Health Care Utilization by Older Adults in Nepal: An Investigation of Correlates and Equity in Utilization

Barriers and Facilitators to Patient Utilization of Non-Communicable Disease Services in Primary Healthcare Facilities in Nepal: A Qualitative Study

Background

The Nepalese government endorsed and implemented the Package of Essential Non-Communicable Disease Interventions (PEN) by the World Health Organization (WHO) to prevent and manage four major non-communicable diseases (NCDs): cardiovascular disease (CVD), diabetes, cancers, and chronic respiratory diseases. This study explored barriers and facilitators to patient utilization of NCD services at primary healthcare facilities in Nepal.

Methodology

We conducted a qualitative study with a 35 purposive sample of patients living with one or more NCDs (hypertension, diabetes, chronic obstructive pulmonary disease (COPD/ asthma) who sought healthcare at primary healthcare facilities in 14 randomly selected districts in seven provinces in Nepal that implemented PEN. Trained qualitative researchers conducted in-depth interviews in-person in a private setting using a semi-structured interview guide developed based on the Health Belief Model in the local language. The interviews were audio-recorded, transcribed verbatim, coded inductively and deductively, and analyzed by a framework approach using Dedoose software.

Results

From the perspectives of patients, key facilitators of service utilization encompassed free medicines, low-cost services, geographical and financial accessibility, less waiting time, positive interactions with health service providers, experiencing improvements in their health conditions, and support from family and peers. Barriers to utilizing services included inadequate health services (e.g., lack of medications and equipment), inaccessibility and affordability, inadequate health-related information from health service providers, low knowledge of NCD care, and lack of reminders or follow ups.

Conclusion

Enhancing NCD service utilization is potentially attainable through interventions that address patients' knowledge, self-motivation, and misconceptions. Furthermore, strengthening the availability and accessibility of crucial services such as laboratory investigations, medications, equipment, and the patient-provider relationship is crucial for sustainable implementation of PEN.

Equity evaluation of intensive care unit admission based on comorbidity in hospitalized patients with COVID-19: a cross-sectional analysis

Background

Intensive care unit (ICU) beds played a crucial role in reducing mortality rates of patients with severe COVID-19. The surge in the number of patients led to a shortage of ICU beds, which may have exacerbated inequity of healthcare utilization. However, most attention has been focused on the horizontal equity in healthcare utilization, where individuals with the same needs receive the same services. Vertical equity, where individuals with higher needs receive more healthcare is often neglected, which might overestimate the equity. This study analyzes the vertical equity of ICU utilization among hospitalized patients with COVID-19.

Methods

In total, 18,547 hospitalized patients with COVID-19 in Maryland in 2020 were enrolled in this cross-sectional study. Logistic regression analysis was conducted to determine the independent factors affecting ICU utilization, and the Shapley value decomposition approach was implemented to assess the contribution of the independent variables to disparities in ICU admission. A concentration curve and concentration index were used to assess the vertical equity in healthcare utilization.

Results

ICU utilization by patients with COVID-19 was significantly affected by Charlson Comorbidity Index (CCI), with odds ratios (OR) 1.09 [95% confidence intervals (CI): 1.07-1.10; p < 0.001] in univariable analysis and 1.11 (95% CI: 1.09-1.13; p < 0.001) in multivariable regression analysis. The most important contributors were household income (32.27%) and the CCI (22.89%) in the Shapley value decomposition analysis. The concentration curve was below the line of equity, and the concentration index was 0.094 (95% CI: 0.076-0.111; p < 0.001), indicating that ICU utilization was concentrated among patients with a high CCI. These results were robust for all subgroup analyses.

Conclusion

Among 18,547 hospitalized patients with COVID-19 in Maryland in 2020, ICU utilization was significantly affected by comorbid conditions. The concentration curve and concentration index also indicated that ICU utilization was more concentrated in patients with a higher CCI. The results was consistent with the principle of vertical equity, whereby healthcare resources are more concentrated on COVID-19 patients with higher health needs.

Older people's challenges accessing health services in central Nepal: a qualitative study using the domain of access framework

BACKGROUND

Low- and middle-income countries face rapid population aging. However, the health system has remained largely unprepared to deliver health services to an aging population. As the population is rapidly aging in Nepal, their challenges and experience should be the focus for health care providers to address these issues. There is a paucity of evidence on barriers and facilitators to accessing health care services among older people in Nepal. The aim of this study was to investigate the challenges that older people experience while accessing health services in central Nepal.

METHODS

This qualitative study was conducted between April and June 2023. In-depth interviews were conducted among older people of a municipality in central Nepal, which were analysed thematically using a deductive-inductive approach based on the theory of access.

RESULTS

Hypertension and diabetes were the most common health problems among the participants. The affordability of health services was a major issue, although there is a health insurance scheme and a major focus on universal health coverage from the Government of Nepal. Other issues included poor acceptability, poor communication between older people and health staff, and poor accommodation due to a lack of elderly-friendly services, including long wait times in the clinic. Living with family was a major facilitator of access to health care services and was interrelated with multiple domains of access.

CONCLUSIONS

This study identified barriers to accessing health care services for older adults in Nepal. We found that the affordability of health services, poor acceptability, poor communication between older people and doctors, and a lack of elderly-friendly services are the key challenges experienced by older people. Older people felt that these barriers were easier to overcome when they had family support. Therefore, for those living with their children, family support was reported as the major facilitator.

Health Service Utilization and Its Determinants among Senior Citizens in the Semiurban Area of Western Nepal: A Cross-Sectional Study

Background

Senior citizens are usually infected by multiple chronic conditions and other health problems. Health needs and demand for healthcare services increase with age. However, healthcare services and facilities and their utilization are limited, particularly in developing countries.

Aims

To identify the utilization of health services among senior citizens and their contributing factors.

Methods

A cross-sectional analytic study was conducted among 293 senior citizens of the Kushma municipality, Nepal, from June to December 2019. A structured questionnaire was used as a data collection tool using a multistage sampling technique. Face-to-face interviews were conducted to collect data on the interview schedule. Reliability and validity were maintained by applying different strategies and carefully developing tools, pretesting, double entry, and validation. Data entry, management, and analysis were performed using Epi Data and SPSS software. Research ethics were maintained. Descriptive and inferential statistical tests were performed to infer the findings.

Results

Study participants had a mean age (±SD) of 70.08 (±7.6) years and had various preexisting chronic diseases such as hypertension (46%), gastritis (41.9%), arthritis (34.3%), and asthma (28.7%). Only eight out of ten senior citizens had used health services in the past year. Factors such as age, ethnicity, residency, household income, family support, the presence of chronic diseases, and being under medication were found to have statistically significant associations with the utilization of health services among senior citizens with a p value less than 0.05 and 95% confidence interval.

Conclusions

A remarkable proportion of older people reported using health services in the last year. However, a substantial proportion did not utilize health services that require further interventions to enable them. Efforts are required to promote the health and well-being of Nepal's growing elderly population, including potential enhancements to rural healthcare infrastructure by policymakers.