Health Service Utilization by Elderly Population in Urban Nepal : A Cross-Sectional Study

Background The elderly population is in increasing trend all over the world. Elderly people experience many physiological, biological and psychological changes. The general objective of the study is to assess the utilization of health care services among the elderly population of Butwal sub-metropolitan city.


Introduction
Ageing is a natural phenomenon and an inevitable process in life.Ageing refers to the increasing inability of the body to maintain itself and to perform the functions it once did.Ageing is a process of gradual change in physical appearance and mental situation that cause a person to grow old. 1 The elderly who are incapable of doing any work need to be specially understood because of their dependence upon others for physical, emotional and medical care.
Previous studies in Nepal revealed that the older population is increasing both in terms of absolute numbers and in percentage. 3 At the population level, overall health care utilization would appear to increase significantly with age. 4   The Senior Citizen Acts of Nepal 2063 defines the senior citizen as "people who are 60 and above".Elderly population increased by 43% during 2001 to 2011. 5 The elderly are one of the most neglected groups in Nepalese society.6   Elderly people are physically disabled, financially weak; their need, interests, wishes are not fulfilled in the family and community due to which they face more health problems.
In a country like Nepal, a marginal increase in the proportion of older people poses serious problem where people are characterized by greater spatial inequalities, poverty, stagnant economy, illiteracy and poor health status.
8 Growing numbers of elderly people are suffering problems in different aspect, but there are limited studies in relation to general morbidities as well as specific in this group of people.

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The individual aged 60 years and above were considered as elderly which is accepted globally as a lower chronological age threshold for older persons. 10This paper attempts to assess the utilization of health care services among the elderly population of Butwal sub-metropolitan city.

Study design and participants:
Butwal sub-metropolitan city, a city located in Western region of Nepal was selected as the site of the study.A quantitative descriptive cross-sectional study design was used to assess the utilization of health care services and to identify factors associated with utilization of health care services by elderly population of Butwal.Total of 212 elderly people were calculated to participate in study based on following assumptions: prevalence (p) =48.5%, sampling error (d) =10%, 95% C.I and 10% of non-response rate.The samples were randomly selected from the sampling frame of the 3 different wards of 22 wards of Butwal submetropolitan city.Cluster random sampling was adopted to collect the information through the use of an interviewer administered semistructured questionnaire.The inclusion criterion was all adults' aged 60 years or older living in the selected wards.The exclusion criteria were being cognitively impaired, deaf and who refuse to participate.

Data collection and study variables
Data collection was performed in April, 2015.The interview questionnaire was pretested with 15 elder people residing in the homogenous non-sampling area to validate the questionnaire.

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The interviewer conducted face-to-face interview at the residing place of the elder people.
Utilization of health care services in past one year is the dependent variable of this study which was asked by, "Have you visited to medical institutions in past one year?"The independent variables of the study are demographic factor (age, gender, marital status, disability), cultural factor (belief on traditional healer), socio-economic factor (personal income, family income, cost of health care services, occupation, education and health insurance), psychosocial factors (preference for seeking care, self medication, revealing health problems to family and service provider), family background (family support, dependency on family) and quality of health service (satisfaction with health care and communication with service provider).
This study collected information on sociodemographic characteristics (age, gender, religion, ethnicity, family type, dependency, living arrangement, marital status, educational status, occupation, monthly income and disability), personal history of respondents (smoking, alcohol, chewing tobacco, performing exercises, self-rated health condition and depend upon family for their daily living activities), utilization of health care services (under regular medication, visit to health facility in past 1 year, visit to emergency department and admitted to hospital in past one year and the reasons for visiting health facility, diagnosed chronic ailment, etc) and on experiences of health care service use (cost of health services, satisfaction with medical care, communication skills of service provider, wait long for seeking care, etc).

Data Analysis
Data analysis was done using descriptive statistics with the aid of statistics package SPSS 15.For meaningful interpretation mean, median and mode were used to organize and summarize the data.Chisquare associations with categorical variables were conducted in order to establish associations between dependent and independent variables.In this study, p-value <0.05 were considered statistically significant.

Ethical Considerations
Approval for conducting this study was obtained from the Institutional Review Committee, Manmohan Memorial Institute of Health Sciences.All respondents were notified that the data collected would be treated with anonymity and confidentiality.Informed verbal consent was obtained from the respondents before interviewing them.

Socio-demographic and personal history of the respondent (n=212)
The mean age of the respondents was 69.8 years.There were more female (50.9%)respondents; the majority of respondents were married (69.3%).Majority of participants were Illiterate (60.8%), although 12.7% participants were able to read and write, 9% of participants received primary level and 17.5% received secondary and higher education.Majority of the participants were from upper caste group and from joint family.9/10 th (91.5%) of participants were Hindu by religion.Around 3/4 th of the participants live with their ISSN: 2091-1041 I VOLUME 2 I2016 JMMIHS-30 son.12.3% of participants were disabled (Table 1).
More than 1/4 th (27.8%) of the respondents were current smoker, 24% current alcohol drinker and 17.5% of respondents are tobacco chewer.Thirty seven percent (37.3%) of respondents are found performing regular exercise.It is revealed that 2/3 of respondent don't depend upon family members for carrying out their Daily Living Activities.Above 4/5 th (84.9%) of respondent rated satisfactory to their health condition (Table 1).

Health service utilization by the respondents
Above 4/5 th (84%) of the older adults were found utilizing health services; where 5.7% and 12.7% of them visited emergency department and admitted to hospital respectively.Over 8/10 th (82.1%) of the participants were diagnosed with one of the chronic ailment whereas 7/10 th (71.7%) of total participants were under regular medication.Hypertension (36.2%) was found to be more common chronic disease among the participants.Majority of the participants (57.5%) have belief on traditional healing system (Table 2).

Factors associated with utilization of health services by elderly people and their socio-demographic factors:
Monthly family income, chronic disease, elderly on medication and self-rated health showed significant association with utilization of health services by elderly population at 95% level of confidence (Table 3).

Discussion
In Nepal, the elderly population is increasing both in terms of absolute numbers and as a proportion of the total population; however, traditional family norms and values of supporting the elderly are eroding.However advances in medical knowledge may have led to an increase in life expectancy and increase in the number of older people in society.The elderly population who are unable of doing work need to be specially implicit because of their dependence upon caregiver for physical, emotional and medical care.
Our study attempted to assess the utilization of health care services among the elderly population of Butwal sub-metropolitan city.
In the present study, we found married couples were utilizing more health care services than of being widowed/divorced/polygamy.However, we didn't found any association between them.The findings observed in our study contrast to that found in Dhulikhel study.A Literature review from Nepal revealed that over 80% of elderly were living with their children (97.3% with sons and 2.7% with daughter) and above 60% of elderly male holds head position in their family. 17n line with this, we found 74.1%, 9%, 12.7% and 4.2% of elderly were living with their son, daughter, couple only and with others(relatives) respectively.Of total, 9/10 th (90.3%) fall sick often but only 67.8% visited health facility when they were seriously sick. 11This confirms that health service utilization was not up to the mark, supported by our study findings where 100% respondents rated health care services as expensive for the elderly who reported any health problems.2] The cost of health service ISSN: 2091-1041 I VOLUME 2 I2016 JMMIHS-31 received was deemed too expensive by 53% of the respondents.

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One of the Korean study showed that elders in poor health status were significantly older and poorer, with higher rates of chronic conditions and health services utilization, which should help in the health care planning required to address this issue. 13 Respondents who rated their health status as satisfactory were found more to be utilizing health care services and there is the significant association between self-rated health and service utilization.
It has been reported that most of the elderly people (84.1%) in western Nepal suffered from one or more health related problem.15   Similarly, another research from Nepal Geriatric Center 2011, showed more than half of the residents in old age home studied were suffering from at least one chronic illness.16   Our study revealed8/10 th (82.1%) of respondent are diagnosed with chronic ailment.In overall, 98.68% of the elderly population under regular medication was found utilizing the health care services.These populations were under medication of the health institution not self medication.Our findings are similar to the study done in central Nepal where they showed association between under medication, presence of chronic ailment and service utilization. 3 In current study, self-reported presence of chronic disease, monthly income of respondent's family, respondent under medication and self rated health status were found to be associated with health care services utilization

5.Conclusion
Health care service utilization among the elderly population of Butwal sub-metropolitan city was assessed; more than 8/10 th (84%) of elderly people utilized the health service in past 1 year.Majority (57.5%) of study population has belief on traditional healing system.
The finding suggests that monthly family income, chronic disease, elderly on medication and self-rated health status are strongly associated to the utilization of health care services among the elderly people.This suggests that provision of free health care services, good interpersonal relations, and awareness programs on health targeting the senior citizens may lead to increase the utilization of health care services by elderly people. ISSN

Table 2Respondents utilizing health services in past one year
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Table 3 Association of health service utilization with socio-demographic factors *
statistically significant at 95% level of confidence.
P Value