Continuous improvements in quality of life (QOL) and health care have led to an increase in the survival of patients with noncommunicable diseases (NCDs) and a concurrent increase in the per capita life expectancy and survival time of such elderly population.[1,2] With reference to this expected increase in the elderly population with NCDs in India in the coming decades, it is essential that we dwell deeper into the dynamics of health care and its utilization among the geriatric population.
Health and morbidity in the elderly are primarily influenced by behavioral decisions of individuals or families, genetically inherited health attributes, and the health environment in which they reside, and is influenced by factors like illiteracy, misconception, income, family composition, social isolation, and dependency. Thus, illness is an event that is systematically related to household and community-level factors. Attribution of deteriorating health to aging, low economic status, and negative attitude of health workers toward the care of the elderly are some of the factors associated with reluctance in seeking health care. Many a times, the health-seeking behavior (HSB) is determined by the type of NCD. It is possible that an individual with multimorbidity showcases different care-seeking behavior toward his own different ailments.
Although there have been many studies analyzing overall HSB in elderly, the current study is novel as it addresses variation in health-care-seeking behavior with respect to different types of NCDs commonly seen in elderly. Analyzing disease-specific variation in HSB in the old population might enhance the scope for better application of the health services available for the geriatric population with different NCDs.
MATERIALS AND METHODS
A cross-sectional study was conducted from January to December 2019 in an urbanized village of Delhi among willing participants over 60 years of age and residing in the area for at least a year. Those who were seriously moribund and unable to respond to the interview were excluded.
The sample size was calculated using the formula N = Z2pq/l2. Taking 64%[6,7] as the prevalence of NCDs, the sample size calculated for 95% level of significance, 10% allowable error, and design effect = 1.5 was found to be 337 participants that was rounded off to 350.
Three out of eight wards of Mehrauli were selected randomly, and subsequently, systematic random sampling was done. The collective approximate population of the selected wards was around 34,000. Sampling frame was assessed using national population percentage of elderly (8.6% of total population). Every eighth house was visited in order to fulfill the sample size. In case there were two or more elderly in a household, only one was randomly selected for the study. In case there was no elderly person in a household, the next house was selected. In case a house was found locked even after three consecutive visits, the next house was selected. Whenever a crossroad came up, the road to the left was taken.
The interview and examination were conducted by the first author in an average duration of 30 min. Permission for conducting the study was taken from the Institutional Ethics Committee for Human Research. Written informed consent was taken from the study participants in the language they understood, and confidentiality of the participants was maintained.
A self-designed, pretested, semi-structured interview schedule was used, which included sociodemographic particulars and screening for selected NCDs (diabetes mellitus, hypertension, osteoarthritis, senile cataract, obesity) through a screening questionnaire that also included questions on latest documented investigation reports. Questions were designed to assess the HSB of the participants suffering from any known NCD and for identifying their determinants including treatment attitude, practices, and clinico-social and financial factors. Detailed general and systemic examination was done. Laboratory investigation included measurement of blood sugar using glucometer. Operational definitions used for diagnosing new cases are as per guidelines.[8–12] Operational definition for appropriateness of HSB was based on the following criteria: regularity of taking treatment, taking treatment from a qualified health practitioner, and loss to follow-up. Presence of out-of-pocket expenditure was analyzed by taking into account any direct (doctor’s fee, purchase of medicine, diagnostic charges, and hospital charges) and indirect (transportation charge, lodging charges, and loss of wages for both patients and their family members) medical expenses made by households in the last 1 year for both outpatient and inpatient services for each of the NCDs.
Data collected from proforma was coded and entered in Statistical Package for the Social Sciences (SPSS) v 25. All quantitative variables were analyzed in terms of mean and standard deviation, while qualitative variables were analyzed through proportions. Chi-square test was employed for testing differences in proportion for utilization pattern between different groups. P < 0.05 was considered the cutoff for statistical significance. Binary logistic regression was applied to determine the independent statistically significant relationship between HSB among the study participants and its determinants. For the regression analysis, the independent variables were recoded into binomial categories as follows:
A total of 350 elderly above 60 years were enrolled in the study, of whom 54.57% were women. Mean age in men and women was 68.09 ± 6.48 and 68.41 ± 6.44 years, respectively. Almost two-thirds (66%) of the participants belonged to young old (60–69 years) age group, and more than two thirds (69.43%) were currently married. More than half (53.71%) of the study participants belonged to upper middle and upper class, and more than one-third (33.71%) of the participants had no formal education [Table 1].
A total of 87.43% of the study population was suffering from at least one NCD. More than two-thirds (68%) of the study participants were having an already known NCD (s). Overall, hypertension (58%) was the most prevalent chronic disease, followed by senile cataract (49.42%), osteoarthritis (32.85%), diabetes mellitus (30.28%), and obesity (26.85%) [Table 2].
Of the total NCDs, for more than a half (51.63%), treatment was taken from a government institution. For over half (55.50%) of the NCDs, duration was for over 5 years. In over two-thirds (68.90%) of the participants’ NCDs, treatment was still being taken. For 95.9% of the NCDs, the study participants preferred going to a nearby health facility that was less than 5 km away and for 48.26% of the NCDs, the participants traveled alone to the health facility. A total of 32.3% of those still continuing treatment were availing a health insurance. For majority (71.21%) of those taking treatment, there was out-of-pocket expenditure involved [Table 3].
Of the total 238 participants with known NCDs, 52.94% (n = 126) had inappropriate HSB. Almost two-thirds (n = 92, 63.89%) of the young old had appropriate HSB toward their known illness, while over three-fourths (n = 54, 77.14%) of the old (71–80 years) and majority (n = 20, 83.3%) of oldest old (≥80 years) had inappropriate HSB [Table 4].
A higher proportion of the elderly suffering from osteoarthritis and diabetes had inappropriate HSB. HSB was more appropriate in women compared to men. Over half (53.33%) of the participants from lower middle class and majority (n = 19, 76%) from lower class had inappropriate HSB. HSB was relatively more appropriate in those with at least a high school certificate (n = 53, 66.25%); over two-thirds (n = 58, 69.88%) of the illiterate participants had inappropriate HSB. A higher proportion of participants who traveled over 5 km distance to reach the nearest/commonly visited health facility showed inappropriate HSB [Table 4]. Table 5 shows that HSB was significantly associated with gender, age, level of literacy, distance of health facility, duration of illness and presence of multiple NCDs.
The prevalence of NCDs among elderly was found to be 87.43% in our study. The prevalence varied from 14.1% to 98.2% among studies conducted in the past. Studies from metro cities showed similar prevalence of NCDs among elderly.[15–17]
Hypertension was the most prevalent chronic disease, followed by senile cataract, osteoarthritis, diabetes mellitus, and obesity. Similar order of proportion of selected NCDs was seen in other studies.[6,18] The report on the status of elderly in select states of India (2011) revealed that women had higher prevalence rate of arthritis and hypertension, which was reflected in this study as well.
Taking no treatment, self-treatment without any consultation from a qualified health practitioner, and traditional treatment from quacks are considered inappropriate HSBs. In this study, one in five elderly suffering from a known NCD initially preferred one of the aforementioned. The numbers were specifically high for participants with osteoarthritis and cataract, where a significant proportion of the participants did not go for treatment initially for as long as the symptoms were bearable. However, for almost all other diseases, the participants preferred to go to an allopathic health practitioner from the beginning. Similar proportions were seen in other studies.[14,20] The percentage of those taking traditional treatment was quite low in our study due to the fact that it was conducted in an urban area where more allopathy practitioners are easily accessible. Of those who did not take treatment for their known illness, common reasons were given, like considering their illness to be minor, facing no present problem due to the disease, and/or not having anybody to accompany them. Similar reasons were reported by Manocha et al. and Patle and Khakse.
A quarter of those suffering from osteoarthritis who initially did not take any treatment continued to avoid taking any treatment in the present. A large number of those taking treatment currently went to the chemist or an AYUSH clinic. Dissatisfaction from treatment available at government institutions and excessive reliance on pain killers were quoted as the most common reasons. For hypertension and diabetes and most of other known NCDs, the participants were taking some form of treatment, most commonly from government set-ups. However, seeking treatment from private practitioners was also significant since for many participants, either their medications were not available at the nearby government institutes or because they felt the treatment was better at private institutions. Majority of the cataract patients in the study group had got surgery done for one or both eyes. Loss to follow-up was the highest among osteoarthritic patients. Sharma et al. and Goodwin et al. observed that substantial proportions of the geriatric patients with musculoskeletal ailments considered it to be a normal part of aging.
For majority of the study population (71.2%), there was out-of-pocket expenditure involved. Similarly, high percentage was found in other studies.[24–26] Around a third of the population was availing benefits of a health insurance policy. Of the around 31% participants availing health insurance, only one in seven had a private health insurance policy. A reason for this was unwillingness to pay a premium when there was no apparent illness. These findings vary slightly from the nationally representative National Health Accounts 2016–2017, according to which 63.25% in the country paid for health care through out-of-pocket expenditure, whereas 31.69% had utilized government insurance schemes and 5.06% had private insurance.
Less than half of the total participants had appropriate HSB. Barua et al. found similar results in their study. In case of osteoarthritis, over two-thirds of the study population had inappropriate HSB, which was worse compared to other common NCDs.
In the study, there was a statistically significant association between age of the study participants and their HSB, with a higher proportion of participants showing inappropriate behavior as age progressed. The reason for this was increased dependence on family/friends to seek optimum treatment on time, every time; relative financial independence due to continuing occupational activity and/or savings in the young old population meant a bigger section could manage to get appropriate HSB. The findings were corroborated by similar studies.[6,14] A statistically significant association was seen between gender and HSB, with a higher proportion of females showing appropriate behavior. Those participants belonging to higher socioeconomic status showed higher proportion of appropriate HSB. The level of literacy had a statistically significant association with HSB, with a higher proportion of participants showing appropriate behavior as the level of literacy increased. This is consistent with the findings from other studies.[22,28–30] Lack of poverty and education, thus, are identified as enabling factors in seeking health care.
Important modifiable factors associated with poor health seeking were distance of preferred health facility and presence of multiple NCDs. It was observed that those who needed specialized treatment from hospitals often missed timely follow-up. Having multiple chronic morbidities often resulted in nonuniform attention to the ailments; more symptomatic NCDs were given extra care, while silent illnesses like diabetes and hypertension were often ignored initially.
Even though majority of the patients were taking some form of treatment, HSB was found to be inappropriate in over half of them, especially for commonly ignored NCDs like osteoarthritis and diabetes. Substantial efforts should be made to make our geriatric population aware of the preventive aspects of health care, available treatment options, programs and schemes designed for the elderly, importance of regular follow-up, and timely investigations. It is important to equip and strengthen primary health-care delivery system to enable management of common NCDs at a community level.
The exact prevalence of some relatively common NCDs like hypothyroidism, asthma, chronic obstructive pulmonary disease (COPD), and others could not be assessed due to diagnostic constraints. In the present study, being cross sectional in design, only the association of sociodemographic determinants could be demonstrated, whereas the causality of these sociodemographic determinants could not be ascertained.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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