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 Table of Contents  
Year : 2022  |  Volume : 12  |  Issue : 6  |  Page : 249-256

Health care utilization among geriatric patients with respiratory diseases – An Indian perspective

1 Department of Respiratory Medicine, SMSR, Sharda University, Greater Noida, India
2 Scientist E, ICMR-NICPR, Noida, Uttar Pradesh, India
3 Department of Surgery, GIMS, Greater Noida, Uttar Pradesh, India

Date of Submission05-Apr-2022
Date of Decision01-Nov-2022
Date of Acceptance14-Nov-2022
Date of Web Publication29-Dec-2022

Correspondence Address:
Dr. Sonisha Gupta
3rd E, House No. 18, Nehru Nagar, Ghaziabad - 201 001, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/cmrp.cmrp_36_22

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Background: The elderly population is continuously growing and respiratory diseases account for 20% of chronic diseases among ageing people; these diseases are often treated imprecisely. Thus, the health-care system should adapt to the growing health needs of the elderly population.
Aims: To study health care utilisation by geriatric patients with respiratory diseases.
Material and Methods: A cross-sectional study of the elderly aged 60 years and over was conducted in the urban and rural areas of the National Capital Region and the Ghaziabad district of Uttar Pradesh. The first part of the study included socio-demographic characteristics and self-reported co-morbidities. In this first part, suspected respiratory cases were screened out, and a questionnaire regarding health-care utilisation was administered. The effect of socio-demographic factors on health-care utilisation was analysed.
Results: In urban areas, 282/1522 (18.5%) and in rural areas, 298/1503 (19.8%) were found to suffer from respiratory illnesses. Health-care utilisation among elderly patients was significantly higher in urban areas compared to rural areas. In both areas, a large number of elderly people (70.5% rural and 61.7% urban) were insufficiently utilising health-care services. The socio-economic status (P = 0.034) and the source of income (P = 0.002) of urban residents were found to be significant factors. Among rural residents, health security (P = 0.05) and source of income (P = 0.002) were found to be statistically significant. Among the combined population (580), socio-economic status (P = 0.020) and source of income (P = 0.002) were found to be statistically significant.
Conclusion: Health-care utilisation was better in urban residents than in rural elderly. However, majority of the elderly were utilising health-care services insufficiently in both areas. Socio-economic status and source of income had a significant effect on health-care utilisation.

Keywords: Elderly, geriatric, health-care utilisation, physical disability, respiratory diseases, socio-demographic factors

How to cite this article:
Gupta S, Asthana S, Gupta AK. Health care utilization among geriatric patients with respiratory diseases – An Indian perspective. Curr Med Res Pract 2022;12:249-56

How to cite this URL:
Gupta S, Asthana S, Gupta AK. Health care utilization among geriatric patients with respiratory diseases – An Indian perspective. Curr Med Res Pract [serial online] 2022 [cited 2023 Feb 5];12:249-56. Available from: http://www.cmrpjournal.org/text.asp?2022/12/6/249/366169

  Introduction Top

Ageing is an irreversible, inevitable biological process. All organ systems are susceptible to infections due to age-related functional changes. In addition, the immune system is weakened. In all parts of the world, the number of the elderly is increasing steadily. According to the World Health Statistics 2011, the proportion of the elderly in India will increase up to 12% by 2026 (173 million) and approximately 20% by 2050 (316 million).[1] The elderly are affected by a variety of physical and mental health problems as well as social problems. In our country, the lack of a proper universal social security system makes the issue of old age much more challenging. The elderly population in India is heterogeneous. Morbidity rates vary based on factors such as gender, location and socio-economic status.

As the elderly population continues to grow, the health-care system must adapt to meet their growing health needs. The concept of Active and Healthy ageing needs to be promoted among the elderly, which includes preventive, promotive, curative and rehabilitative aspects of health.[2] In India, there is limited research in the field of gerontology and geriatrics. Most studies have focused on the morbidity profile of the elderly.[3],[4] A small number of studies have been conducted to understand the special needs of the elderly, obstacles to the utilisation of the available health-care facilities, and difficulties and shortcomings of the current health-care system from the perspective of the end user. Among the elderly, respiratory diseases are a leading cause of morbidity and mortality. Increasing urbanisation, industrialisation, and air pollution may further increase their prevalence. In the elderly, respiratory diseases represent a significant portion (up to 20%) of the chronic disease burden, and are often treated improperly. Literature from India on respiratory disease utilisation by the elderly is limited.[5]

A proper understanding of the problems faced by the elderly in using health-care services, their expectations, and their attitudes is necessary. By doing so, policymakers and health-care planners will be able to formulate policies and plan health-care facilities that are tailored to the needs of the elderly in India while making the best use of the available resources.

  Methodology Top

We conducted a descriptive survey of geriatrics aged 60 and above in the NCR and Ghaziabad district of Uttar Pradesh. We selected urban colonies and rural villages based on convenience, which were conglomerated in a closed area. From each urban and rural selected units, the elderly in every alternate household was interviewed till an adequate sample size was achieved. The study was conducted from January 2015 to January 2018.

Population setting

Urban area-Nandgram is a locality in Ghaziabad city with more than 10,000 houses with seven blocks and free households, inhabited mainly by lower middle-class families. Rural area – six selected villages were – Chipiyana Buzurg and Shah beri from Greater Noida, Chhaprauala and Shahpur Bamheta from one side, while Iliachipur and Khanpur from the other side of Ghaziabad.

A sample of 51 elderly from Shah Beri village, 343 from Chipyana, 405 from Chhapraula, 136 from Shahpur Bamheta, 495 Ilaichipur and 73 were collected from Khanpur village. The total rural sample was 1503. Total urban sample of 1522 was collected from Nandgram. Total combined sample was 3025.

Sample size

For qualitative data, the formula used to derive sample size is: N = 4pq/L2 (p – prevalence). The available literature on the prevalence of respiratory illness among the elderly was assumed as 20% with an allowable error of 3%. For a 95% confidence level, by simple random sampling, a sample size of 682 was required. By adding 10% attrition, the sample size was fixed at 750. As the sampling procedure was systematic, we doubled the size and fixed it at 1500 each in rural and urban groups. It was predicted to give an average of 300 respiratory cases of the elderly in each group.

Tools and methodology

Door to door survey was conducted using pre-designed, pre-tested questionnaire having two parts. The first part included socio-demographic characteristics, self-reported comorbidities and physical disabilities. Medical records of patients were seen. Three health-care workers were trained for this purpose. After analysing screening pro forma, elderly with suspected respiratory disease were selected. In the second stage, screening pro formas of suspected cases were verified. General and respiratory system examination was carried out. These patients with respiratory diseases were asked about the frequency of their health-care utilisation. Subjective analysis about health-care utilisation was done after history taking and questioning about the frequency of utilisation of health services for their illnesses. Finally, health-care utilisation was classified into Yes (regular), No (none), Inadequate (irregular and occasionally). Those who were available for the first part of the survey but not for the second part regarding confirmation of respiratory disease by history and physical examination were considered 'dropouts'.

From the Urban population, 282 respiratory cases of the elderly were collected. From the rural population, 298 respiratory cases of the elderly were collected (Total = 580).

Statistical analysis

Data were entered using Microsoft Excel 2010, and statistical analysis was performed using IBM SPSS v 20.0.0 and 23.0.0 both (statistical package of social science, New York). Categorical variables were analysed using proportions and percentages. In the first stage, a descriptive analysis was performed for all records (n = 3025), both urban and rural separately. Association between categorical variables was studied by two-way cross-tabulations and the significance was established by Chi-square test. The level of statistical significance was assessed at (P < 0.05) 5% probability.

The odd ratio at 95% confidence intervals was used for the strength of association and interpretation of the bivariate analysis. If differences found to be signficant on univarate analysis, further analysis of the data was conducted by regression analysis. Multiple regression analysis was used to analyse various factors for assessing their independent contribution after adjusting for various factors in the model.

  Results Top

Out of 1522 elderly screened in urban areas, 367 (24.1%) were suspected of respiratory illness. Out of these, 282 (18.5%) were established as respiratory cases. In rural areas, 1503 elderly were screened. Of these, 429 were suspected of respiratory illness. Of these, 298 (19.8%) were found to be suffering actually from respiratory illness [Table 1].
Table 1: Distribution of cases (N=3025)

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Health-care utilisation was significantly better in the elderly residing in urban areas than those residing in rural areas. A large number of elderly in both areas (70.5% rural and 61.7% urban) were using health-care services inadequately [Table 2].
Table 2: Health-care utilisation for respiratory disease

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In urban areas, 66 (39.1%) out of 169 elderly males were utilising health services regularly compared to only 25 (22.1%) out of 113 females. In contrast, irregular utilisers were much more among females (72.6%–82/113) than males (54.4%–92/169) [Table 3].
Table 3: Socio-demographic versus health-care utilisation

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In the urban population socio-economic status (P = 0.034) and source of income (P = 0.002) were found to be significant (P < 0.05) factors. In the rural population, health security (P = 0.055), source of income (P = 0.002) were found to be statistically (P < 0.05) after analysis of socio-demographic variables. In the combined population, socio-economic status (P = 0.020), source of income (P = 0.002) were found to be statistically significant (P < 0.05) after analysis of socio-demographic group.

  Discussion Top

Health-care utilisation refers to how individuals use available health-care facilities, either public or private, to maintain, achieve, or regain health and prevent illness. In the present study, 21.6% (125) of the total 580 elderly with respiratory disease utilised health-care facilities regularly, while 66.2% (384) accessed them inadequately (irregularly or going to a quack or taking over-the-counter drugs from a medical store. Twelve percent (71) were not utilising health services at all [Table 2]. In our study, we distinguished between regular and inadequate health-care use. The other studies have used the term utilisation if the respondent has ever visited a health-care facility. We did not observe any difference between regular and irregular utilisation. To prevent long-term complications and maintain a good functional state, chronic respiratory illnesses should be treated properly and regularly. Taking over-the-counter medications from the pharmacy, visiting a quack, or visiting a qualified medical practitioner occasionally is not sufficient. A study in Kathmandu found that 68.0% (136/200) of elderly people in the study area visited a medical professional in the past year.[6] According to a study conducted in Scandinavia, this figure was 90%.[7] Goswami et al. found that 83.2% (675/811) of rural Faridabad's elderly sought treatment for their illness.[8] The high utilisation rate in these studies can be attributed to the inclusion of all those who used health services even once, regardless of their regularity and quality. In order to address the problem of non-utilisation, it is important to include irregular utilisers since they represent populations who are aware of health services and seek to utilise them but are discouraged by various factors. Utilisation can only be improved by understanding these problems and addressing them.

We found that elderly males utilised health-care services more frequently than elderly females. In urban elderly, this gender difference in behaviour was particularly significant (P = 0.008). The difference in urban areas may be due to the different statuses of men and women in our society. This is because the health of elderly women is neglected both by their families and by the women themselves. Due to other factors, this difference is not reflected in rural areas (P = 0.916) since regular utilisation as such was very poor among both sexes. There is a wide variation in the effect of gender on health-care utilisation in the literature. The study from Kathmandu found that females (71.4% - 80/112) made more visits to medical personnel than males (63.6%–56/88).[6] According to studies conducted in Canada, Australia and Brazil, females are more likely to utilize health-care services than males.[9],[10],[11] Studies conducted in India, Thailand, and Taiwan found no gender differences in health-seeking behaviour.[5],[12],[13] In contrast, Nipun et al. reported that males utilised health facilities more frequently than females.[14] Education is one of the most important factors in bringing about behavioural changes. The level of education was associated with a more efficient use of health-care services in our study [Table 3]. However, this effect was statistically significant only in urban populations (P = 0.001). Although education increased health-care utilisation linearly in urban populations, the effects of education on health-care utilisation were inconsistent in rural populations. Again, it could be due to some other factors that offset the effect of education on poor utilisation among rural elderly. Education affects health-care utilisation directly by increasing awareness about health-care facilities as well as indirectly by improving socio-economic status and financial independence.

Numerous studies have reported that education has a positive effect on health-care utilisation. According to an Indian study involving rural and urban populations with symptoms of chest disease, literate participants sought medical treatment at a higher rate than illiterate participants, although the difference was statistically significant only for rural participants (P = 0.01 and 0.4, respectively).[5] Agrawal and Keshri found that those with education above high school sought treatment more often than those without formal education.[14] According to a study conducted on elderly widows, the likelihood of seeking medical care increased significantly as the level of education increased. Compared to illiterate widows, older widows who were literate up to middle school were 1.6 times more likely to seek medical attention. Among older widows with middle-pass and high-school education, it was3.6 (P = 0.001) and 3.8 times (P = 0.001), respectively.[15]

According to the findings of another study, education, occupation, morbidity and age were not found to be associated with a particular type of healthcare-seeking behaviour, whereas income was significantly associated (P < 0.05).[16]

Our study found a direct relationship between socio-economic class and health-care utilisation. In urban areas (P = 0.011), socio-economic class had a statistically significant effect, but not in rural areas (P > 0.05). A positive effect of socio-economic class on health-care utilisation is understandable. This is because it reflects both the financial and educational status of an individual, both of which are independent predictors of health-care utilisation. The positive effect of socio-economic class on health-care utilisation in our study is in agreement with previous literature.

A study conducted in Assam indicates that health-care utilisation for chronic diseases decreased progressively with decreasing socio-economic status. In another study,[17] the highest utilisation of health services was found among subjects belonging to the medium socio-economic class, followed by those belonging to the lowest socio-economic status. A study by Zhang et al. found that elderly migrants with higher household incomes were more likely to visit doctors and more likely to use inpatient services than migrants with low household incomes.[18] Families are the primary and often the only caregivers for elderly people in our society, and their influence on their health-seeking behaviours is significant. The respondents were classified into three categories of living status: Independent living with a spouse only, independent living without a spouse, and living in joint families. Our study found that elderly couples living independently with a spouse used health-care services most frequently compared to the other two groups. It is possible that this effect is due to the fact that couples living independently with a spouse are likely to be economically independent. In addition, the presence of a spouse made it easier for one to respond to health care needs. Another possible explanation is that insistence by one partner made the other partner take care of his or her health. The effect of living status on health-care utilisation was statistically significant (P = 0.001) only in rural populations. According to William Joe's analysis of the 2006 data from the National Sample Survey Organization, living with a spouse is the most important factor contributing to the utilisation of health-care services.[19] In contrast, an Australian study found that both men and women sought health services more frequently after separation or divorce.[20] In our study, marital status did not affect health-care utilisation in either an urban or rural population [Table 3]. Various studies have described contradictory effects of marital and living status on health-care utilisation in the literature. In a Brazilian study, individuals over the age of 80, who were married, or who were living with someone else had the highest prevalence of using health-care services within the 3 months before the interview (92.5%, 90.3% and 89.6%, respectively). However, these findings lacked statistical significance.[11] Interestingly, Batra found that elderly people living in joint families were more satisfied with the availability of health-care facilities.[21] The importance of joint families on health-care utilisation is also strongly influenced by the family's income and socio-economic status. Since the health care needs of the elderly are given low priority, elderly individuals who are part of a joint family that has a low income are likely to have poor utilisation of health-care services. As the majority of the population in our study belonged to the lower and upper lower classes, this could explain why the elderly living in joint families do not utilise health-care services effectively. According to our study, while 57.7% of pensioners were using health-care services regularly, only 15.9% of those dependent on family support were doing so [Table 3]. Pensioners were most likely to use the service in both urban and rural areas. The reason for this is that most of those receiving pensions were economically independent as well as being beneficiaries of health insurance coverage provided by their previous employers. The positive effect of health security coverage on utilisation is consistent with the literature. Using regression-based indirect standardisation of the National Sample Survey organization 2006 data, William Joe calculated the need-standardised distribution of elderly health-care utilisation. According to Joe W,[22] elderly with some insurance coverage were 40% more likely to utilize health services. In addition, he observed that income and economic independence had a positive impact on health-care utilisation. It is understandable that elderly persons from low socio-economic backgrounds are less likely to utilise health-care services due to economic dependency on family support. In our study, urban residents had significantly better health-care utilisation than rural elderly [Table 2]. Better educational status, socio-economic status, health security coverage, smaller family, higher working population and lesser financial dependence may be partly responsible for better health-care utilisation by urban elderly as compared to their rural counterparts. This finding of better health-care utilisation by urban elderly than rural elderly is consistent with various national as well as international studies. Joe et al. found urban residents having much better utilisation than their rural counterparts and this difference persisted even after correcting for income and other socio-demographic parameters.[19] In a Mexican study also, rural elderly utilised health-care services much less than their urban counterparts. This difference was partly explained by the difference in health insurance coverage.[23] Thematic review of literature by Sahoo et al. stated that high health spending among the elderly coupled with the absence of insurance coverage exposes the elderly, particularly those belonging to lower socio-economic strata, to great financial risk.[24]

On regression analysis, socio-economic class and source of income were found to be independently affecting health-care utilisation in both urban and combined data [Table 5]. Those still working or receiving pensions had understandably better health-care utilisation than those dependent on family. Socioeconomic class being amalgamation of educational status and financial status was directly affecting health-care utilisation, while educational status alone was not a sufficient predictor.
Table 5: Regression analysis of urban data-Socio-demographic factors

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The effects of physical disabilities on health-care utilisation are complex. Although physical disability may affect health-care utilisation by making the elderly dependent on others, it can also have a positive impact if it is correctable and treatment is readily available in a society where it is widely recognised and treated. In our study, visual disability (cataracts being the most common cause) showed a significantly positive effect on health-care utilisation (P = 0.037) in urban populations. Considering that these patients are visiting health-care facilities for visual impairments, they may also be suffering from respiratory problems. However, this effect was not evident in rural populations [Table 4]. In some studies, physical disabilities have been found to negatively influence health-care utilisation, however, no such effect was observed in this study.[25]
Table 4: Physical disability versus health-care utilisation

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  Conclusion Top

In this study, male gender, health security, pension from the past employer, living independently, higher education and higher socio-economic status were associated with better health-care utilisation. Effect of socio-demographic factors was mainly evident in the urban population. Some sort of universal social and health security cover for the elderly is very important. Society needs to be sensitised to the problems and special needs of the elderly. Thus, recognising the determinants (social, economic and medical) of health service utilisation and health expenditures are essential for targeted health-financing policies to establish equitable health-care delivery among the Indian elderly.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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