Utilization of healthcare facilities and associated factors among rural elderly in Kanyakumari District, Tamil Nadu

Background: Rapidly progressing population ageing in India translates into more chronic diseases and healthcare expenditure among the elderly. But inadequate geriatric centred services in rural areas may hinder the health seeking behaviour among rural elderly. Hence, this study was done to assess utilization of healthcare facilities by elderly in rural Kanyakumari and to identify factors associated with it. Methods: Elderly people above 60 years of age were selected from rural Kanyakumari by multistage sampling. 250 subjects for the cross-sectional study were finalised after excluding debilitated elderly. Data was collected by a pretested questionnaire after getting informed consent. Results: Mean age of the study group was 70.12 years. 60% of elderly were currently married while 70.8% elderly were unemployed. More than half of the elderly population (57.6%) claimed to avoid healthcare facilities in times of need, citing cost of hospital care (27.6%) and perceived triviality of illness as the most common reasons. More than 75% elderly used out of pocket expenditure to meet healthcare expenses. Most of them (96%) did not have health insurance. Elderly people with education beyond primary school level and belonging to upper socioeconomic status had a statistically significant association with better healthcare utilization. Conclusion: Perception of disease as an age-related phenomenon has to be negated in order to improve healthcare utilization. Also, the importance of healthcare in improving functionality has to be conveyed to the community. Affordable and universal healthcare suited to geriatric needs have to be made available to the rural elderly population.


Introduction
India is experiencing demographic transition at such alarming rates that it will soon be home to the world's second-largest population of elderly people above 60 years [1]. While the increased life expectancy is indeed a public health success, this ageing of the population poses a challenge to the healthcare systems, questioning their ability to deal with felt needs of the elderly population. The ageing process in itself results in an increased susceptibility to diseases, co-morbidity, polypharmacy, loss of personal autonomy and high rates of disability [2]. In a developing country like India, this means the elderly are exposed to the double burden of communicable and non-communicable diseases [3]. Chronic diseases and disability often lead to increased use of healthcare facilities and this in turn leads to increased healthcare expenditure. Moreover, latest innovations in medical technology and expensive medicines exert a greater influence on healthcare costs than population ageing itself [2].
The exorbitant costs of healthcare services often result in impoverishment of the family rather than improvement in the health of the elderly [4]. Daily functionality also follows a strong socio-economic gradient in India, revealing that the wealthy elderly have access to better healthcare facilities than the impoverished elderly [5]. WHO has also reported that catastrophic health expenditure is more among households with older people, rural households and in households headed by women [6].

Original Research Article
Public Health Review: International Journal of Public health Research Available online at: www.medresearch.in 2| P a g e Elderly people living in rural areas face a higher disadvantage of fewer geriatric care centred health services [5]. The morbidity profile and perception of health problems among rural elderly are very different from the urban elderly population. Lower socioeconomic status (SES) and lower financial stability may also hinder health seeking behaviour in rural elderly, unlike their urban counterparts. Such constraints are often magnified in rural elderly and the elderly women who are more likely to be unemployed or living alone.
The new era of Sustainable Development Goals aims to bring about Universal health coverage, 'leaving no one behind'. The goals of 'No poverty', 'Good Health', 'Gender Equality', and 'Reduced Inequalities' are aimed at people of all ages, especially the rural elderly who are more vulnerable to these inequalities [1]. In order to address the felt needs of the elderly and to improve healthcare service delivery in rural areas, disaggregated information regarding the utilisation of available services by the elderly and the potential factors that may influence utilisation patterns need to be obtained. Hence, this study was undertaken to assess the utilization of healthcare facilities by the elderly in the rural areas of Kanyakumari and to identify factors that are associated with healthcare utilization.

Study design: Cross-sectional study
Place of study: Thiruvattar block of Kanyakumari district, Tamil Nadu Study duration: June 2015 to July 2016 Sample size calculation: Based on 65% elderly utilizing healthcare services as reported by Nipun Agarwal et al, p was taken as 65 with relative precision of 10% in the prevalence formula 4pq/L 2 to get a sample size of 215 [7]. This was then rounded to 250 study subjects.
Sampling methods: Multi-stage random sampling was done at three levels. By simple random sampling, Thiruvattar block was selected out of nine blocks in Kanyakumari district, then three PHCs under it were selected and finally, ten subcenters under these PHCs were selected. From the final ten subcenter populations, 25 persons were chosen from each cluster to get 250 subjects.
Inclusion criteria: Elderly people more than 60 years of age and who were permanent residents of Thiruvattar were included in the study Exclusion criteria: Debilitated or seriously ill elderly who could not give a coherent reply to questions Sample collection: Twenty-five subjects were chosen from each subcenter population. Those who were not willing for the study or were unavailable even after 2 visits were skipped and the next household with elderly in the family register of subcenter was included. Ethical clearance was obtained from Institutional Ethical Clearance Committee before starting the study. The subjects were interviewed with a pretested questionnaire by the principal investigator. Privacy was ensured and informed consent was obtained before conducting the interview.

Data analysis: SPSS version 16
Statistical methods: Descriptive statistics, Chi square test, Fisher's exact test and binomial logistic regression were used for data analysis with a predetermined statistical significance level of 5%.

Socio demographic profile:
The age distribution of the study group ranges from 60 to 90 years. Mean age of the study group was 70.12 years (95% CI 69.3, 70.9). About 130 out of the total 250 study population were women comprising 52%, while men formed 48% (120) of the population. Across the 250 elderly subjects, Hindus formed the majority at 56.8% (142), followed by Christians at 33.6% (84) and Muslims at 9.6% (24).
Among the 250 elderly people, 60% (150) of them were currently married (95% CI 54, 66%), while 36.8% (92) of them lost their spouses to death. One person was divorced and 1.2% (3) of them was separated from their spouses. Another 1.6% (4) of them were never married. About 68% (170) of the elderly have completed their education up to high school level (95% CI 62.2, 73.8%), while 14.4% (36) elderly were illiterate. 13.6% (34) of the elderly have a graduate degree. Of the 36 illiterate elderly, 66.7% were women. About one fourth of the elderly were engaged in skilled and unskilled occupations previously, through the main course of life or before retiring (25.6% and 25.2%, respectively). About 34% elderly were unemployed throughout life. However, currently around 70.8% elderly were unemployed. Among the elderly who were still working, majority were doing unskilled labour (15.6%). Among the female elderly population, 63.8% women were unemployed previously while 69.2% were currently unemployed.

Original Research Article
Public Health Review: International Journal of Public health Research Available online at: www.medresearch.in 3| P a g e More than half of the elderly people belonged to upper lower SES (54%) while 30.4% elderly belonged to lower middle class. Only a small proportion of elderly belonged to Upper middle class and lower class at 9.6% and 5.6% respectively. Most of the elderly people lived in extended families (44%). About a quarter of elderly each claimed pension, remittances from children and jobs as a source of income while 18% elderly had no income at all. The baseline characteristics of the study population are described in detail in Table 1. . The other reasons cited were that their children did not allow them to get admitted in hospitals, they do not believe in allopathic drugs, etc and account for 0.8% of responses. The reasons cited by the elderly are as listed below in Table 2.  Table 3, for not complying with medical treatment regimes. The most commonly cited reasons for avoiding medicines were that the elderly felt that their illness was not important enough (25.4%) and the high cost of medicines (21.8%). Among the 87 elderly persons with debt, personal expenses were cited as the most common reason for debt in 57.5% elderly. This was followed by medical expenses in almost one third of elderly (33.3%), and other reasons like loans taken for farming, businesses, etc in 9.2% of the elderly.
Factors associated with utilization of Healthcare Facilities (HCF): Being younger than 75 years of age, education above primary school, being married, being currently unemployed and belonging to an upper socioeconomic status were the factors found to be significantly associated with better utilization of Healthcare Facilities (HCF) among the elderly on bivariate analysis. Gender, occupation before retirement or family type did not have a statistically significant association with better healthcare utilization. The statistically significant factors are described in detail below in Table 4.

Original Research Article
Public Health Review: International Journal of Public health Research Available online at: www.medresearch.in 5| P a g e Binomial logistic regression models were built for proper utilization of HCF against the associated independent variables from bivariate analysis. The final regression model for factors with a statistically significant association with utilizing healthcare included education above primary school level (p=0.02) and upper socioeconomic status (p=0.01). Factors like marital status, current unemployment and age less than 75 years were removed from regression model as they were not statistically significant. The elderly belonging to upper SES were 2.2 times more likely to utilize healthcare than those belonging to lower SES (OR 2.2; 95% CI 1.2, 4). Elderly people educated beyond primary school level were two times more likely to utilize healthcare properly than elderly educated up to primary level alone (OR 2; 95% CI 1.1, 3.5).

Discussion
In the present study, 57.2% of elderly subjects belonged to the age group of 60-69 years, 34% were aged from 70 to 80 years and 8.8% were above 80 years of age. Goel  Extended family was the most common type of family in our study at 44% with nuclear families also predominant at 41.2%. However, Sharma et al. found 89.5% of elderly belonging to joint families [13]. This may be due to the differences in the definition used for joint and extended families in our study.
As per our study, more than half of the elderly population (58%) in rural areas of Kanyakumari district avoid utilization of healthcare facilities due to the high cost of healthcare (27.6%) and because they perceive their illness to be trivial (26.4%). Similar patterns of reasons for avoiding healthcare facilities were seen in Public Health Review: International Journal of Public health Research Available online at: www.medresearch.in 6| P a g e other studies though healthcare utilization was much better among their elderly. In a study by Sharma et al, 84% of the rural and urban elderly in Shimla were suffering from at least one medical problem and two thirds of the elderly (65.8%) were seeking treatment for their problems [13]. This projects a higher utilization of healthcare facilities among the Shimla elderly but area of residence may be a potential confounding factor.
Elderly living in urban areas of Shimla were significantly more likely to access health services than the rural elderly, because they lived closer to these services. Among the reasons cited by Shimla elderly for not seeking treatment, most common reason reported was that 'morbidities were part of old age', followed by perceived distance to the healthcare facilities. This is similar to the elderly in our study not utilizing healthcare because they feel their illness is not important.
Another study by Nipun et al in Bareilly, Uttar Pradesh also found a higher health seeking behaviour (65%) among elderly [7]. Among the reasons cited by the elderly in Bareilly for not seeking treatment, the most common was affordability, followed by long waiting time and long distances. In our study also, travel to healthcare facilities was cited as a reason for avoiding hospitals, though by fewer elderly. Health seeking behaviour of rural elderly in Mangalore was much better with 97.4% elderly seeking treatment for their health problems but even less aged people (72%) visiting a health facility for checkups for their chronic conditions [14].
Among the factors influencing utilization of healthcare among elderly, those with education above primary school level in our study were two times more likely to utilize healthcare facilities than elderly with education at or below primary level. A similar finding was reported by Arokiasamy et al in 2010 where they found elderly who were high school graduates were four times as likely in Maharashtra and twice as likely in Uttar Pradesh to seek treatment when compared to illiterate elderly [15].
They also found that the older elderly (70 years and older) were significantly less likely to seek treatment when compared to the 60-69 category, while Muslims were more likely to seek treatment when compared to Hindus. Also, elderly in SC/ST categories were 54% less likely to seek treatment for existing conditions in Maharashtra when compared to other castes. Bhat et al identified age as the sole demographic factor influencing healthcare utilization [14]. However we did not find any significant association of healthcare utilization with age, gender or religion in our study. Agarwal et al reported a higher percentage of elderly men and single elderly (either widowed or separated) visiting the hospital for treatment when compared to elderly women or married elderly respectively in Bareilly [7]. They also got similar findings of elderly with education of high school level and beyond and belonging to upper class SES having better healthcare utilization than those with primary school education or lower SES, as in our study.
In our study, 34.8% of elderly had some amount of indebtedness which is higher than the Ageing report's findings of 10% of elderly households in debt, of which more households were rural than urban [5]. The fact that medical expenses were the reason for indebtedness in more than one third of our rural elderly subjects is alarming and suggests that high cost of healthcare has catastrophic impacts on households with aged people. A reason for such catastrophic impacts may be that more than three fourths of our elderly subjects used out of pocket expenses to meet medical expenditure. This is similar to findings reported by Duggal in 2007 that 83% of healthcare expenses in India are private out-of-pocket (OOP) expenditures [16]. Dey et al reviewed the plight of elderly and concluded that in case of healthcare expenditure, those above 65 years spent on average about 1.5 times as much as those in the 60-64 year age category [17].
This shows the financial strain placed on households with elderly people increases with increasing age. Pal et al also noted that the probability of catastrophic OOP expenses in households with elderly is much higher when compared to households without elderly members [18]. In the context of current trends of increasing dependence on investigations, unregulated cost of medicines and profit based healthcare provision, an exorbitant increase in healthcare expenditure is to be expected. This may have the disastrous effect of putting affordable healthcare out of reach of elderly population. Improved coverage of health insurance schemes and better geriatric or palliative care facilities in rural areas are thus the need of the hour in improving cover and reach of healthcare facilities. Involving community members or local self help groups in providing assistance to households with elderly people will reduce the burden on the family and improve healthcare utilization.
Organising mobile health camps, providing home delivery of regular medications and subsidising healthcare for the elderly will also improve medical compliance and treatment outcome in elderly with chronic diseases. Special attention has to be paid to those elderly who belong to lower SES and those with only primary school education as they have been identified as being more likely to avoid healthcare utilization.

Conclusion
Healthy ageing is the emerging challenge faced by health system and policy makers in India. Seeking healthcare services earlier will help to reduce morbidity and mortality among the elderly. The importance of healthcare in improving functionality has to be conveyed to the older persons and their family members who are the primary caregivers. Affordable and universal healthcare suited to geriatric needs has to be made available to the rural elderly population. Health insurance coverage among the elderly was very poor. Financial protection through better insurance coverage and provision of good quality public health facilities will go a long way in improving healthcare utilization by the rural elderly.

Study Implications:
This study has identified that more than half the rural elderly population avoid utilizing healthcare facilities in times of need claiming high cost and perception that illness is part of old age. Perception of disease as an age-related phenomenon has to be negated. Factors like lack of insurance coverage, low educational status and low income have been identified as factors having an impact on healthcare utilization. This evidence will guide policy makers in drafting public health reforms that will ensure equitable and affordable healthcare to the rural elderly population of India.
Funding: Nil, Conflict of Interest: None Permission from IRB: Yes Authors Contribution: PRP was the principal investigator, wrote the manuscript and provided the data for the study while PJD helped with data tabulation and final proofreading.