eld-
erly in particular. The experiences and demands of the
elderly are not the same as the general population, and
the current study shows that social determinants of
health are somewhat different for the general elderly
population and the poor elderly cohort. The WHO [51]
opined that the social determinants of health for the most
part account for the health inequities between and within
nations, which substantiates the differences that emerged
between the elderly in other studies [20,23-24] and the
current study of the poor elderly. These findings are
far-reaching, and can be used to guide policy and re-
search. The elderly-poor in Jamaica are experiencing
‘health poverty’ which cannot be alleviated by unre-
searched policies or research policies on the general
population, but by the elderly cohorts in particular.
5. CONCLUSION
In summary, the number of elderly persons who reported
health conditions in Jamaica is 3 times more than that for
the nation (i.e. 12.6%), suggesting that health care ex-
penditure for Jamaicans is substantially used to address
health care needs for the aged population. With the
number of elderly come 2025 estimated to be 14.5%
over 10.9% for 2007, health care expenditure will be
primarily absorbed in caring for this age cohort. Public
health practitioners must begin programmes to deal with
this pending reality. Ageing is a process which denotes
that the high number of health conditions affecting the
elderly would have started earlier, based on some of the
decisions that they undertook (or did not) leading up to
their current age. Hence, there is a need to have a public
health campaign geared towards the promotion of healthy
lifestyle practices for ages close to sixty years, in con-
junction with one for children and for the working-age
population. The programme should target check-ups,
preventative care, signs of the onset of particular health
conditions, and the distinction between ill health and
good health care practices. The demand of the health
services in Jamaica in the future must be geared towards

P. A Bourne et al. / J. Biomedical Science and Engineering 3 (2010) 700-710 709
a particular age cohort and certain health conditions, and
not only to the general population, as the social deter-
minants which give rise to inequities are not the same
even among the same age cohort.
6. DISCLOSURE
The author reports no conflict of interest for this study.
7. DISCLAIMER
The researcher would like to note that while this study
used secondary data from the Jamaica Survey of Living
Conditions, none of the errors in this paper should be
ascribed to the Planning Institute of Jamaica or the Sta-
tistical Institute of Jamaica, but to the researcher.
8. ACKNOWLEDGEMENTS
The dataset for this study was made available from the databank of
SALISES (Sir Arthur Lewis Economic Institute), Faculty of Social
Sciences, the University of the West Indies, Mona, Jamaica and for this
the researcher is indebted and greater appreciate this gesture.
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