Ageing in place: Implications of morbidity patterns among older persons – findings from a cross-sectional study in a developing country (Jamaica)

ResearchAgeing in place: Implications of morbidity patterns among olderpersons – findings from a cross-sectional study in a developingcountry (Jamaica)ajag_565 1..6

Kenneth James, Desmalee Holder-Nevins, Chloe Morris,Denise Eldemire-Shearer, Jeneva Powell and Hazel LawsMona Ageing and Wellness Centre, Department of CommunityHealth and Psychiatry, University of the West Indies, Mona,Kingston, Jamaica

Aim: This paper describes morbidity patterns among olderpeople, relevant health-care resources in a localisedpopulation in a developing country (Jamaica) andimplications for ‘ageing in place’ in the community.Methods: Local morbidity patterns among older peoplewere determined in Jamaica from a 2007 cross-sectionalstudy involving record searches at major hospitals andclinics. Age-specific morbidity distributions were compiled.Data on health-care staff complement were also collected.Results: Non-communicable diseases predominate in olderpeople in Jamaica; 50% of diagnoses related tocardiovascular disorders and diabetes. Staff-to-populationratios were low compared with other international data.Conclusion: A high prevalence of non-communicabledisease coupled with inadequate staffing threatens thelikelihood of ‘ageing in place’ in the Jamaican community.Secondary prevention efforts and social support serviceswhich enhance ageing in place are needed.

Key words: ageing in place, developing country, healthcare, morbidity.

Introduction‘Ageing in place’ implies that persons remain in their localenvironments with the ability to live in their own home for aslong, confidently and comfortably, as possible. It inherentlyincludes not having to move from one’s current residence inorder to secure necessary support services in response tochanging needs [1]. The United Nations advocates the devel-opment of initiatives for older people: independence, partici-pation, care, self-fulfilment and dignity [2]. The likelihoodthat persons will ‘age in place’ depends on the extentto which these initiatives are realised and promote health [3],and is inextricably linked to health status and healthcare [4].

Research on active ageing and the social determinants ofhealth has drawn additional attention to the many dimen-

sions of health [5–7]. The ability to ‘age in place’ is dependenton services and programmes being available, which meetphysical, social, economic and psychological needs. Givenprojections [8] which indicate substantial increase in disabil-ity owing to age-related chronic diseases, ‘ageing in place’issues assume even greater importance.

Jamaica has not been immune to the trend of rapid popula-tion ageing in many developing countries [9,10]. Health-caresystems to foster ageing in place must meet the emergingchallenges inherent in caring for an increasingly ageing popu-lation. Ageing of the Jamaican population has simulta-neously been accompanied by an epidemiological transition,with mortality/morbidity now predominantly due to chronicnon-communicable diseases [11].

While ageing is not a disease itself, age-associated diseaseis increasingly evident. Non-communicable disease andpathological impairment manifest as morbidity, disabilityand loss of function among older persons. These diseasesdiminish the capacity to continue to carry out activitiesof daily living (ADLs) and instrumental activities ofdaily living (IADLs). As functional capacity declines, sodoes the ability to maintain independence and to ‘age inplace’. Consequently, the need for support services tends toincrease.

Evidence from both the developed and developing worldsuggests that although the majority of older people enjoyreasonably good health, perceive their health as good, or leadpurposeful lives [12–14], there still exist many challengesrelated to morbidity prevention and control [15]. Addition-ally, the tendency of older people to overestimate their levelof well-being has been recognised [16], making early inter-ventions for morbidity control less likely, and ‘ageing inplace’ more difficult to achieve. Some authors [17] haveargued that chronic diseases occur at earlier ages in develop-ing countries and note that overall compression of morbidityis yet to occur in the developing world. Compared withdeveloped countries, older persons arrive at old age withfewer reserves [18].

The aggregate local pattern of disease dictates service needs,and ultimately the capacity to age in place. If ageing in placeis to occur, then the local pattern of diseases must be exam-ined to identify the problems and gaps which need to beaddressed.

Correspondence to: Dr Kenneth James, Department of CommunityHealth and Psychiatry, University of The West Indies.Email: [email protected]

DOI: 10.1111/j.1741-6612.2011.00565.x

1Australasian Journal on Ageing, Vol •• No •• •• 2011, ••–••© 2011 The AuthorsAustralasian Journal on Ageing © 2011 ACOTA

Aim and objectivesThe study sought to document local patterns of morbidityamong older persons in a defined region of Jamaica and theimplications of these patterns for ageing in place. Theprimary objectives were: (i) to describe local morbidity pat-terns among older persons utilising public health-care facili-ties in the parish of Clarendon, Jamaica; (ii) to describemorbidity patterns by age, sex and ‘rural/urban’ residence;and (iii) to assess the adequacy of human resources (health-care workers) given the prevailing morbidity patterns amongolder people.

MethodsData were extracted from health and statistical records ofhospital and health centres in the parish of Clarendon duringa community health profile and health impact assessmentstudy. A parish is a defined geographic area administered bya municipal authority. With an estimated population of237 024 persons [19], Clarendon is one of the most populousparishes in the island (8.8% of the national population). Therecords reviewed were those of all attendees to above-mentioned facilities for two randomly chosen months, April2006 and August 2006. The year 2006 was the most recentyear with complete data available at the time of the study.The records examined were distributed proportionally by thevolume of patients seen, ensuring that the sample was repre-sentative of each facility’s usage.

The records used were from three health centres and twohospitals chosen because they are major health facilities uti-lised by parish residents. Relevant data were manuallyobtained from these paper records as well as from line itemlistings in ‘visit and diagnosis’ registers. Monthly ClinicSummary Reports from the health centres and HospitalMonthly Summary Reports augmented the records. Data oneach patient’s address, diagnosis, age and sex were collected.There was no direct linkage to names or hospital/clinic recordnumbers, ensuring patient anonymity. Recognising that resi-dents may also use private practitioners, five randomlyselected private practitioners were visited and, as available,records from the patients seen in the two randomly chosenmonths were examined.

Each diagnosis recorded was initially coded according to theInternational Classification of Diseases (ICD-10) system.Subsequently, research team physicians schematically organ-ised these into mutually exclusive categories, namely, trauma,cancer, cardiovascular, diabetes, gastrointestinal, genitou-rinary, infection, musculoskeletal disorders, respiratoryand other. The data were entered into a spss database andanalysed.

Health staff complements for the parish were derived fromsources including parish administrative personnel and com-pared with standard staff to population ratios. Basic sociode-mographic information was collected for the parish.Descriptive statistics were used to summarise the data; infer-

ential statistics (c2 tests and independent t-tests) to examinerelationships between categorical variables and differences inmeans, respectively. The University of the West Indies (UWIMona) Medical Faculty Ethics Committee approved thestudy.

Results

Sociodemographic characteristicsFor 3019 older patients seen at the facilities surveyed, 5420diagnoses were recorded; a mean of 1.8 diagnoses perolder person seen. Age ranged from 60 years to 102years (mean age of 72.5 years, SD = 8.2). Persons aged60–74 years accounted for the majority (60.6%) of themorbidity recorded. Less than 10% was attributable topersons 85+ years (see Table 1): two-thirds of older peopleoccupied their own homes with 41.3% residing in urbanareas.

Of the 5420 diagnoses at visits for the period under study,57.1% were for older women and 42.9% for older men.There was no statistically significant difference in the meannumber of visits to health facilities made by men (2.526) andwomen (2.527) (P = 0.91).

There was a statistically significant association between ageand sex (Table 1) (c2 = 30.6, d.f. = 2, P < 0.001) with greaterproportions of the morbid conditions at older ages seenamong women.

The majority of the morbid conditions among older personsat the facilities surveyed were for persons from rural areas,58.5% versus 41.2% from urban areas. There was no statis-tically significant difference in the distribution of diagnosesfor rural and urban persons by age category (P = 0.31). Fordiagnoses for persons from rural areas, 60.9%, 30.2% and8.9% of morbid conditions diagnosed were for the agegroups 60–74 years, 75–84 years and 85+ years, respectively.The corresponding urban figures were 59.9%, 31.9% and8.2% (P = 0.83).

A greater proportion of diagnoses recorded for women(61.5%) were for persons from rural areas compared withthat for men (54.9%; Table 1) (c2 = 24.1, d.f. = 2, P < 0.001).

Table 1: Distribution of total recorded diagnoses(morbidity) by sex, age and urban/rural residence

Male, % (n) Female, % (n) Total, % (n)

Age group60–64 56.4 (1310) 63.8 (1974) 60.6 (3284)75–84 34.0 (789) 28.5 (882) 30.8 (1671)85+ 9.7 (225) 7.8 (240) 8.6 (465)Total 100 (2324) 100 (3096) 100 (5420)

ResidenceUrban 45.1 (1045) 38.5 (1186) 41.3 (2231)Rural 54.9 (1272) 61.5 (1898) 58.7 (3170)Total 100 (2317) 100 (3084) 100 (5401)

J a m e s K , H o l d e r - N e v i n s D , M o r r i s C e t a l .

2 Australasian Journal on Ageing, Vol •• No •• •• 2011, ••–••© 2011 The Authors

Australasian Journal on Ageing © 2011 ACOTA

Disease conditionsThe most prevalent morbid conditions were related to car-diovascular disease and diabetes. These two conditions aloneaccounted for more than 50% of the conditions seen in thehealth services. Cardiovascular disease was responsible for35.7% of such morbid conditions followed by diabetes(14.2%). Genitourinary disorders (13.9%) and musculoskel-etal conditions (10.2%) were relatively common diagnoses.Respiratory disorders and gastrointestinal conditionsaccounted for approximately 5% and 6%, respectively,of the morbidity recorded. In the study, 38% of older personshad two chronic diseases while 8% had three or more(Figure 1).

With regard to cardiovascular conditions (n = 1934), hyper-tension (79.8%), congestive heart failure (5%), ischaemicheart disease (4.9%) and cerebrovascular accidents/strokes(4.6%) largely comprised this category. Arthritis accountedfor 88.9% (490) of the 551 musculoskeletal disordersrecorded. Disaggregation of morbidity pattern by sex

(Table 2) revealed statistically significant differences in thedistribution of disease conditions.

Women were preponderantly diagnosed with cardiovasculardisease, diabetes and musculoskeletal disorders. On the otherhand, significantly higher proportions of the diagnoses con-cerning genitourinary disorders/dysfunction, trauma andcancer were related to male sex. Of the 201 instances oftrauma-related diagnoses, 17.9% (36) resulted from vio-lence. For the latter subgroup of diagnoses involving vio-lence, 77% (28) of those seeking care were men. Aftercontrolling for sex, no statistically significant difference wasfound in the morbidity pattern (broad disease categoryprofile) of urban and rural dwellers seen at the health facili-ties studied (P > 0.05).

Human resources for health and parish demographicsThe parish falls within the purview of the Southern HealthRegional Authority, one of the four decentralised healthauthorities in the island. The parish health staff compositionis shown in Table 3.

Pertaining to parish demographics, the overall sex distribu-tion of male to female was 50.5% (119 840) to 49.5%(117 481); a 1.02:1 ratio. The older people (age 60 years andolder) comprise 10.8% (25 687) of the population; the sexratio for that group being 1:1.07 (48.3% male, 51.7%female) [21,22].

Figure 1: Percentage distribution of morbidity seen amongpersons 60 years and older in study health-care facilitiesduring the months of April and August 2006.

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Cerebrovascular accidents included in the cardiovascular group. Infections do not includerespiratory infections which are classified under respiratory disorders.

Table 2: Diagnoses (morbidity categories) disaggregatedby sex (n = 5420)

Disease category Male, % (n) Female, % (n)

Cardiovascular* 30.5 (590) 69.5 (1344)Diabetes* 27.1 (208) 72.9 (559)Genitourinary* 92.2 (693) 7.8 (59)Musculoskeletal* 26.1 (144) 73.9 (407)Respiratory 53.8 (182) 46.2 (156)Gastrointestinal* 40.5 (106) 59.5 (156)Trauma* 63.2 (127) 36.8 (74)Infections 35.9 (46) 64.1 (82)Cancer* 74.0 (71) 26.0 (25)Other 40.2 (157) 59.8 (234)

*Indicates P < 0.001; binomial test used (test proportion = 0.429 given that 42.9% of alldisease conditions are for men).

Table 3: Public sector staff complement for selected categories of health workers, 2009, Clarendon, Jamaica

Staff category No. Staff-to-population ratio (Clarendon§) International ratios for comparison

Doctors 58 1:4086 1:910†Nurses 172 1:1378 1:769†Environmental health officers 22 1:10 773 1:5425‡Community health aides 58 1:4086 —Social workers 1 1:237 024 1:510‡Nutritionists 1 1:237 024 1:5330‡Physiotherapists 1 1:237 024 1:1756‡Pharmacists 1 1:237 024 1:1250‡Pharmacy technicians 5 1:47 405 1:1067‡

†Pan-American Health Organization recommended ratios [19]. ‡Based on data from the United States Department of Labor [20]. §Source data: Clarendon Health Department, Annual StaffMeeting minutes, 2009.

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DiscussionChronic non-communicable diseases, which often manifestin late middle-age and persist throughout the rest of thelifespan, were prevalent. Increasingly, greater morbidity wasreported at higher ages for men. This may reflect a combina-tion of two factors. First, men tend to not to seek health carein the early stages of disease and present later, an assertionsupported by the fact that the mean age associated with thedisease conditions documented for men was higher than thatof women. This has been found in another study of oldermen in Jamaica [23]. A second factor, delayed morbidity/disability, may be at work. Older men tend to have moresudden and catastrophic declines in health at later ages ratherthan slow progression of disease or disabilities more com-monly observed among females. Evert et al. [24] noted thatwomen were more likely to develop chronic disease beforeage 80 years than men, but appeared to better cope and livewith age-associated disease. In contrast, men were moreprone to die from potentially lethal illnesses with greatercompression of morbidity towards the end of their lives. Athird observation is higher rates of obesity and differentialpatterns of work by sex. Less physical demanding work maycontribute to higher rates of, and earlier development of,chronic non-communicable disease among women, partiallyexplaining the disease pattern by sex and age group [25].

There were no major differences in mortality pattern byrural vis-à-vis urban residence. The basic amenities forliving are present in most rural areas. In Jamaica, access toessential primary health has been a hallmark of its health-care system. Nutritional patterns with consumption of highcalorie foods are common in both urban and rural areas,and with improvement in motor transportation, the differ-ences in walking habits between urban and rural folk havebeen eroded. Cardiovascular disease, diabetes and the mus-culoskeletal disorders (arthritis) cannot be ignored. Theseconditions account for the bulk of morbidity in olderpersons.

What are the implications for ageing in place? First, a con-certed thrust to advance secondary prevention aimed atcontrolling disease and preserving function is needed. Cur-rently, this is inadequate [15]. The heart failure from hyper-tensive heart disease or ischemic heart disease or strokesrelated both to diabetes and hypertension will definitelycurtail functional capacity and may prevent older personsfrom ageing in place, especially if caregivers are not resi-dent in the home. Increasing rural–urban and internationalmigration of young adults reduces the physical availabilityof family caregivers. Declines in total fertility rates anddecreasing family size will likely exacerbate non-availabilityof family caregivers.

The older person may have to move to a relative’s home or toan institution if such events ensue. The result is prematuredisruption of the desired ageing in place process with all itsattendant social consequences (disruption of community ties

and social networks, unhappiness, depression or isolation).Where institutional care is neither widely available nor likelyto be so available given the economic climate in developingcountries such as Jamaica, the imperative to promote ageingin place is even greater.

The findings of the study argue for sex-specific interven-tions. The preponderance of women diagnosed with diabe-tes dictates the adoption of intervention strategies, whichbegin much earlier in life, and added attention paid toweight management and energy balance throughout thereproductive years of life. This study revealed (similar tothat of Morris [23]) the importance of genitourinary disor-ders in men, which may reflect urinary obstruction andprostate gland enlargement. Mobile clinical teams to carryout catheter changes may be critical if men with these con-ditions disease are to ‘age in place’. Addressing leakagefrom catheters can preserve social links and reduce isola-tion and withdrawal, allowing them to ‘age in place’ withdignity.

Increasing frailty from chronic diseases may necessitate‘bringing health to the home’ rather than waiting for theolder person to be brought to the clinic. An initiative could bedeveloped using trained community heath aides providingbasic health care, and oversight and support provided bynurse practitioners and physicians. Alternatively, a ‘carpool’for older persons could be used for transport to health facili-ties. Novel ways of financing such a service such as commu-nity funding supported by subsidised fees will need to beexamined. ‘Ageing in place’ will be promoted if non-healthservices such as home help and help with daily business (suchas paying bills) are developed. For example, an older personwith significant unilateral weakness or difficulty with mobil-ity from a mild stroke can certainly benefit from home helpwith household chores or shopping or retrieval of mails fromthe post office. Other healthy older people as well as fraternaland benevolent organisations, which often have significantnumbers of older persons, may be marshalled to provide suchservices.

What target population does the cadre of parish staff serve?The 2001 parish population estimate is 237 024. The staff-to-population ratios for allied health professionals are inad-equately low by comparison to international data. There areno allied health professionals that are exclusively dedicatedto the care of older people. Older people compete withother sectors of the population for the services of the fewallied health professionals. The dearth of physiotherapists/occupational therapists, nutritionists and social workersmust to be addressed if ageing in place is to be more than justrhetoric. The benefits for investing in such services exist[26,27]. ‘Gerontology social workers’ can be trained to advo-cate for, and coordinate services for older people with variousagencies. Ageing in place will be promoted, when olderpeople are able to navigate the health-care system and capit-alise on available benefits.




Modification of the home environment can facilitate ageingin place. Such age-friendly modifications include rails, orremoval of clutter and obstacles that may result in a fall.Appropriate use of non-glare lights, non-slip tiles and lowerlevel shelves are simple interventions that can allow a personto better age in place. Assistive devices, such as glasses,walkers or telephones with larger than standard lettering/numerals, can help maintain the ability to perform ADLs andIADLs.

Almost a fifth of visits for trauma among older people wereassociated with violence. Crime, violence and unsafe environ-ments are inimical to ageing in place. In countries where theseare problematic, such as Jamaica, ‘ageing in place plans’should incorporate security concerns.

The study had various strengths and limitations. The largesample of records had high statistical power to detect anysignificant differences or relationships among the variablesexamined. Data were obtained from the major local publicsector care facilities, which older people are likely to usewhen accessing health care [22] and also from the diversetypes of health centres offering physician-provided healthservices. Additionally, the data were based upon recordedclinical diagnosis rather than on patient recall, improving thelikelihood of data accuracy. The use of standard ICD codesenhanced consistency in disease classification and the selec-tion of the same months across the different facilities mini-mised the possibility that differences might be attributable toseasonal variation. The age distribution of the sample wassimilar to that the most recent (2001) census for the parish[21], suggesting it was representative of the wider parishpopulation. The study was based largely on clinic and hospi-tal attendee records and one may raise the issue of generalis-ability to the wider population. In Clarendon, Jamaica, olderpeople have access to and utilise the hospital and clinicsystem which was studied. Morbidity patterns seen in privatesector system were similar.

The method used also points to an approach for use indeveloping countries through the analysis of data generatedfrom an ongoing survey rather than a more expensive sepa-rate de novo survey. It was thus possible to identify localdisease priorities in this Jamaican sample of older people andinform policy-makers of ‘the need’ associated with the ageingof the population in a cost-efficient manner.

ConclusionThere is a high prevalence of non-communicable disease,which, coupled with low staff-to-population ratios, threatensthe likelihood of ‘ageing in place’ in this Jamaican parish.Efforts aimed at the development of strategies which enhanceageing in place are needed. Local planners in developingcountries need to be cognizant of local morbidity trends, andthe mix of services required. These characteristics can affectthe likelihood of ageing in place.

Key Points• Non-communicable diseases are major causes of

morbidity among older persons.

• These influence and threaten the ability to ‘age inplace’.

• Adequate health staff complements as well associal and support services for older personsare required to better enhance the likelihood of‘ageing in place’.

• Prevention is important for enabling ‘ageing inplace’.

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Ageing in place: Implications of morbidity patterns among older persons – findings from a cross-sectional study in a developing country (Jamaica)