The Social Determinants of Healthcare Access for Rural Elderly Women - A Systematic Review of Quantitative Studies

A comparison of quality of life between older adults living in high and low altitude areas

Background

High altitude is known to have a significant impact on human physiology and health, therefore, understanding its relationship with quality of life is an important research area. This study compared the quality of life (QOL) in older adults living in high and low altitude areas, and examined the independent correlates of QOL in those living in a high altitude area.

Methods

Older adults living in three public nursing homes in Xining (high altitude area) and one public nursing home in Guangzhou (low altitude area) were recruited. The WHOQOL-BREF was used to measure the QOL.

Results

644 older adults (male: 39.1%) were included, with 207 living in high altitude and 437 living in low altitude areas. After controlling for the covariates, older adults living in the high altitude area had higher QOL in terms of physical (P = 0.035) and social domains (P = 0.002), but had lower QOL in psychological (P = 0.009) domain compared to their counterparts living in the low altitude area. For older adults living in the high altitude area, smoking status was associated with higher social QOL (P = 0.021), good financial status was associated with higher physical QOL (P = 0.035), and fair or good health status was associated with higher physical (p < 0.001) and psychological QOL (P = 0.046), while more severe depressive symptoms were associated with lower QOL.

Conclusion

Appropriate interventions and support to improve depressive symptoms and both financial and health status should be developed for older adults living in high altitude areas to improve their QOL.

Public healthcare system utilization for chronic hepatitis C infection in Vietnam

BACKGROUND

Healthcare utilization is typically adversely affected when the treatment is expensive and requires multiple visits. We examined the determinants of healthcare-seeking for Hepatitis C virus (HCV) infection which is asymptomatic, chronic, and requires costly treatment in an urban tertiary care referral hospital in Vietnam.

METHODS

We conducted a secondary analysis of hospital data for patients attending the Hospital for Tropical Diseases in Ho Chi Minh City, Vietnam between 2017 and 2020 specifically for HCV infection treatment. Poisson regression was used to determine the effect of personal factors (age, sex, comorbidities) and structural factors (health insurance, proximity to the facility, seasonality, year of visit) on the number of hospital visits.

RESULTS

From 2017 to 2020 a total of 22,052 eligible patients sought treatment in the hospital. Among the patients, 50.4% were males and 58.7% were > 50 years of age. The mean number of visits per person was 2.17. In the multivariate analysis compared to 2017, the number of hospital visits increased by 4% in 2018 and then significantly decreased in 2019 and 2020. Visit numbers were significantly lower (6%) among South East region residents compared to those from Central Highlands and for those who lived further away from the hospital. The visit numbers were significantly higher among older age groups (5-11%), those with health insurance (6%), and those with comorbidities (5%) compared to others. Although the number of hospital visits by females was higher (7%) than males in 2017, it significantly decreased in subsequent years.

CONCLUSIONS

Our study indicated that there are both structural and individual factors affecting the number of visits for HCV treatment. To meet the global strategy for elimination of HCV, Vietnam Government needs to address the structural and personal barriers to healthcare seeking, with a special focus on women.

Tuberculosis in older adults: challenges and best practices in the Western Pacific Region

The Western Pacific has one of the fastest-growing older adult populations globally, and tuberculosis (TB) remains one of the foremost infectious causes of disease and death in the region. Older adults are at higher risk of TB due to immunosenescence, comorbidities, and increased institutionalisation. Atypical symptoms and reduced access to health services may delay care-seeking and TB diagnosis, while co-morbidity and increased risk of adverse drug reactions complicate TB treatment. Post-TB sequelae and socioeconomic challenges may decrease the quality of life after TB treatment completion. Despite their high disease burden and special challenges, there is a lack of regionally coordinated policies and guidelines to manage TB among older adults. Routine TB screening at aged-care facilities, age-friendly infrastructure and services, awareness of atypical TB features, integration of TB and non-communicable diseases services, and person-centred approaches to treatment support could improve TB management among older adults. Addressing these challenges and adopting the best practices identified should inform policy formulation and implementation.

Funding

This project was funded by 1) the World Health Organization Regional Office for the Western Pacific, with financial contributions from the Government of the Republic of Korea through the Korean Disease Control and Prevention Agency and the Government of Japan through the Ministry of Health, Labour and Welfare, and 2) NUS Start-up Grant. The funders had no role in the paper design, collection, analysis, and interpretation of data and in writing of the paper.

Healthcare seeking behaviour during illness among older adults in Ghana: does food security status matter?

BACKGROUND

Ghana's growing older adult population raises critical questions regarding healthcare for these older adults. At the same time, food insecurity is high among older adults in Ghana. This underscores the need to investigate the issues of food security and healthcare seeking behaviour among older adults. However, research on the association between food security status and healthcare seeking behaviour among older adults is scant in the Ghanaian context. In this study, we advance the social gerontology literature by examining the association between food security status and healthcare seeking behaviors among older adults.

METHODS

Using a multi-stage sampling framework, we collected data from a representative sample of older adults across three regions in Ghana. Data were analyzed using logistic regression technique. We determined the significance of the test at a probability value of 0.05 or less.

RESULTS

Over two-thirds (69%) of respondents did not seek care during their last illness. Additionally, 36% of respondents were severely food insecure, 21% were moderately food insecure, 7% were mildly food insecure, and 36% were food secure. After controlling for theoretically relevant variables, our multivariable analysis revealed a statistically significant association between food security status and healthcare seeking behaviors with older people who are food secure (OR = 1.80, p < 0.01) and mildly food insecure (OR = 1.89, p < 0.05) being more likely to seek healthcare compared with their counterparts who are food insecure.

CONCLUSION

Our findings highlight the need for sustainable intervention programs to improve food access and health service use among older adults in Ghana and similar contexts.

Investigating the Spatial Relationship between Social Vulnerability and Healthcare Facility Distribution in Nassau County, New York

Health is a fundamental human right, yet healthcare facilities are not distributed equitably across all communities. This study aims to investigate the distribution of healthcare facilities in Nassau County, New York, and examine whether the distribution is equitable across different social vulnerability levels. An optimized hotspot analysis was conducted on a dataset of 1695 healthcare facilities-dental, dialysis, ophthalmic, and urgent care-in Nassau County, and social vulnerability was measured using the FPIS codes. The study found that healthcare facilities were disproportionately distributed in the county, with a higher concentration in areas of low social vulnerability compared to areas of high social vulnerability. The majority of healthcare facilities were found to be clustered in two ZIP codes-11020 and 11030-that rank among the top ten wealthiest in the county. The results of this study suggest that socially vulnerable residents in Nassau County are at a disadvantage when it comes to attaining equitable access to healthcare facilities. The distribution pattern highlights the need for interventions to improve access to care for marginalized communities and to address the underlying determinants of healthcare facility segregation in the county.

"When I suffer from fever, I eat mangos." Determinants of health-seeking beliefs and behaviors of rural older women in Sylhet, Bangladesh

Poverty, poor living conditions, religious values and norms, lack of education, and gender discrimination influence the beliefs and behaviors of rural older women in many low-income countries. This paper aims to report the socio-ecological determinants of health-seeking beliefs and behaviors of rural older women in North-eastern Bangladesh and how these behaviors impact their recognition within the setting. It involved semi-structured interviews with 25 older women and 11 healthcare professionals. The findings revealed various determinants at the personal level (awareness of illness, mistrust toward medical treatment, self-treatment, and religious values and norms), the interpersonal level (isolation in family and communication with clinicians), community level (community perception of aging, neighboring and community organizations), and in the sphere of human rights (care affordability, social safety-net coverage and national policy). Four core determinants (poverty, education, gender and religiosity) were intertwined in shaping beliefs and behaviors.

Health Services Utilization Barriers for Rural Elderly Women in Bangladesh: Narratives of Clinicians, Pharmacists and Public Health Assistants

Bangladesh has the third largest population of poor older adults in the world and 73% of them live in rural areas. Disparity in the country's health services is evident that creates a substantial pressure, especially on rural elderly women who live in a compromised socio-cultural atmosphere. This is true that we know about rural elderly women's self-reported health and service use barriers, but no studies captured the views of health staff. This study presents a qualitative exploration of the views held by rural health staff whose role is to provide care to local elderly women. We conducted 11 interviews with clinicians, pharmacists and public health assistants in Sylhet district, Bangladesh. A critical thematic discourse analysis, using the critical social constructs of Habermas and Honneth, of the data informed the women's inadequate healthcare access and associated barriers that were complex and overlapping but had explicit institutional, subjective and material consequences. Five major themes emerged including: unequal distribution of health services; marginalization in patient-staff relationships; living with poverty; social relegation; and mistrust of clinical treatment. Rural areas were viewed with inequitably distributed health services and traditionally a large proportion of elderly women living in poverty who lacked social support and demonstrated a mistrust towards healthcare system. No recognition of the women and power differences were underpinned by economic factors and cultural societal values. The findings suggest a need for health policy solutions and education of healthcare staff and elderly women regarding accessing healthcare.

Primary Health Care sustainability in rural remote territories at the fluvial Amazon: organization, strategies, and challenges

The article analyzes singularities of the Primary Health Care (PHC) organization in rural remote municipalities (RRM) in the Amazon under the influence of rivers and discusses challenges for comprehensive care in the Unified Health System (SUS). This is a qualitative and quantitative study of multiple cases in seven RRM through the analysis of interviews with managers, visits to services and secondary data. The RRM of the fluvial Amazon are small, with a sparse, dispersed population living in conditions of social vulnerability. Long distances, rivers and transport irregularities interfere with access to PHC services. The Family Health Strategy is implemented in the municipal system, however areas without assistance coverage, unavailability of PHC services and adaptations to the Strategy imposed by the characteristics of the context remain. The challenges are related to the financing, provision and fixation of the workforce and barriers of geographic access compromise the PHC response capacity in SUS. PHC sustainability requires strategic measures, resources and actions from multiple sectors and public agents; national support policies with feasibility for local execution, so that PHC services are established and make sense in such unique spaces.

Critical social framework on the determinants of primary healthcare access and utilisation

This paper aims to contextualise ‘healthcare access and utilisation’ within its wider social circumstances, including structural factors that shape primary healthcare for marginalised groups. Mainstream theories often neglect complexities among the broader social, institutional and cultural milieus that shape primary healthcare utilisation in reality. A blended critical social framework is presented to highlight the recognition and emancipatory intents surrounding person, family, healthcare practice and society. Using the theoretical contributions of Habermas and Honneth, the framework focuses on power relationships, misrecognition/recognition strategies, as well as disempowerment/empowerment dynamics. To enable causal and structural analysis, we draw on the depth ontology of critical realism. The framework is then applied to the case of rural elderly women’s primary healthcare use in Bangladesh. Drawing on the literature, this article illustrates how a blended critical social perspective reveals the overlapping and complex determinants that affect primary healthcare utilisation, before concluding with the importance of situating healthcare access in sociocultural structures.

Factors influencing access and utilization of health services among older people during the COVID - 19 pandemic: a scoping review

Background

Access to healthcare and service utilization are both considered essential factors for improving the general health and wellbeing of older people, especially at the time of COVID-19 pandemic. The aim of the study is to explore factors affecting healthcare access and health service utilization for older people during the pandemic.

Methods

PubMed, Web of Science, Scopus and Embase were systematically searched for relevant articles. Access, utilization, health, elderly and COVID-19 were used as keywords in the search strategy. A total of 4308 articles were identified through the initial database search; 50 articles were included in the review as passing the eligibility criteria. The searches were conducted up to August 2021. Data extraction was performed, and evidence was descriptively illustrated. Thematic analysis was used to explore factors influencing the elderly’s access and utilization of healthcare services, using Max QDA₁₀, a qualitative analysis software.

Results

Among articles included in the review (n = 50), a majority of the studies were from the United States (36%), followed by India (8%). According to the main healthcare services, a large number of articles (18%) were related to mental health services, followed by digital health services (16%). Factors were identified at an individual, provider and systems level. Seven main themes emerged from the thematic analysis, as determinants of elderly’s access and utilization of healthcare services during COVID-19 pandemic. These included: access to non-COVID related services, access to COVID-related services, literacy and education, accommodation challenges, perceived attitudes of aging, and policies and structures, and social determinants.

Conclusion

Mental health and digital health services were identified as major issues influencing or contributing to or influencing older people’s health during the COVID-19 pandemic. We also argue on the importance of a rounded view, as attention to a range of factors is vital for policy decisions towards sustainable care and equitable interventions for improving the health of older people.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13690-021-00719-9.

A socio-geographic perspective of health and economic impacts of COVID-19 on poor households in ghana

COVID-19 outbreak has had multidimensional effects on human lives. The impacts are expected to be more severe on poor households, especially in resource-constraint economies such as Ghana. The Country has a higher poverty rate [24.2%] and this is likely to upsurge in the coming years due to this pandemic. We aimed to document the pandemic-related health and socioeconomic hazards in Ghana. A content analysis of relevant literature, and a qualitative survey using a socioecological lens were conducted. Based on the Ghana Living Standard Survey report (GLSS 7), twenty interviewees were recruited from 3 most poverty-stricken regions in the country to verify the findings of the content review. The findings indicate a significant health burden and a large-scale socioeconomic negative outcome among the Ghanaian poor households. The disproportionate health access by the poor and the rural inhabitants has and will continue to exacerbate. The social hazards are mainly circumscribed relating to poor economic conditions due to job losses, lack of access to income/savings, food insecurity, and lack of welfare support. At the national level, the economy is particularly vulnerable due to low levels of economic diversification. The ultimate manifestation of the pandemic impacts are higher risk of morbidity and mortality rates, and deteriorating wellbeing and livelihoods. These highlights are beneficial to policymakers, development partners, and human rights advocates to make collaborative efforts in helping the poor households during and the post-pandemic periods.

Exploring the System Determinants Associated with Senior Women's Access to Medical Care in Rural Bangladesh

Senior women's access to medical care in rural Bangladesh is a major public health concern. This study aims to explore the system determinants that impact on rural senior women's utilization of healthcare. Following a qualitative critical social research design, healthcare staff and senior women living in three rural villages of Bangladesh were approached to participate in face-to-face audio-recorded interviews. A total of 11 staff and 25 senior women were interviewed with questions about health policy, healthcare services and management of aged care. Data was analyzed using a blend of critical discourse and thematic analysis methods. Several healthcare system determinants were identified that were complex and cross-sectional. Three major themes emerged from the system determinants: legal framework of aged care; inadequate healthcare support; and professional knowledge and skills of healthcare staff that led the rural senior women to avoid or delay access to hospitals and clinics. The findings revealed that a lack of health focus and professional skills among healthcare staff can be considered as critical. This study recommends that policy and organizational changes are made to improve the women's access to rural hospitals and clinics in Bangladesh.

Aging, care and dependency in multimorbidity: how do relationships affect older Bangladeshi women's use of homecare and health services?

Gender issues can create major barriers to healthcare utilization for older women with multimorbidity, especially in developing countries like Bangladesh. Elderly rural women in Bangladesh, are the poorest of the poor, and the women with multimorbidity live in a regulated family atmosphere. This study explored the relationship dimensions of older women with multimorbidity in homecare and their utilization of health services. To gain a deeper understanding of these complex issues, a qualitative case study was conducted. Semi-structured, in-depth interviews were conducted with 11 health staff and 22 older women with multimorbidity, living in three residential communities of the Sylhet District, Bangladesh. Our analysis used critical thematic discourse, a technique developed from Axel Honneth's recognition-and-misrecognition theory. Seven relationship dimensions have been identified, and grouped under three major themes: intimate affairs [marital marginalization and parent-children-in law dynamics]; alienation in community relationships [patriarchal sibling relationships, neighborhood challenges, and gender inequality in interactions]; and legal disconnections [ignorance of rights and missed communication]. Our findings revealed a lack of understanding of the women's multimorbid care needs and patriarchal marginalization in family. This lack of understanding together with poor peer-supports in healthcare is perpetuated by misrecognition of needs from service providers, resulting in a lack of quality and poor utilization of homecare and health services. Understanding the high needs of multimorbidity and complexities of older women's relationships can assist in policy decisions. This study deepens our understanding of the ways gender inequality intersects with cultural devaluation to reduce the well-being of older women in developing countries.

The World Is Not Mine - Barriers to Healthcare Access for Bangladeshi Rural Elderly Women

Social determinants of health is a core cross-cutting approach of the World Health Organization to reduce health inequalities, and places an emphasis on aged care planning in rural areas of low- and lower-middle income countries including Bangladesh. The complex correlated health and social factors in Bangladesh interplay to shape the healthcare access of rural people. This impact is significant for rural elderly women in particular who have been shown to access healthcare in ways that are described as 'socially determined'. This study aimed to explore how this cohort related their healthcare access to their living circumstances and provided insight into how their healthcare access needs can be addressed. This study was a critical social theoretical exploration from conversational interviews held over three months with 25 elderly women in rural Bangladesh. Two critical social constructs, 'emancipation' of Habermas and 'recognition' of Honneth, were used in the exploration and explanation of the influence of personal circumstances, society and system on rural elderly women's healthcare access. The concept of 'social determinants of healthcare access' is defined from the physical, emotive, symbolic and imaginative experiences of these women. Interviewing the women provided information for exploration of the determinants that characterized their experiences into an overall construct of 'The World is Not Mine'. This construct represented four themes focusing on the exclusion from healthcare, oppressive socioeconomic condition, marginalization in social relationships and personal characteristics that led the women to avoid or delay access to modern healthcare. This study confirms that the rural elderly women require adequate policy responses from the government, and also need multiple support systems to secure adequate access to healthcare. As healthcare services are often a reflection of community values and human rights concerns for the elderly, there is a need of recognition and respect of their voice by the family members, society and the healthcare system in planning and implementation of a prudent aged care policy for rural elderly women in Bangladesh.

Self-reported Seasonal Symptoms and Diseases and Primary Healthcare Utilization Among Rural Elderly Women in Sylhet District, Bangladesh

The physical health and conditions of elderly people are challenged by the adverse effects of seasonal variations in sub-tropical countries, including Bangladesh. Research to date does not feature the risk of seasonal changes for primary healthcare infrastructures and practices in supporting elderly women's care, especially in rural areas. This study aims to identify the health effects of seasonal variations that place increased risk of symptoms and diseases on rural elderly women, and to explore the determinants associated with the women's use of healthcare locally. Using a mixed-methods approach, audio-recorded semi-structured interviews including a short survey with sixty-five rural elderly women and eleven healthcare professionals were conducted. Quantitative data were analyzed in SPSS, and a thematic analysis of the qualitative data was facilitated by NVivo. Self-reported health history by rural elderly women identified the prevalence of three major seasonal symptoms: headache (28/43.1%), digestive disorder (27/41.5%), and physical pain (27/41.5%). The prevalence of three symptoms such as nausea, headache and digestive disorder varied significantly (p < 0.05) across the study villages. Of the women, the age group (60-70 years) recorded the highest number of cases (20), followed by age group (71-80 years/15), where the number of cases significantly varied across three seasons (p = 0.021). While 78.5% and 55.4% reported one and two symptoms/diseases respectively, the community clinic visits differed significantly (p = 0.011) among the seasons. The utilization of primary healthcare was low, and marginalization in using healthcare was underpinned by the health system, the poor living conditions of the women, and their reluctance to seek treatment. The findings suggest a need for policy solutions in promoting preventive measures and treatments by strengthening local clinics and on-going health education and training of staff and elderly women.

Access to Ambulatory Medicines for the Elderly in Georgia

Pensioners in Republic of Georgia are covered by the Universal Healthcare Program. In addition, socially vulnerable chronic patients additionally benefit from the Program for Providing Medicine for the Chronic Diseases (PPMCD). The research aims to assess the financial accessibility to outpatient medicines for the elderly in Georgia. Totally, 700 pensioners were surveyed within the quantitative research. The study showed that PPMCD (launched in 2017) has facilitated the affordability of medicines for elderly, especially the socially vulnerable chronic patients. However, the out-of-pocket spending on medicine is still high for most respondents. The main problem for the family is the high unaffordable price (26%). Nearly a third of respondents (31%) could not fully purchase all the outpatient medicine prescribed by the doctor, and 15% could not purchase them at all due to the high costs. Most of the respondents (57%) buy outpatient medicine without visiting family doctor and 37% self-medicate. This shows the irrational choice of elderly people during their health problems. In this regard, the pharmacy and self-treatment play an important role in the informal network of medical service. A significant part of the respondents (36%) does not know about PPMDC. The low level of awareness of the PPMCD among pensioners increases the risk of impoverishment. It is necessary to increase pensioners’ awareness about PPMCD. It is recommended to include not only socially vulnerable people in the PPMDC, but also chronic patients of pension age, because the expenses may often be catastrophic for them.