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].

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

obtained before conducting the interview.

Data entry: Microsoft Office Excel 2007.

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.

Table-1: Background characteristics of study participants.

need. That they would utilise healthcare facilities in case of need. The most commonly cited reasons for not utilising health facilities are the cost of hospital care (27.6%) and that the elderly feel their illness is not important enough (26.4%). 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-2: Reasons affecting utilization of Healthcare Facilities (HCF) among elderly

*Multiple responses per subject

About 42% of the elderly population claimed they are on regular medication always (95% CI 35.9, 48.1%), while 38.4% elderly said they take regular medication ‘sometimes’ as opposed to 17.2% who ‘rarely’ take and 2.4% who ‘never’ take any regular medicines. Only less than half of the elderly (46.8%) claimed compliance with regular medications.

The remaining 53.2% elderly (95% CI 47.1, 59.3%) cited multiple reasons, as listed below in 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%).

Table-3: Reasons cited by elderly for not complying with medical treatment

* Multiple responses per subject

The most common way of meeting the healthcare expenses among the elderly was through Out of Pocket expenditure (OOP) in the case of 75.6% of the elderly (95% CI 70.3, 80.9%).

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).

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 et al. in Meerut found 47.2%, 37.8% and 15% of elderly in young elderly, old elderly and the oldest elderly groups, respectively [8].

Lena et al. had a higher proportion of elderly in the 60-69 age group (72.3%) with a very small fraction of oldest elderly (2.8%) in their study in Udupi [9].

Out of the 250 elderly subjects studied, 70.8% of the elderly were currently unemployed, which is higher than NSSO findings of 64% and other Government of India figures of 52.9% unemployment among rural elderly [10,11]. About 29.2% of the elderly in our study were working currently, of whom 54.1% were women and 45.9% were men.

The proportion of elderly who were unemployed for most part of their life in our study was 34% while 66% elderly had worked in some sort of employment for most part of their life. The ageing report found a similar percentage of 64.4% elderly who had ever worked at all in their life [5].

Regarding income source, 24.8% of the elderly in our study earned income through work while 28% received a pension and 18% had no income at all. Vedantam et al reported similar findings of 22% earning elderly and 29% receiving a pension in Kaniyambadi block, Tamil Nadu [12].

But in that study 49% subjects claimed to have no income. Remittances from children were not taken into account in that study, whereas in our study, 26.8% of elderly had claimed remittances as a source of income thus accounting for the discrepancy in numbers.

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.

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,

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.

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.

PRP was the principal investigator, wrote the manuscript and provided the data for the study while PJD helped with data tabulation and final proofreading.