1.Happiness in OlderAdulthoodWellbeing, Health & life satisfactionPaul Andrew Bourne

2. Happiness in OlderAdulthoodWellbeing, Health & life satisfactionPaul Andrew BourneSocio-Medical Research InstituteKingston, Jamaicai 3. Paul A. Bourne, 2011First Published in Jamaica, 2011 byPaul Andrew Bourne66 Long Wall DriveStony Hill,Kingston 9,St. AndrewNational Library of Jamaica Cataloguing DataHappiness in Older Adulthood: Illness, Health & lifesatisfactionIncludes indexISBNBourne, Paul AndrewAll rights reserved. Published, 2011Covers designed by Paul Andrew BourneAll the photographs were taken by Paul A. BourneSocio-Medical Research Institute, 66 Long Wall Drive, Stony Hill,Kingston 9, Kingston, Jamaicaii 4. PrefaceDr. George Engel has expanded the biomedical model in the 1960s, in which he emphasizes theimportance of socioeconomic and psychological conditions in treating mentally ill patients, andthat this extended beyond this group to all patients. Other scholars have used happiness, lifesatisfaction, self-rated health and quality of life to evaluate health instead of the traditionalabsence of illness. Happiness, life satisfaction and health status are as close as possible to theideal definition of health as offered by the WHO. However, these are infrequently used in healthdiscourse, particularly among those in older adulthood in Jamaica. Understanding and planning for aged Jamaicans cannot rely on only illness, self-ratedhealth and mortality. Since 1989, the Statistical Institute of Jamaica and the Planning Institute ofJamaica have been collecting data on Jamaicans to guide policy formulation. Self-reportedillness is usually collected and this is used to assess the health status of the population. The firsttime that self-rated health status was collected from Jamaicans was in 2007. Therefore, planningfor the health of the population was primarily based on the traditional perspective (biomedicalmodel or the germ theory). Despite Dr. George Engels proposition of the biopsychosocial model since the 1950s,the Planning Institute of Jamaica and the Statistical Institute of Jamaica have not seen it fitting tocollect data on different subjective indices of health such as happiness, life satisfaction, qualityof life and self-rated health status all at once (up to 2007). This means that researchers who usethe data from the aforementioned institutes as well the institutions cannot verify the validity ofdifferent subjective indices as well as whether there are differences among the measures. The iii 5. elderly are people who are highly vulnerability to diseases, loneliness, fear, frustration,depression and frailty, and so planning for their health cannot limit itself to health conditions andself-reported health. This is moreso on the premise that we do not know the coverage ofexogenous health, life satisfaction, wellbeing and illness. This book intends to commence a discourse on health that is expansive from the absenceof illness to include 1) self-rated health, 2) wellbeing, 3) life satisfaction, and 4) happiness.Happiness in Older Adulthood: Wellbeing, Health & life satisfaction comprises of 15 chapters,and the author intends for this to be a thrust in expanding the construct of health in datacollection as well as understanding peoples perspective on health. iv 6. AcknowledgementThe completion of this book is owed to a number of people who offered their time, cognitiveskills and data availability. In keeping with the aforementioned issues, I am grateful, pleased andindebted to the following people and/or institutions including relatives such as my aged mother(Ms. Janet Medda Green), brother (Mr. Kervin Roger Smith), niece (Janet Smith), nephew(Kevin Smith). And, 1) Ms. Neva South-Bourne for her advice in penning my ideas, 2) Mrs.Evadney Bourne, my wife, for support, understanding and patience when things were difficultand surmountable at times, 3) all my co-writers, 4) God, for his wisdom, 5) the Data Bank in SirArthur Lewis Institute of Social and Economic Studies, the University of the West Indies, Mona,Jamaica for making the dataset available for use in this study, and 6) all my associates (includingbest friends) whose love, support and encouragement provided the impetus that I drew from tocomplete this project. I would also like to single out the different journals that gave me thepermission to reproduce some of the chapters including North American North of MedicalSciences, and Current Research in Social Sciences. v 7. Table of ContentsPreface iiiAcknowledgementvIntroduction viiiChapter 11Happiness among Older Men in Jamaica: Is it a health issue?Chapter 233Happiness, life satisfaction and health status in a Caribbean nation: Using a cross-sectionalsurveyChapter 366A cross-sectional survey of the health status, life satisfaction and happiness of older men inJamaica - associations between questionnaire scoresChapter 489Good Health Status of Older and Oldest Elderly in Jamaica: Are there differences between ruraland urban areas?Chapter 5 118Decomposing Mortality Rates and Examining Health Status of the Elderly in JamaicaChapter 6 149An Epidemiological Transition of Health Conditions, and Health Status of the Old-Old-To-Oldest-Old in Jamaica: A comparative analysisChapter 7 179Health status of patients with self-reported chronic diseases in JamaicaChapter 8 205The changing faces of diabetes, hypertension and arthritis in a Caribbean populationvi 8. Chapter 9230Comparative Analysis of Health Status of men 60+ years and men 73+ years in Jamaica: Arethere differences across municipalities?Chapter 10 260Health in Older AdulthoodChapter 11 285Self-rated Wellbeing of Elderly JamaicansChapter 12 319Wellbeing in Older AdulthoodChapter 13 352Social Determinants of Subjective Wellbeing of Elderly in JamaicaChapter 14 393A conceptual framework of wellbeing in some Western nationsChapter 15 414The wellbeing discourse vii 9. Introduction Paul A. BourneHuman AgeingThe Caribbean has been identified as the most rapidly ageing region of the world. During the1960 -1995 period, there was a 76.8% increase in the elderly population (United Nations, 2005;Bourne, 2010). The mean growth rate in the elderly population was 5.3%, which was recordedfor the period 1995-2000. The Caribbean elderly as a percentage of total population has beenprojected to reach about 15% by 2020, an almost four-fold increase over the 1950 figure of 4.3%(United Nations, 2005; PAHO, 1997). Is this any different in Jamaica? Jamaicas elderly population (ages 60+ years) has increased significantly since the mid1960s (Eldemire, 1997; Bourne, 2010) indicating increased life expectancy. Life expectancy atbirth for males between 1879 and 1882 was 37.02 years and for females it was 39.80 years(Bourne, 2010; Statistical Institute of Jamaica, 2010). Between 2002 and 2004 males areexpected to live for 71.26 years and females 77.07 years (Appendix I), which is a clear indicationof demographic ageing of the Jamaican population. Statistics revealed that over 10% ofJamaicans were older than 60 years in 2009 (Bourne, 2010; Statistical Institute of Jamaica,2010). An examination of 5-year age cohorts of the elderly population in Jamaica revealed that85+ years is the fastest growing from the general elderly population (Figure 6.1). Thus, thesociety is experiencing an oldest-old population explosion never before seen in its history, andthis point to the gains made in public health measures, and improvements in the standard ofliving of the general populace since the 20th century.viii 10. Figure 6.1: Percentage change in elderly population by five year age groups, 1991-2001.Global Issues on Ageing Even though, the ageing process is lifelong and though this may be constructed withineach society differently, many decades have elapsed since Galtons study on the health status ofpeople. Despite changes in human development and the shifts in world population towarddemographic ageing people living beyond 65 years (see ILO 2000; Wise 1997), the issues ofthe aged and their health status have not taken front stage on the radar of demographers unlikemany other demographic issues. This is equally true for many Caribbean nations. Demographershave spent years studying mortality, and this has been used as an indicator of life expectancysuch as the Coale and Demeny Model life tables and by extension health status. Life expectancy,on the other hand, has always been viewed as the avenue through which demographers evaluateix 11. the health status of people; as lived years is an indicator of living beyond certain healthconditions. Thus, health and wellbeing are tied to mortality patterns, which is rightfully so butthis approach gives little emphasis on conditions that are likely to decrease morbidity andthereby reduce mortality. With this being the case, demographers have consumed more timeassessing mortality and life expectancy and morbidity because of their close approximation ofwellbeing (or health status), and this is similarly the case for Caribbean demographers. Caribbean Demographic TrendsDemographic development in the Caribbean has taken a similar path like the rest of the world(STATIN 2006; United Nations 2005c). Over the years, the movement as being such thatmortality and fertility has been declining, and the population 60 years and older has beenincreasing proportionately more than percentage who are children. Jamaica as well as the rest ofthe Caribbean and Latin America is said to be at the second stage of the demographic transitionmodel. (STATIN 2007). Several Caribbean countries such as Jamaica, Cuba, Barbados, Trinidadand Tobago could be said to be approaching the third stage of the transition. The demographictransition refers to the changes in population growth that is attributable to transition from high tolower levels of fertility and mortality. So for countries to be at the third stage of the transition,they would be experiencing population ageing due to persistently low fertility, even lowermortality. Like the rest of the world, these changes also brought improvement in livingconditions, advancement in medicine and improvement in health care and discovery and use offamily planning measures. Statistics revealed that the total fertility from 1970 to 1975 for the world was 4.49 andfrom 2000 to 2005, it fell to 2.65; whereas in Latin America and the Caribbean between 1970and 1975, it was 5.05 and this was further reduced to 2.55 from 2000 to 2005 (United Nations x 12. 2005c, xxi). As early as 2005, some countries in the Caribbean had reached replacement levelfertility. Total fertility per woman in the Bahamas reached is 2.2, Barbados 1.5, Jamaica 1.93(Demographic Statistics, 2006) and Trinidad and Tobago, 1.6 (United Nations 2006, 87-89).Barbados, Jamaican and the twin islands of Trinidad and Tobago are currently experiencingbelow replacement level fertility (Total Fertility Rate TFR of 2.1 United Nations 2000, 4).Since 2005, this has become a demographic reality for many developed nations. The exampleshere are some countries in Eastern Europe (TFR, 1.3) Southern Europe (TFR, 1.4) and NorthernEurope (TFR, 1.7) and the United States, 2.0 (United Nations 2007; 2005c, xxi). In addition,mortality in the Caribbean has been falling coupled with increased life expectancies that arecomparable with those in developed nations, beyond 71 years. (United Nations 2005c, xxii),which according to Rowland (2003, 18) are components within the demographic transitionmodel. Return migration also plays a significant role in the ageing of the Caribbeans population.Jamaica, like Trinidad and Tobago, and Barbados are experiencing the return of some of thosepeople who migrated in the 1950s-1960s, who are now elderly. In addition to return migration ofaged Jamaicans, the continuously high emigration of young people (Caribbean Food andNutrition Institute 1999) has further exasperated population ageing in the country. From the datareported in Table 1.14, at least 65 percent of the net migration is accounted for by ages less than30 years. Even though the negative net migration of Jamaicans has been reduced by more one-half since the last twenty years (1988-2006), the pattern of those who emigrate has remained thesame. This explains the return migration of elderly Jamaicans within the context of net outflowat the younger ages which is depletion of the human resources of the country. Although the netmigration outflow of migrants from Jamaica, for each year, has never surpassed 1 percent of thexi 13. total population for the year in question, the cumulated effect of this over a long period is equallyaiding in the explanation of the nations ageing population. Therefore, many Caribbean countries began experiencing population ageing since asearly as in the 1950s and/or the 1960s. In 1950, 8.5 percent of Barbados population was 60years and older; Suriname, 8.4, which was higher than 6.9 percent for the Caribbean and 8.2percent for world. Jamaicas population ageing, on the other hand, did not begin until the 1960s.Using the growth rate of the population for different age groups as an indicator of ageingpopulation, Jamaicas population 65 years and over doubled from 1960-1970 and 1943-1960,which only occurred in this age group. However, in the Caribbean, the matter has recently begunto be of concern (Caribbean Food and Nutrition Institute 1999, 192, 217). The reason for thisthrust is because the rate of increase of this age cohort compared to the other age cohort. By2050, the population of people 60 years and older in some Caribbean nations will more thandouble, while the young population (ages 0 to 14 years) would have been reduced by one-half. Some developing states such as Barbados, and Trinidad and Tobago, and Jamaica arecurrently experiencing a shift toward a population age. In 2007, all three Caribbean nations hadin excess of 10 percentages of their population ages 60 years and older. Barbados, on the otherhand, has the largest percentage of person 60 years (13.2%). The issue of the ageing of apopulation cannot be simply overlooked and has far reaching implication for labour supply,pension system, health care facilities, products demanded, mortality, morbidity, and publicexpenditure among other events.Ageing is not simply about mortality, fertility and/ormorbidity. The phenomenon is about people, their environment and how they must coexist inorder to survive. Ageing, therefore, is here to stay. In order to grasp the complexities of thisxii 14. phenomenon, Lawsons monograph adequately provides a summative position on the matter.She noted that: Actually, it is predicted (U.N) that developing countries are likely to have an oldergeneration crisis about the year 2030, that is about the same time as most developed countries(Lawson 1996, 1). This demographic transition is not only promulgated by Lawson, but was argued byCowgill (1983) who believed that during the next half-century (2050), there is strong possibilitythat this transition will be an issue for some developing nations. This implies that populationageing which has been the experience of many developed nations (Gavrilov and Heuveline 2003;Marcoux 2001; Lawson 1996) will be a reality for some lesser developed countries and moredeveloping regions in the future. Seniors cannot be neglected as they will constitute an increasingly larger percentage oftotal population and sub-populations in different regions than in previous centuries (UN 2005;WHO 2005; Chou 2005; STATIN 2004; Apt 1999; Caribbean Food and Nutrition Institute1999a; Randal and German 1999; US Census Bureau 1998; Eldemire 1995, 1994; EuropeanFoundation for the Improvement of Living and Working Conditions 1993; Mesfin et al. 1987;Grell, 1987; National Health and Welfare 1982). According to Randal and German (1999), thenumber of aged persons living in developing countries will more than double by 2025, reaching850 million. The Caribbean is not different as according to Grell (1987), the English-speakingCaribbean from the 1970 census revealed that between 8.8 and 9.8 percent of the populace were60 years and older. A matter Lawson noted began in Jamaica since the 1900s (Lawson 1996, 1-37). To be more specific population ageing in Jamaica, began in the 1960s. xiii 15. Demographic Trends: JamaicaIn 2007, the annual growth rate for the Jamaican population since 1996 has always been less than1.0%, and the figure for 2006 is estimated to be 0.5% (Demographic Statistics 2006) which islower than the global average of 1.2 percent (CIA 2007). With regard to globes population,10.4% of individuals are 60 years or older (United Nations 2005c). Jamaicas elderly populationin 2005 rose marginally by 0.3% to 10.7% in 2006 (PIOJ 2007). The United Nations data showthat 8% of people in the developing nations are 60 years or over (United Nations 2005c), whichis approximately 2% less than the number of aged people in Jamaica. According to theDemographic Statistics (2006), 10.9% of Jamaicans females are 60 years and older compared to10.3% of males. Eldemire notes that the increased aged populace in Jamaica began in the 1960s(Eldemire 1995). Despite the indecisiveness to reach consensus on a definition of ageing from the UnitedNations perspective on the elderly, old age begins at 60 years while other scholarsconceptualize ageing to commence at age 65 years or older (See for example Lauderdale 2001;Elo 2001; Manton and Land 2000; Preston et al. 1996; Smith and Kington 1997a; Smith andWaitzman 1994; Rudkin 1993). The WHO says that we can either use the chronological age of60 or 65 years or over to indicate the beginning of ageing (WHO 2002, 125). So why is there nostandardized definition for the elderly or where ageing begins? Thane (2000) noted that old agefor all people was defined as 60 years in medieval times. She justified this by forwarding anargument for the established age. In medieval England, men and women ceased at 60 years to beliable for compulsory service under labour laws or to participate in military duties. AncientRome, on the other hand, old age began from early 40 to 70 years, with 60 years being somesort of annus climactorius. Some Demographers see seniors - the elderly or the aged (old xiv 16. people) - as beginning at chronological age of 65 years and older, and not an individual who is60 years of age. Up to 1992, the Statistical Institute of Jamaica defined old-age as those people65 years and older (Demographic Statistics 1992). At that time Professor of demographer at theUniversity of the West Indies at Mona was primarily responsible for the many of the output ofthat Institution, and the training of staff. This may explain why the Statistical Institute ofJamaica used 65 years in its conceptualization of old-age. Furthermore, Western societies use 65years and older to represent the elderly (seniors) as this is the period when people become fullyeligible for Social Security benefits. One Caribbean scholar emphasized that there is no absoluteness in the operationaldefinition of the elderly (Eldemire 1995, 1). She commented that from the World Assembly ofAgeing (which was held in Vienna in 1982), the elderly is using the chronological age of 60years and older as the beginning of the ageing process. Jamaica having signed the ViennaDeclaration of Ageing, which defines ageing to begin at 60 years, Eldermire questionedacademics and other scholars for their rationale in using 65 years. This paper seeks to evaluatethe wellbeing of the age and not those who are eligible for Social Security benefits. Hence, forthis study old age or the elderly (seniors) will begin from the chronological age of 60 years andolder. From the JSLC reports published by the PIOJ and STATIN, which is primarily focusedon the traditional construct of health using the biomedical model, the researcher is forwarding aposition that if we were to more effectively capture the wellbeing status of Jamaicans, we mustoperationally expand the definition of health in such a manner that it encompassesbiopsychosocial factors such as (i) biological; (ii) psychological; (iii) social; (iv) economic, and(v) environmental conditions, as this vulnerable group may even be worse off than reported, xv 17. given the definition chosen to measure health status. There is no published works on the generalwellbeing of the Jamaican elderly in which the researchers have sought to capture a quality oflife index which encompasses biological, sociological, psychological and environmentalconditions. It is within this general framework, that this study of the elderly is timely as it seeksto expand an assessment of the subjective wellbeing of aged Jamaicans from the perspective ofmore comprehensive model. The rationale that explains the use of 65+ to represent elderly is solely due to thestatistical data that are available prior to 1991. Before 1991, the Statistical of Jamaicasoperational definition for the elderly was 65 years and older. Hence, their publication between1844 and 1991 did not produce years for 60+. However, post 1992; the organization beganproviding data for both ages. As such, the researcher used 65+ because he wanted to examinefigure from 1844 to 2006. However, in the Caribbean, the matter has recently begun to be of concern (CaribbeanFood and Nutrition Institute 1999, 192, 217). The reason for this thrust is because the rate ofincrease of this age cohort compared to the other age cohort. By 2050, the population of people60 years and older in some Caribbean nations will more than double, while the young population(ages 0 to 14 years) would have been reduced by one-half. Some developing states such as Barbados, and Trinidad and Tobago, and Jamaica arecurrently experiencing a shift toward a population age. In 2007, all three Caribbean nations hadin excess of 10 percentage of their population ages 60 years and older. Barbados, on the otherhand, has the largest percentage of person 60 years (13.2%). xvi 18. Life expectancyDoes the increase in life expectancy means a better quality of life or subjective wellbeingof elderly Jamaicans? A study by Powell, Bourne and Waller (2007) found that the psychosocialwellbeing of Jamaicans was moderately high (mean score = 6.8 out of 10), and offers anexplanation for the quality of life of its people. Furthermore, they found that the subjectivewellbeing of those in the lower subjective social class had a minimal score (mean score = 5.8 outof 10) compared with those in the upper class (mean score = 6.5 out of 10) and those in themiddle class (mean score = 6.8 out of 10) (Powell, Bourne and Waller 2007). They continuedthat Jamaicans (69%) indicated that their current economic situation was at most average, with19% reporting that it was bad. Nothing was mentioned about the elderlys population quality oflife, but can we assume that a two-fold increase in life expectancy over 1880-1882 means betterquality of life?Using the antithesis of illness to measure health (not reporting an illness), many studieshave examined health of the Jamaican elderly population (Bourne, 2008a; 2008b; Bourne, 2009a;Bourne, 2010) and another decomposed the mortality rate of the aged population (Bourne,McGrowder and Crawford, 2009). The use of illness to evaluate health is both narrow andnegative in scope (Bourne, 2009b; Longest, 2002; Brannon & Feist, 2007), which is thejustification of the World Health Organizations (WHO) broadened conceptualization of healthto more than the absence of illness to social, physical and psychological wellbeing (WHO,1948). Within the broadened conceptualization of health forwarded by the WHO in the preambleto its Constitution in 1946, the use of illness or antithesis of illness is emphasizes the absence ofsome disease causing pathogens, and not really health (Bourne, 2009b). Thus there is the need toexpand the measurement of health from illness or the antithesis of illness to evaluate a broaderxvii 19. definition of health and/or wellbeing, particularly among the elderly population because of thecomposition of this cohort and the importance of understanding their wellbeing for the purposeof planning. This study investigates health, happiness and satisfaction with life for older men in amiddle-income developing country, Jamaica. Happiness, life satisfaction, and health status areamong some of the subjective indexes used to evaluate health (or wellbeing) of an individual,community or population. Happiness is well established in the scientific literature as a goodpredictor of subjective wellbeing and/or overall life with satisfaction as it covers a number ofpositive psychological conditions such as marriage, a job, success in life, adaptation to lifeevents, and negative affective conditions such as the lost of life or property, failed examinations,and dissolution of union deteriorate both health and further deepen the negative impact on lifeand by extension happiness (Diener, 1984; 2000; Easterlin, 2001a; 2001b; 2003; 2004; Stutzer &Frey, 2003; Frey & Stutzer, 2000; 2002; Ng, 1996; 1997). Subjective indexes cover a wider gamut of an individuals life compared to diagnosedhealth conditions, morbidity, reproductive health and life expectancy. Yet, the planning andstatistical agencies in Jamaica have been collecting national living conditions data includinghealth conditions since 1989 (Planning Institute of Jamaica (PIOJ) and Statistical Institute ofJamaica (STATIN), 1989-2008), and health condition has been used to measure the health of thepopulation, gender of the participants and health within areas of residence. For the first time in2007 both agencies added health status to health conditions in the yearly national cross-sectionalsurvey that is used to evaluate the populations living conditions. Happiness therefore, like lifesatisfaction and health status, provides a better idea of peoples quality of life than does illhealth. The use of objective indexes such as diagnosed illness, gross domestic product, life xviii 20. expectancy and mortality are among measures that are said to be limited in scope and justify theuse of subjective indexes by some scholars (Diener, 1984; 2000; Easterlin, 2001a; 2001b; Stutzerand Frey, 2003; Frey and Stutzer, 2000; Ng, 1996; 1997; Oswald, 1997). Despite theaforementioned rationale on happiness, no national study has been conducted in Jamaica onhappiness, life satisfaction and health status, particularly on older men. Initially, when happiness was put forward by Diener (1984) as a measure of wellbeing, itwas rigorously opposed by some scholars as subjective who said it could not be used to measurehealth or wellbeing. Many traditional economists believed that happiness was subjective and thatthis could not be precisely measured, and this accounted for their reservations about accepting it.They believed that Gross Domestic Product per capita (GDP per capita) or income per capita wasan objective measure and that could in fact be precisely quantified. Unlike traditionaleconomists, Diener (1984; 2000), a psychologist, theorized that happiness could in fact be usedto measure subjective wellbeing and this was later adopted by economists (Oswald, 1997; Ng,1996; 1997; Blanchflower and Oswald, 2004; Veenhoven, 1991; 1993; Easterlin, 2001a; 2001b;Stutzer and Frey, 2003; Frey and Stutzer, 2000; DiTella, et al., 2003). Easterlin (2001a, 2001b, 2003, 2004) found a statistical association between happinessand income. He argued that, The relationship between happiness and income is puzzling,(Easterlin, 2001a: 465) and that people with higher incomes were happier than those with lowerincomes, but that economic growth does not mean happiness. Easterlin used happiness tomeasure subjective wellbeing, which was found to be highly correlated with income. He wentfurther when he said that, Those with higher income will then be better able to fulfill theiraspirations and, other things equal, will, on average, feel better offThis is the point-of-timepositive association between happiness and income(Easterlin 2001a:472). Like Easterlin, all xix 21. the aforementioned economists used happiness to evaluate subjective wellbeing as they acceptedthat happiness is an indicator of peoples judgement of their overall quality of life (Veehnoven,1991; 1993). Randomly selecting Europeans and Americans from the 1970s to 1990s, Di Tella etal. (2003) did not find this complex relation between income and happiness. They however notedthat some variables such as unemployment, unemployment benefits and others are exogenousvariables as they are influenced by political decisions and do influence income. Diener (2000) argued that wellbeing can be explained outside of welfare theory or apurely objective utility approach, and this was supported by other scholars (Liang, 1984; Dieneret al., 1999; Diener and Suh, 1997; Cummins, 1997). Arthaud-day et al.s (2005) work appliedstructural modeling and found that subjective wellbeing comprised of (1) cognitive evaluationsof ones life (i.e., life satisfaction or happiness); (2) positive affect; and (3) negative affectiveconditions. Unlike Arthaud-day et al., Diener (2000) proposed that subjective wellbeing can beoperationalized by some basic indicators such as emotional components (Taking all thingstogether, how happy would you say you are?) and cognitive components or life satisfaction(All things considered, how satisfied are you with your life as a whole nowadays?). Summers & Heston noted that, GDPPOP is an inadequate measure of countriesimmediate material well-being, even apart from the general practical and conceptual problems ofmeasuring countries national outputs (Summer & Heston, 1995:2) From that perspective, themeasurement of quality of life is highly economic and excludes psychosocial factors as theemphasis is on objective indexes of wellbeing (Gaspart, 1998) and not in keeping with thebreadth of wellbeing offered by the World Health Organization in the preamble to itsConstitution (WHO, 1948). Thus, quality of life (wellbeing) extends beyond financial resources(money), although they improve wellbeing or the human lot.(Easterlin, 1974; 1995; Marmot,xx 22. 2002). Using data for developing countries, Camfield noted that subjective wellbeing constitutesthe existence of positive emotions and the absence of negative ones within a space of generalsatisfaction with life. Cummins (1997) argued that subjective and objective indexes of materialwell-being along with the absence of illnesses, efficiency, social closeness, security, place incommunity, and emotional wellbeing means that lifes satisfaction comprehensively envelopessubjective wellbeing. Diener (2000) in an article titled Subjective Well-Being: The Science ofHappiness and a Proposal for a National Index theorized that the objectification of wellbeing isembodied within satisfaction of life. This explains the rationale for the use of life satisfactionand/or happiness to operationalize wellbeing instead of GDP per capita (or income per capita). Extensive review of the literature turned up just one study in Jamaica that examined lifesatisfaction (Hutchinson, et al., 2004). In this study, the scholars found that women had a loweroverall life satisfaction (72%) than men (76%). Employment status, education, gender, unionstatus, church attendance, self-esteem, and current health status were determinants of lifesatisfaction. In Di Tella et al.s work, they found income, employment status, interpersonal trust,health status, marital status, education, sex and inflation, the rate of change of consumer prices inthe country, unemployment benefits, and the number of children in households was predictors ofhappiness. In descending order, they found that marital status, income and employment statushad the greatest influence on happiness. Although there is very little or research study in the English speaking Caribbean onhappiness of the general populace or on the elderly population, Stutzer & Frey (2003) hasidentified a few predictors of happiness: income; aspiration; and unemployment. Konow &Earleys study (1999) revealed that employment status, positive and negative affective xxi 23. conditions, social support and marital status were correlated with happiness. Some of these (i.e.,employment status, marital status, living arrangement, age, education, gender) were alsorecorded as being statistical associated with happiness in Blanchflower & Oswalds study.ReferencesArthaud-day ML, Rode JC, Mooney CH, Near JP. The Subjective Well-being Construct: A Testof its Convergent, Discriminant, and Factorial Validity. Social Indicators Research, 2005;74(3):445-476.Blanchflower DG, Oswald AJ. Well-Being Over Time In Britain And The USA. Journal ofPublic Economics, 2004, 88(7-8,Jul):1359-1386.Bourne PA. Health Determinants: Using Secondary Data to Model Predictors of Well-being ofJamaicans. West Indian Medical J. 2008a; 57(5):476-481. [Pub Med]Bourne PA. Medical Sociology: Modelling Well-being for elderly People in Jamaica. WestIndian Medical Journal 2008b; 57(6):596-604. [Pub Med]Bourne PA. Good Health Status of Older and Oldest Elderly in Jamaica: Are there differencesbetween rural and urban areas? Open Geriatric Medicine Journal. 2009a; 2:18-27.Bourne PA. (2009b). Social determinants of health in Jamaica: Are there differences between thesexes and are of residence? HealthMED Journal 3(4):359-373. [2009 Impact factor = 0.125].Bourne PA. 2010. Population Ageing and the State of the Elderly, with emphasis on Jamaica.Caribbean Quarterly 56(2).Bourne PA, McGrowder DA, & Crawford TV. (2009). Decomposing Mortality Rates andExamining Health Status of the Elderly in Jamaica. The Open Geriatric Medicine Journal 2:34-44.Brannon L, Feist J. Health psychology. An introduction to behavior and health, 6th ed. LosAngeles: Wadsworth; 2007.Camfield L. Using subjective measures of wellbeing in developing countries. Glasgow,Scotland: University of Strathclyde; 2003.Centre of Health Service Development, Faculty of Health and Behavioural Sciences Universityof Wollongong; Towards a National Measure of Functional Dependency for Home Care Servicesin Australia: Stage 1 report of the HACC dependency data items project 2000 updated 2001.xxii 24. Clark AE, Frijters P, Shields MA. Income and happiness: evidence, explanations and economicimplication. Working paper No. 5. National Center for Econometric Research; 2006.Cohen L, Holliday M. Statistics for Social Sciences. London, England: Harper and Row, 1982.Cummins R. Self-rated quality of life scales for people with an intellectual disability: a review.Journal of Applied Research in Intellectual Disabilities 1997; 10:199216.Di Tella R, MacCulloch RJ, Oswald AJ. The macroeconomics of happiness. Review ofEconomics and Statistics 2003;85:809-827.Diener E, Larson RJ, Levine S, Emmons RA. Intensity and frequency: Dimensions underlyingpositive and negative affect. Journal of Personality and Social Psychology, 1985; 48:1253-1265.Diener E, Oishi S, Lucas RE. Personality, culture and subjective wellbeing: Emotional andcognitive evaluations of life. Annual Review of Psychology 2003; 54:403-425.Diener E, Suh E. Measuring quality of life: Economic, social subjective indicators. SocialIndicators Research1997; 40:189-216.Diener E, Suh M, Lucas E, Smith H. Subjective well-being: Three decades of progress.Psychological Bulletin 1999; 125:276-302.Diener E. Subjective well-being. Psychological Bulletin 1984; 95: 54275.Diener E. Subjective well-being: the science of happiness and a proposal for a national index.Am Psychologist 2000; 55: 3443.Easterlin RA. Building a better theory of well-being. Prepared for presentation at the ConferenceParadoxes of Happiness in Economics, University of Milano-Bicocca, March 21-23, 2003.Easterlin RA. Does Economic Growth Improve the Human Lot? Some Empirical Evidence inNations and Households in Economic Growth: Essays in Honour of Moses Abramowitz, EdDavid PA, Reder MW, Academic Press, New York and London; 1974.Easterlin RA. How Beneficent Is the Market? A Look at the Modern History of Mortality, theReluctant Economist. Cambridge: Cambridge University Press 2004; 101-38.Easterlin RA. Income and happiness: Towards a unified theory. The Economic Journal 2001;111:465-484. (2001a)Easterlin RA. Life Cycle Welfare: Evidence and Conjecture. Journal of Socio-Economics 2001;30:31-61.Easterlin RA. Will Raising the Incomes of All Increase the Happiness of All? Journal ofEconomic Behavior and Organization1995; 27:35-47. xxiii 25. Easterlin, R. (1996). Growth Triumphant: The Twenty-first Century in Historical Perspective,Ann Arbor, MI: University of Michigan Press.Eldemire D. The Elderly and the Family: The Jamaican Experience. Bulletin of EasternCaribbean Affairs, 1994; 19:31-46.Eldemire, D. 1997. The Jamaican elderly: A socioeconomic perspective and policyimplications. Social and Economic Studies, 46: 175-193.Frey BS, Stutzer A. Happiness and Economics. Princeton University Press; 2002.Frey BS, Stutzer A. Happiness, Economy and Institutions. Economic Journal 2000; 110:918-938.Gardner JW, Lyon JL. Cancer in Utah Mormon men by lay priesthood level. American Journalof Epidemiology 1982; 116:243-257.Gaspart F. Objective measures of well-being and the cooperation production problem. SocialChoice and Welfare 1998; 15 (1):95-112.Graham TW, Kaplan BH, Cornoni-Huntley JC, James SA, Becker C, Hames CG, Heyden S.Frequency of church attendance and blood pressure elevation. Journal of Behavioral Medicine1978; 1:37-43.Hutchinson G, Simeon DT, Bain BC, Wyatt GE, Tucker MB, LeFranc E. Social and Healthdeterminants of well-being and life satisfaction in Jamaica. International Journal of SocialPsychiatry 2004; 50(1):43-53.Jackson M, Walker S, Forrester T, Cruickshank J, Wilks R. Social and dietary determinants ofbody mass index in Jamaican of African. European Journal of Clinical Nutrition 2003; 57:621-627.Kahneman, D. & Riis, J. (2005). Living, and thinking about it, two perspectives, inHuppert, F.A., Kaverne, B. and N. Baylis, The Science of Well-being, Oxford UniversityPress.Kart CS. The Realities of Aging: An introduction to gerontology, 3rd. Boston, United States:Allyn and Bacon; 1990.Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffe MW. Studies of illness in the ages. Theindex of ADL: standardized measure of biological and psychosocial function. JAMA, 1993; 185(12):914-919. xxiv 26. Katz, D.L., Brunner, R.L., St. Jeor, S.T. et al. Dietary fat consumption in a cohort of Americanadults, 1985-1991: covariates, secular trends, and compliance with guidelines, American Journalof Health Promotion, 1998; 12 382- 390.Katz, S., Down, T.D., Cash, H.R., & Grotz, R.C. Progress in the development of the index ofADL. The Gerontologist, 1970;10(1), 20-30.Kidd S and Whitehouse E, Pensions and old age poverty, in Closing the coverage gap, 2009,pp.41-56.Kimball M, Willis R. Utility and happiness; 2005. Available at:www.stanford.edu/group/SITE/papers2005/Kimball.05.doc. Accessed on: August 31, 2006.Konow J, Earley J. The Hedonistic Paradox: Is Homo-Economicus Happier? Mimeo, LoyolaMarymount University, Dept. of Psychology; 1999.Kurlowicz L, Wallace C. The Mini Mental State Examination (MMSE) Number 3, Series.Hartford Institute of Geriatric Medicine; 1999Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental activitiesof daily living. Gerontologist. 1969; 9(3):179-86.Leung BW, Moneta G, McBride-Chang C. Think positively and feel positively: Optimism andlife satisfaction in late life. International Journal of Aging and human development 2005;61:335-365.Liang J. Dimensions of the Life Satisfaction Index A: A structural formulation. Journal ofGerontology, 1984; 39:613-622.Longest BB, Jr. Health Policymaking in the United States, 3rd. Chicago, Illinois: Foundation ofthe American College Healthcare; 2002.Lyubomirsky S, King L, Diener E. The benefits of frequent positive affect: Does happiness leadto success? Psychological Bulletin 2005; 6, 803-855.Lyubomirsky S. Why are some people happier than others? The role of cognitive andmotivational process in wellbeing. American Psychologist 2001; 56:239-249.Marmot M. The influence of Income on Health: Views of an Epidemiologist. Does money reallymatter? Or is it a marker for something else? Health Affairs. 2002; 21: 31-46.Moody HR. Is religion good for your health? Gerontologist 2006:147-149.Ng YK. A Case for Happiness, Cardinalism and Interpersonal Comparability. Economic Journal1997; 107:1848-1858.xxv 27. Ng YK. Happiness Surveys: Some Comparability Issues and an Exploratory Survey Based onJust Perceivable Increments. Social Indicators Research 1996; 38:1-27.Oswald AJ. Happiness and Economic Performance. Economic Journal 1997; 107:1815-1831.Palmore, E. 1981. Social patterns in normal aging: Findings from the Duke longitudinal study.Durham: Duke University Press.PAHO (Pan-American Health Organization). (1997). Health Conditions in the Caribbean.Scientific Publication No. 561; Washington DC: PAHO;Pavot W, Diener E. Review of the Satisfaction with Life Scales. Psychological Assessment 1993;5:164-172.Planning Institute of Jamaica (PIOJ). Economic and Social Survey Jamaica 1980-2008.Kingston: PIOJ; 1981-2009.Planning Institute of Jamaica, (PIOJ), Statistical Institute of Jamaica (STATIN). Jamaica Surveyof Living Conditions, 1989-2007. Kingston: PIOJ, STATIN; 1990-2008.Powell, L.A., Bourne, P., Waller, L. Probing Jamaicas Political Culture, vol. 1: MainTrends in the July-August 2006 Leadership and Governance Survey. Kingston: Centre ofLeadership and Governance, Department of Government, University of the West Indies,Mona; 2007.Schimmel J. Development as happiness: The subjective perception of happiness and UNDPsanalysis of poverty, wealth and development. Journal of Happiness Studies 2009; 10:93-111.Sheldon K, Lyubomirsky S. How to increase and sustain positive emotion: The effects ofexpressing gratitude and visualizing best possible selves. Journal of Positive Psychology 2006;1:73-82.Statistical Institute of Jamaica (STATIN). 1977-2010. Demographic statistics, 1976-2009.Kingston: STATIN.Statistical Institute of Jamaica. Population Census 2001 (Volume 8): Marital and Union Status.Kingston, Jamaica: Statistical Institute of Jamaica; 2004.Stutzer A, Frey BS. 2003. Reported subjective well-being: A challenge for economic theory andeconomic policy. Working paper No. 07. Center for Research in Economics, Management andthe Arts; 2003Subramanian SV, Kin D, Kawachi I. Covariation in the socioeconomic determinants ofhappiness: A multivariate multilevel analysis of individuals and communities in the USA.Journal of Epidemiology and Community health 2005; 59:664-669. xxvi 28. Summers R, Heston A. (1995). Standard of Living: SLPOP An Alternative Measure of NationsCurrent Material Well-Being. CICUP 96-2, A. Available at:http://pwt.econ.upenn.edu/papers/standard_of_living.pdf. Accessed on: November, 2010.United Nations (UN). 2005. World population prospect: The 2004 revision. Department ofEconomic and Social Affairs, Population Division. New York: UN.United Nations Development Programme. Human Development Report, 1997. New York,United States: UNDP; 1997.Veenhoven R. Happiness in Nations: Subjective Appreciation of Life in 56 Nations, 1946-1992.Erasmus University Press, Rotterdam; 1993.Veenhoven R. Healthy happiness: Effects of happiness on physical health and the consequencesof preventive health care. Journal of Happiness Studies 2008; 9:449-469.Veenhoven R. Is Happiness Relative. Social Indicators Research 1991; 24:1-34.Warnes, A. M, ed. 1982. Geographical perspectives on the elderly. New York: John Wiley andSons.Watson D, Clark LA. Self Versus Peer Ratings of Specific Emotional Traits: Evidence ofConvergent and Discriminant Validity. Journal of Personality and Social Psychology 1991;60:927-940.World Health Organization (WHO). Preamble to the Constitution of the World HealthOrganization as adopted by the International Health Conference, New York, June 19-22, 1946;signed on July 22, 1946 by the representatives of 61 States (Official Records of the World HealthOrganization, no. 2, p. 100) and entered into force on April 7, 1948. Constitution of the WorldHealth Organization, 1948. In Basic Documents, 15th ed. Geneva, Switzerland: WHO, 1948.WHO. World report on violence and health. Geneva, Switzerland: WHO; 2002.Wilks R. Hypertension in the Jamaican Population. A presentation to the Trinidad & TobagoNational Consultation on Chronic Non-Communicable Diseases, September 2007.Wills E. Spirituality and subjective wellbeing: Evidence for a new domain in the personalwellbeing index. Journal of Happiness Studies 2009; 10: 49-69.Winkelmann L, Winkelmann R. Why are the unemployed so unhappy? Evidence from paneldata. Economics 1998; 65:1-15.Wooden M, Headey B. The effects of wealth and income on subjective well-being and ill-being.Australia: Melbourne Institute of Applied Economic and Social Research; 2004.xxvii 29. Happiness in OlderAdulthoodWellbeing, Health & life satisfaction xxviii 30. Chapter 1Happiness among Older Men in Jamaica: Is it a health issue?Paul Andrew Bourne, Chloe Morris & Denise Eldemire-ShearerThis paper seeks to expand the literature by investigating the effect of health status on happiness,happiness on health status, life satisfaction on happiness as well as some demographic variablesin order test the existing knowledge on elderly men (ages 60 years and older) in Jamaica. Astratified random sample of 2,000 elderly men in Jamaica was used to carry out this paper. Thedata were collected with a 137-item self-administered questionnaire, and entered, retrieved andstored in SPSS for Windows 16.0 (SPSS Inc; Chicago IL, USA). Happiness was found not to becorrelated with health status of elderly men in Jamaica nor was health status associated withhappiness; and that there was no difference based on area of residence. Happiness and healthstatus cannot be used to proxy each other for the elderly cohort as they are independent events.IntroductionHappiness is well established in scientific publications as a good predictor of subjectivewellbeing and/or overall life satisfaction (Graham, 2008; Selim, 2008; Borghesi, & Vercelli,2007; Mahon et al., 2005; Layard, 2006; Seligman & Csikszentmihalyi, 2000; Diener, Lucas, &Oishi, 2002; Diener, 1984, 2000; Easterlin, 2001; Veenhoven, 1993). A group of scholars foundthat the statistical association between happiness and subjective wellbeing was a strong one -correlation coefficient r = 0.85 in the 18 OECD countries (Kahneman, & Riis, 2005), whichemphasizes the importance that people place on happiness in assessing their subjectivewellbeing. Happiness which is an area in positive psychology (Seligman & Csikszentmihalyi,1 31. 2000; Huppert, 2006; Brannon & Feist, 2007) goes beyond the mere positive state of anindividual to physical health and social life, and economic state to life in general (Borghesi, &Vercelli, 2007; Lima & Nova, 2004; Stutzer & Frey, 2003; Easterlin 2003; Frey & Stutzer,2002a, 2002b; Brickman, Coates, & Janoff-Bulman, 1978). Happiness is as a result of a number of positive psychological factors such as marriage, ajob, success in life, adaptation to life events, and negative affective conditions such as the lost oflife or property, failed examinations, and dissolution of union deteriorate both health and furtherdeepen the negative impact on life and by extension happiness (Borghesi & Vercelli, 2007;Easterlin, 2003; Kahneman, & Riis, 2005). In seeking to unearth why some people are happier,Lyubomirsky (2001) approached it from the perspective of positive psychology. She noted that,to comprehend disparity in self-reported happiness between individuals, one must understandthe cognitive and motivational process that serve to maintain, and even enhance happiness andtransient mood (Lyubomirsky, 2001, 239)Lyubomirsky identified comfortable income,robust health, supportive marriage, and lack of tragedy or trauma in the lives of people asfactors that distinguish happy from unhappy people (see also, Borghesi & Vercelli, 2007;Kahneman, & Riis, 2005; Frey & Stutzer, 2002a, 2002b; Easterlin, 2003). Those findings onlyconcurred with an earlier work by Diener, Suh, Lucas, & Smith (1999). Diener, Horwitz &Emmon (1985) were able to add value to the discourse when they showed that income affectssubjective wellbeing. Frey & Stutzer (2002a) provided more information on the aforementioneddiscourse, when he opined that absolute income does not seem to have a strong influence onhappiness or health (or subjective wellbeing). Researchers found that the wealthy (those earningin excess of US 10-million, annually) had a marginally greater self-reported wellbeing (personal2 32. happiness) than that of those who were lower wealthy (earned less than 10 million US annually)(Diener, Horwitz & Emmon, 1985). Peoples cognitive responses to ordinary and extraordinary situational events in life areassociated with subjective wellbeing (Chida & Steptoe, 2008; Steptoe et al., 2008; Pressman &Cohen, 2005; Lyubomirsky, 2001; Sheldon & Lyubomirsky 2006). It is found that happierpeople are more optimistic and as such conceptualize lifes experiences in a positive manner.Studies revealed that positive moods and emotions are associated with wellbeing (Fowler &Christakis, 2008; Leung, Moneta, & McBride-Chang, 2005) as the individual is able to think,feel and act in ways that foster resource building and involvement with particular goalmaterialization (Lyubomirsky, King, & Diener, 2005).This situation is later internalized,causing the individual to be self-confident from which follows a series of positive attitudes thatguide further actions (Sheldon & Lyubomirsky, 2006). Positive mood is not limited to activeresponses by individual, but a study showed that counting ones blessings, committing acts ofkindness, recognizing and using signature strengths, remembering oneself at ones best, andworking on personal goals all positively influence wellbeing (Sheldon & Lyubomirsky, 2006;Abbe, Tkach, & Lyubomirsky, 2003). Recently conducted meta-analysis longitudinal studiesrevealed that happiness and other positive moods are not only positively correlated with healthstatus; but that they are negatively associated with mortality Chida Y, Steptoe A. (2008),suggesting the value of happiness to life. Happiness is not a mood that does not change with timeor situation; hence, happy people can experience negative moods (Diener & Seligman, 2002);and happiness is a good proxy for assessing subjective wellbeing.3 33. Human emotions are the coalesced of not only positive conditions but also negativefactors (Watson et al. 1999). Hence, depression, anxiety, neuroticism and pessimism are seen asa measure of the negative psychological conditions that affect subjective wellbeing (Evans et al.2005; Harris & Lightsey, 2005; Kashdan 2004). From Evans and colleague, Harris & Lightseyand Kashdons monographs, negative psychological conditions affect subjective wellbeing in anegative manner (i.e. guilt, fear, anger, disgust); and positive factors influence self-reportedwellbeing in a direct way this was concurred in a study conducted by Fromson (2006); and byother scholars (McCullough et al. 2001; Watson and Clark et al 1988a, 1988b). Acton & Zodda(2005) aptly summarized the negative affect of subjective wellbeing in the sentence that saysexpressed emotion is detrimental to the patients recovery; it has a high correlation with relapseto many psychiatric disorders. Previously mentioned studies using happiness to examine wellbeing were on populationand not on elderly cohorts (ages 60 years and older). McConville et al. (2005) in Positive andnegative mood in the elderly: the Zenith study established that different moods of people affectboth their physical as well as their mental well-being. They argued, Poor quality moods wereassociated with deficits in diverse areas of cognitive function, health, and social relationship(McConville et al., 2005). The Zenith study was to examine the quality of positive and negativeattitudes on health status. The population was 387 individuals from three European countries(France, Italy and Ireland). Another study on the elderly population found that biologicalchanges of humans do affect their psychological state, and that psychological and psychosocialchanges influence biological functioning (or physical health) (Kart, 1990) Well-being for some scholars, therefore, is a state of happiness (ie positive feeling status 4 34. and life satisfaction) (Diener, 1984; Easterlin, 2003; Diener, Larson, Levine & Emmon, 1999).Simply put, well-being is subjectively what is good for each person (Crisp 2005).It issometimes connected with good health. Crisp offered an explanation for this, when he said thatWhen discussing the notion of what makes life good for the individual living that life, it ispreferable to use the term well-being instead of happiness (Crisp, 2005). ODonnell and Tait(2003) believed that health is a primary indicator of well-being; and so provide an understandingof the correlation between health, subjective wellbeing, happiness, and lifes satisfaction(ODonnell & Tait, 2003; Ringen, 1995). From the scientific literature, self-rated health status ishighly reliable to proxy for health which successfully crosses cultural lines (Ringen 1995).ODonnell and Tait concluded from their study that self-reported health status can be used toindicate wellbeing as all respondents who had chronic diseases reported very poor health. From the literature, happiness and health status, happiness and wellbeing, and happinessand life satisfaction are associated. Using the scientific findings on the aforementioned issue, anextensive review of the literature found no study that has every examined happiness and healthstatus of elderly men in Jamaica, which is the rationale for this paper. Given that happinesscovers life satisfaction and health, an examination of happiness and health status of elderly menin Jamaica will provide invaluable information as to the state of this group. An extensive review of the literature revealed that there has never been a study done inthe Caribbean, in particularly Jamaica on happiness of this vital cohort, so this is a criticalrationale for the study as it will provide insight in this cohort along with an understanding of howthey perceive things and life which can guide public policy. Another rationale is happiness, apredictor of health status which would allow for the collection of data on whether or not they are5 35. good predictors of each other. This paper examined whether (1) happiness is a function of healthstatus; (2) happiness is a function of health status and some demographic variables; (3) healthstatus is a function of happiness; (4) health status is a function of happiness and somedemographic variables in order to provide information on this cohort. Using probit analysis, thispaper sought to model the aforementioned issues from data on elderly men (ages 55 years andolder) in Jamaica.MethodsParticipants and questionnaireThe study used primary cross-sectional survey data on men 55 years and older from the parish ofSt. Catherine in 2007; it is also generalizable to the island. The survey was submitted andapproved by the University of the West Indies Medical Facultys Ethics Committee. Stratifiedmultistage probability sampling technique was used to draw the sample (2,000 respondents).A132-item questionnaire was used to collect the data. The instrument was sub-divided intogeneral demographic profile of the sample; past and current health status; health-seekingbehaviour; retirement status; social and functional status. The overall response rate for the surveywas 99% (n=1,983). Data was stored, retrieved and analyzed, using SPSS for Windows (16.0). The Statistical Institute of Jamaica (STATIN) maintains a list of enumeration districts(ED) or census tracts. The parish of St. Catherine is divided into a number of constituenciesmade up of a number of enumeration districts (ED). The one hundred and sixty-two (162)enumeration districts in the parish of St. Catherine provided the sampling frame. Theenumeration districts were listed and numbered sequentially and selection of clusters werearrived at by the use of a sampling interval. Forty (40) enumeration districts (clusters) were6 36. subsequently selected with the probability of selection being proportional to population size(Table 1.1). The enumeration districts in the parish of St. Catherine provided the sampling frame andthe sample size was determined with the help of the Statistical Institute of Jamaica (STATIN).The enumeration districts were listed and single-stage cluster sampling was used to select thesample. The enumeration districts were numbered sequentially and selection of clusters wasarrived at by calculating a sampling interval. From a randomly selected starting point, forty (40)enumeration districts (clusters) were subsequently selected with the probability of selectionbeing proportional to population size. The sample of 2000 was selected based on a proportion ofthe Census Data (Table 1.1). The parish of St. Catherine had approximately 233,052 males, (preliminary census data2001) of which 33,674 males were 55+ years. STATIN maintains maps with enumerationdistricts or census tracts which included the selected EDs and access routes and had references tothe selected site of a starting point household within each ED. The starting point was determinedby randomly selecting a household with a man 55 years and over from the list of persons in theED. With this information the interviewers travelled in a north-easterly or closest to north-easterly direction beginning with the first selected household, and conducted interviews in eachhousehold that had a male 55 years and older. Only one male per household was selected; and inhouseholds with more than one individual fitting the characteristic of the sample, a coin wastossed to determine the person who will be interviewed. (North-East was randomly selected bySTATIN as the direction of travel from the starting point). Where the selected household was found to be subsequently devoid of an older man (dueto out-migration or death), an adjacent household was canvassed. Where households had a man7 37. 55+ years as a resident and he was not at home a call-back form was left indicating a proposedtime that the interviewer would return which would not be longer than two days after the initialvisit. The sample population does not only speak to the parish of St. Catherine, it isgeneralizable to the island of Jamaica. The sampling frame was men fifty-five years and older inthe parish of St Catherine. The parish of St. Catherine was chosen as previous data suggested thatit has the mix of demographic characteristics (urban, rural and age-composition) which typifyJamaica surveys (Statistical Institute of Jamaica 2004; Wilks 2007; Jackson et al. 2003) For this paper descriptive status was employed to provide background information on thesample; and chi-square was used to examine non-metric variables. Level of significance waspvalue