Effects of demographic and socio-economic factors on dissatisfaction with formal healthcare utilisation among older adults with very low incomes in Ghana

Abstract

The older adult population has increased in the past few decades, and this is coupled with an increasing burden of chronic non-communicable diseases and a higher rate of healthcare utilisation among this population group. However, studies on healthcare utilisation have not tackled the healthcare service use dissatisfaction dynamics and associated factors, especially among older adults with very low incomes surviving under a social protection programme. The purpose of this study was to estimate demographic and socio-economic factors driving dissatisfaction with the utilisation of formal healthcare services among older adults with very low incomes in Ghana. Using data from a larger Ageing, Health, Lifestyle and Health Services survey conducted in the Atwima Nwabiagya District of Ghana, we estimate dissatisfaction with formal healthcare utilisation using multivariate logistic regression analysis. The study revealed that about 29% of the participants were dissatisfied with utilising formal healthcare services. The study showed that females (adjusted odd ratio (AOR): 0.42, 95% CI: 0.15–0.76) and those with high school education (AOR: 0.35, 95% CI: 0.23–0.79) were significantly less likely to be dissatisfied with the utilisation of formal healthcare services compared with males or those with no formal education. We found that participants who earned a monthly income of GH¢201 or more were significantly more likely to be dissatisfied with the utilisation of formal healthcare services than those who earned less than GH¢100 (AOR:1.16, 95% CI: 1.06–3.94). Our findings provide evidence that few older adults with very low incomes are dissatisfied with using formal healthcare services. The study has shown that demographic and socio-economic factors, particularly, gender, income, marital status, and education, are significant drivers of dissatisfaction with formal healthcare utilisation among older adults with very low incomes. This study, therefore, has implications for policy, practice, and future research decisions.

Keywords:

• patient acceptance of healthcare
• sociodemographic factors
• health services accessibility
• ageing
• health policy
• patient satisfaction

Public interest statement

Studies have shown that older adults tend to utilise more healthcare services because of the health challenges associated with increasing ageing. However, in Ghana and other low-and middle-income countries, older adults tend to face several barriers to healthcare utilisation (such as communication, transportation, financial, and transportation) which are likely to impact their satisfaction with formal healthcare utilisation. Yet, the literature on demographic and socio-economic factors predicting dissatisfaction with formal healthcare use among older adults with very low incomes is scant in sub-Saharan Africa and Ghana in particular. Drawing evidence from a probability based cross-sectional survey, this study examined the effects of demographic and socio-economic factors on dissatisfaction with formal healthcare use among older adults with very low incomes in Ghana. The study revealed that females and participants with high school education were significantly less likely to be dissatisfied with the utilisation of formal healthcare services compared with males and those with no formal education, respectively. We discuss the implications of this study for policy, practice, and future research.

1. Introduction

Satisfaction of healthcare use is multi-dimensional, determined by the construct of both healthcare users and healthcare workers (Naidu, 2009). Whereas healthcare use satisfaction is difficult to measure, patients’ inputs and expert judgment are necessary for quality purposes and further planning of the adequate and quality delivery of healthcare service (Naidu, 2009; Schmidt et al., 2008). According to Fatima et al. (2018), the delivery of quality healthcare services would build satisfaction and loyalty among healthcare users. Besides, the expression of a satisfactory attitude would likely ensure the long-term success of service providers through continuous use. Cabrera-Barona et al. (2018) have noted that satisfaction with healthcare use may be influenced by the gap between potential healthcare use and realised utilisation. Besides, populations’ level of deprivation from healthcare access would influence healthcare satisfaction (Cabrera-Barona et al., 2018).

In the healthcare setting, older adults are likely to use healthcare services frequently (Arthur-Holmes et al., 2020; Wendt et al., 2010). Thus, there is a need to assess their dissatisfaction with healthcare use and ensure that at the latter stages of life, people can utilise healthcare without hindrances, including the possibility of getting the services requested. For instance, under the Livelihood Empowerment Against Poverty programme in Ghana, to ensure ease of access to healthcare services, older adults are enrolled in the National Health Insurance Scheme (NHIS) free of charge (Debrah, 2013). Besides, beneficiaries under the programme receive cash transfers to cater for their needs (Debrah, 2013; Handa & Park, 2012). However, this has not significantly contributed to reducing health poverty (Agyemang-Duah et al., 2019a).

The growing concerns that the Livelihood Empowerment Against Poverty cash transfers are very low and inadequate and even target a few households because of limited operation budget to take care of the basic needs of the beneficiaries (Debrah, 2013; Handa et al., 2014; Wodon, 2012) call for the need to examine dissatisfaction with healthcare use among older adults who live on low incomes. Such a study could create a moment for policy amendment and improvement that transcend the enrolment of older adults in the National Health Insurance Scheme. This is because healthcare coverage is a major component of the Livelihood Empowerment Against Poverty programme and would likely be impacted by the programme's budget allocation challenges. Thus, a study that investigates the dissatisfaction with healthcare use among older adults under the Livelihood Empowerment Against Poverty programme would draw the attention of policymakers to approach their healthcare needs from a multifaceted dimension.

Previous studies on satisfaction with healthcare use among older adults have focused on how cost and accessibility influence satisfaction (Fenton et al., 2012; Liew, 2018). Other studies have also focused on healthcare satisfaction among older adults with special needs (autism care, stroke, cancer, etc.) (Gerber et al., 2017; Mariano et al., 2016; Park, 2008). General hospital satisfaction among older people has been assessed using sociodemographic factors (Chumbler et al., 2016), but did not specifically consider the factors associated with healthcare satisfaction among older adults with very low incomes surviving under social protection programmes. Under social protection programmes, other studies have focused on poverty alleviation and livelihoods (Poku, 2019) and financial, communication as well as transportation barriers to formal healthcare utilisation among older adults with low incomes (Oduro Appiah et al., 2020a, 2020b; Agyemang-Duah et al., 2020a). Additional work on older adults with very low incomes in Ghana have explored prevalence and patterns of healthcare utilisation (Agyemang-Duah et al., 2019a), barriers to healthcare utilisation (Agyemang-Duah et al., 2019b), drivers of healthcare utilisation (Agyemang-Duah et al., 2019c, 2020b), motivation for the utilisation of private and public healthcare facilities (Agyemang-Duah et al., 2020c), dynamics of healthcare expenditure (Agyemang-Duah et al., 2019d) and dynamics of health information-seeking behaviour (Agyemang-Duah et al., 2020d). However, these studies did not focus on healthcare use dissatisfaction among older adults with low incomes and surviving under a social protection programme. Thus, little is known about the demographic and socio-economic factors that influence dissatisfaction with formal healthcare utilisation among older adults with very low incomes in sub-Saharan Africa and Ghana in particular. We fill this gap by analysing the socio-economic and demographic factors that are associated with healthcare use dissatisfaction among older adults with low incomes surviving under the Livelihood Empowerment Against Poverty programme in Ghana.

This study is important for at least two reasons. First, understanding dissatisfaction with formal healthcare use and associated factors among older adults with very low incomes surviving under the Livelihood Empowerment Against Poverty programme can inform the formulation of health policies andprogrammes that aim at lessening dissatisfaction with utilisation of formal healthcare services. Secondly, the implementation of the results from this research may be important to contributing to the realisation of goal 3 of the Sustainable Development Goals. Based on the research gap identified and the importance of the study, our objective is to assess formal healthcare use dissatisfaction and associated factors (e.g., income, education, marital status, age, gender, etc.) using survey data of older adults with low income in the Atwima Nwabiagya District of Ghana. Given that this study focuses on older adults who are enrolled in a social protection programme (Livelihood Empowerment Against Poverty), we conceptualise an older adult as an individual who is 65 years or above (Agyemang-Duah et al., 2020b; Oduro Appiah et al., 2020a, 2020b).

1.1. Material and methods

1.1.1. Sampling procedure and data collection

Data for this study were drawn from a larger Ageing, Health, Lifestyle and Health Services (AHLHS) survey on the determinants of healthcare utilisation among older adults with very low incomes conducted between 01–20 June 2018 in the Atwima Nwabiagya District (now Atwima Nwabiagya Municipality and Atwima Nwabiagya North District) in Ghana. The majority of the healthcare facilities (15/53.6%) are owned by private practitioners with 12/42.9% belonging to the Ghana Health Service (GHS). The study even though was conducted in the Atwima Nwabiagya District,selecting 16 communities based on the north, central, and south delineations made it possible to include diverse participants (participants of different socio-economic and demographic positions). In all, 4 communities (Abira, Boahenkwaa, Adagya, and Wurapong), 6 communities (Asakraka, Amadum-Adankwame, Kontomire, Hiawu-Besease, Kyereyease, and Apuyem), and 6 communities (Amanchia, Koben, Seidi, Fankamawe, Nkorang, and Nkaakom) were selected from the north, central, and south, respectively. In this study, we employed a cross-sectional study design to measure the demographic and socio-economic factors associated with dissatisfaction with formal healthcare utilisation among older adults with very low incomes who survive under a social protection scheme. Here, we conceptualised older adults with very low incomes as individuals who have attained a minimum of 65 years and receive financial support from the Livelihood Empowerment Against Poverty programme. This definition is consistent with previous Ghanaian studies and the criteria for classifying an individual as an older adult under the Livelihood Empowerment Against Poverty programme (Agyemang-Duah et al., 2020d, 2020c). Given the focus of the Livelihood Empowerment Against Poverty programme, which is a cash transfer intervention for lowincome households (such as older adults with low incomes, people with extreme disability, orphans, etc.) in Ghana, older adults with very low incomes in the study area were recruited.

The sample size for the AHLHS survey was 200 participants recruited from 16 communities in the study area using cluster and simple random sampling techniques. According to the AHLHS, 170 older adults with very low incomes utilised formal healthcare services. Because we were interested in dissatisfaction with formal healthcare use among older adults with very incomes, the sample size for this current study was 170 participants. The AHLHS survey collected data from older adults with very low incomes using questionnaires. The questionnaire was initially developed in Englishto ensure better understanding and interpretations. However, given that majority of the participants understand and interpret the local language (Twi), the questionnaire was translated into the local language (Twi) during the data collection exercise (Agyemang-Duah et al., 2020a). The explanation of the translation processes and the validity of the data collection instrument (that is questionnaire) are found in previous work (see Agyemang-Duah et al., 2019c). The administration of each questionnaire lasted between 30 to 40 minutes. Three field research assistants helped us collectthe data. These field research assistants were trained for two days to ensure quality control and ensure that the research ethics procedures were followed during the field survey. Before the start of the data collection, we sought both written and verbal consent from the participants. Ethical approval for this study was granted by the Committee on Human Research Publication and Ethics (CHRPE), KNUST School of Medical Sciences and Komfo Anokye Teaching Hospital, Kumasi, Ghana (Reference: CHRPE/AP/311/18).

1.1.2. Measures

1.2. Outcome variable

In this study, the outcome variable was dissatisfaction with the utilisation of formal healthcare services. Dissatisfaction with formal healthcare utilisation was defined as how older adults with very low incomes are discontent (in terms of healthcare desires) with their use of formal healthcare services in the past one year preceding the survey. This was measured as a dichotomous variable (1 = dissatisfied with the utilisation of formal healthcare services , 0 = satisfied with the utilisation of formal healthcare).

1.3. Explanatory variables

The explanatory variables comprise gender (1 = male, 2 = female), age (years) (1 = 65–74, 2 = 75–84, 3 = 85 or above), ethnicity (1 = Akan, 2 = non-Akan), religion (1 = Christian, 2 = non-Christian), marital status (1 = single, 2 = married), education (1 = no formal education, 2 = basic school education, 3 = high school education), income (GH¢) (1 = 100 or below, 2 = 101–200, 3 = 200 or more) [1 USD = GH¢ 4.76820 as at the time of the survey], and employment (1 = employed, 0 = Unemployed). The conceptualisations and measurements of the predictor variables are consistent with previous studies conducted among older adults with very low incomes in Ghana (Agyemang-Duah et al., 2020a, 2019c, 2020b; Oduro Appiah et al., 2020a, 2020b).

1.3.1. Analysis

In this study, we used both descriptive and inferential statistical methods to analyse the data. Regarding the descriptive statistics, we used percentages and frequencies to describe the background characteristics of the study participants and the prevalence of dissatisfaction with the utilisation of formal healthcare services among them. With the inferential statistics, binary logistic regression embedded in the Statistical Package for the Social Sciences (version 20) software was used for the analysis. We performed both bivariate and multivariate logistic regression analyses to estimate the role of demographic and socio-economic factors in the dissatisfaction with the utilisation of formal healthcare services among older adults with very low incomes in Ghana. All tests were considered significant at a p-value of ≤ 0.05.

2. Results

2.1. Demographic and socio-economic characteristics of the participants

The demographic and socio-economic characteristics of the participants are presented in Table 1. About 80.6% of the participants are females, 48.2% are aged between 65–74 years, 83.5% are Akan and 84.1% are Christian. Approximately, 72.9% of the participants are single, 64.1% have no formal education, and 38.2% earn between GH¢101-200. More than half of the participants were employed (57.6%; see Table 1).

Table 1. Sample characteristics of the participants (n = 170)

Variables	Response	Count	%
Gender	Male	33	19.4
	Female	137	80.6
Age (years)	65-74	82	48.2
	75-84	46	27.1
	85 or above	42	24.7
Ethnicity	Akan	142	83.5
	Non-Akan	28	16.5
Religion	Christian	143	84.1
	Non-Christian	27	15.9
Marital Status	Single	124	72.9
	Married	46	27.1
Education	No formal education	109	64.1
	Basic school education	43	25.3
	High school education	18	10.6
Monthly Income (GH¢)	100 or below	61	35.9
	101-200	65	38.2
	201 or more	44	25.9
Employment Status	Employed	98	57.6
	Unemployed	72	42.4

3. Dissatisfaction with the utilisation of formal healthcare services

The results showed that 28.8% of participants were dissatisfied with the utilisation of formal healthcare services. This indicates that few of the participants are dissatisfied with the utilisation of formal healthcare services.

4. Demographic and socio-economic factors explaining dissatisfaction with formal healthcare utilisation

Table 2 presents the results of the bivariate and multivariate models regarding the demographic and socio-economic factors influencing dissatisfaction with the utilisation of formal healthcare services among older adults with very low incomes.

Table 2. Bivariate and multivariate logistic regressions explaining demographic and socio-economic factors influencing the dissatisfaction with formal healthcare utilisation

Variables	COR [95% C.I. for COR]	p-value	AOR [95% C.I. for AOR]	p-value
Gender
Male (Ref)	1.00		1.00
Female	0.61 (0.25–1.51)	0.286	0.42 (0.15–0.76)	0.014
Age (years)
65–74 (Ref)	1.00		1.00
75–84	1.05 (0.47–2.34)	0.904	1.09 (0.46–2.57)	0.850
85 or above	1.03 (0.46–2.35)	0.936	0.99(0.39–2.46)	0.973
Ethnicity
Akan (Ref)	1.00		1.00
Non-Akan	1.59 (0.60–4.21)	0.348	1.62(0.58–4.55)	0.362
Religion
Christian (Ref)	1.00		1.00
Non-Christian	1.28(0.32–2.87)	0.573	1.10 (0.74–2.39)	0.111
Marital Status
Single (Ref)	1.00		1.00
Married	0.52(0.25–0.86)	0.033	0.43 (0.19–0.97)	0.042
Education
No formal education (Ref)	1.00		1.00
Basic school education	1.03 (0.47–2.25)	0.948	1.13 (0.48–2.66)	0.458
High school education	0.50(0.27–0.91)	0.043	0.35 (0.23–0.79)	0.023
Monthly Income (GH¢)
Below 100 (Ref)	1.00		1.00
101–200	0.75 (0.34–1.61)	0.455	0.766(0.34–1.73)	0.528
201 or more	1.15(1.13–3.98)	0.015	1.16(1.06–3.94)	0.014
Employment Status
Employed (Ref)	1.00		1.00
Unemployed	1.78 (0.89–3.56)	0.105	1.84 (0.87–3.91)	0.111

Ref = Reference Group = 1.00, AOR = Adjusted Odd Ratio, COR: Crude odd Ratio, CI = Confidence Interval, * p < 0.05

The bivariate results showed that married participants were 0.52 times significantly less likely to be dissatisfied with formal healthcare utilisation compared with those who are single (Crude Odds Ratio (COR): 0.52, 95% CI: 0.25–0.86). The study further revealed that participants with high school education were 0.50 times significantly less likely to be dissatisfied with formal healthcare utilisation compared with those with no formal education (COR: 0.50, 95% CI: 0.27–0.91). Also, participants who earned GH¢ 201 or more in a month were significantly more likely to be dissatisfied with formal healthcare utilisation than those who earned below GH¢100 (COR: 1.15, 95% CI: 1.13–3.98).

The multivariate results showed that females were 0.42 times significantly less likely to be dissatisfied with formal healthcare services compared with their male counterparts (Adjusted Odds Ratio (AOR): 0.42, 95% CI: 0.15–0.76). The results further indicated that married participants were 0.43 times significantly less likely to be dissatisfied with formal healthcare utilisation compared with those who were single (AOR: 0.43, 95% CI: 0.19–0.97). We found that those with high school education were 0.35 times significantly less likely to be dissatisfied with the utilisation of formal healthcare services compared with those who had no formal education (AOR: 0.35, 95% CI: 0.23–0.79). With regard to income, participants who earned GH¢201 or more were 1.16 times significantly more likely to be dissatisfied with the use of formal healthcare services than those that earned below GH¢100 (AOR: 1.16, 95% CI: 1.06–3.94).

5. Discussion

5.1. Key findings

The study revealed that gender, marital status, education, and income are significantly associated with dissatisfaction with formal healthcare utilisation among older people with low incomes in Ghana. Specifically, we found that females, married participants, and those with high school education were significantly less likely to be dissatisfied with the utilisation of formal healthcare services. We further found that those who earned GH¢ 201 or more were significantly more likely to be dissatisfied with the utilisation of formal healthcare services.

5.2. Possible interpretation in relation to previous studies

This study highlights the relationship between dissatisfaction with formal healthcare services utilisation among older adults in Ghana and various economic and socio-demographic factors. As noted earlier, there is a significant association between dissatisfaction with formal healthcare utilisation (the dependent variable) and gender, marital status, education, and income (independent variables). Whereas the study notes that few of the participants are dissatisfied with the formal health services they utilise, it would also be important to ensure equitable access, utilisation, and satisfaction with the services utilised (Abatemarco et al., 2020; Cloninger et al., 2014; Daniels, 2017; Fourie & Rid, 2017). Situating this within broader discourses on (dis)satisfaction with formal healthcare utilisation, it is imperative to ensure that the needs of healthcare users, especially older adults with very low incomes, are met and that they are satisfied with formal healthcare use.

The findings of our study indicate that there are gender disparities in terms of dissatisfaction with the utilisation of formal healthcare services. Females are less likely to be dissatisfied with formal healthcare services utilisation as compared to males. Thus, it is likely that the needs or services requested by females at healthcare facilities are met than that of their male counterparts. Our study outcome corroborates that of a study on healthcare utilisation satisfaction among the elderly in rural Vietnam (Pham et al., 2019). It was reported that in rural Vietnam, elderly women are more likely to be satisfied or very satisfied with healthcare utilisation as compared to their male counterparts who utilise the same healthcare facilities. Similarly, in a study about patients’ satisfaction with primary healthcare utilisation in Lebanon, Hemadeh et al. (2019) noted that men are less likely to be satisfied with the healthcare services provided as compared to women.

Furtherance to the gender disparity in healthcare services utilisation dissatisfaction, in a related study in Turkey, Karaca and Durna (2019) found that there is a significant difference between men and women in terms of dissatisfaction with healthcare services. However, estimating or predicting how much these gender groups are dissatisfied with the health services they utilise was beyond the scope of their study. The differences between the findings from these studies would likely be a result of differences in the quality of healthcare received, differences in the access to healthcare, and health literacy by the different gender groups. However, regardless of the differences in the outcome, healthcare policymakers should ensure that all gender groups have equal access to healthcare services by instituting gender-specific programmes to ensure equity in the satisfaction with formal healthcare use among older adults with very low incomes in Ghana. Most importantly, healthcare policymakers should take note of healthcare service user satisfaction and incorporate measures to ensure that all users are provided with the services requested. Besides, policymakers should ensure that where necessary, appropriate explanations of how healthcare professionals addressed the health concerns of users is given, especially to men who according to this study are more likely to be dissatisfied with the services they utilise in healthcare facilities.

The study outcome suggests that people who have a high school education are less likely to be dissatisfied with healthcare service utilisation than those with a low level of education. The results from our study are similar to that of Al-Harajin et al. (2019) who found that patients with an average to a high level of education are less likely to be dissatisfied as compared to those with a low level of education. Oduro Appiah et al. (2020b) in a previous study argue that those with high education are more likely to access formal healthcare most of the time, and thus would be more likely to access all the services they need satisfactorily. The difference in healthcare services dissatisfaction can also be as a result of differences in the ability to read and understand health services reports, treatment summaries, and outcomes. Thus, policymakers should improve access to education, including high school literacy which would allow more persons to read and comprehend the reports, explanations, and the different procedures performed by the healthcare providers. Also, having high education would position patients to adequately evaluate the procedures and treatment options provided by the healthcare professionals and thus, improve healthcare delivery in the future (Deshpande & Deshpande, 2014; Kamra et al., 2016; Khan et al., 2018).

The findings demonstrate that income is an important factor associated with dissatisfaction with formal healthcare utilisation. Our study suggests that older adults with high incomes are more likely to be dissatisfied with the services they utilise than those with low incomes. Older adults with high incomes are more likely to pay for their services without any financial barriers. Given that provided healthcare services often do not meet the expectations of these older people, they are more likely to be dissatisfied. On the other hand, those with low incomes may be satisfied with whatever services they are provided with and would not question the quality of these services. However, as noted in a previous study (Oduro Appiah et al., 2020a), older adults with higher incomes are more likely to access healthcare and less likely to face financial barriers to formal healthcare utilisation as compared to those with low incomes. All things being equal, it is expected that participants with higher income can afford healthcare expenditure and receive quality and timely healthcare services thereby increasing their satisfaction with formal healthcare utilisation. Whereas previous studies (Bawelle, 2016; Sackey, 2019) highlight the inadequacy and irregularity of the cash transfers made to low-income adults under the Livelihood Empowerment Against Poverty programme, this study finding has implications for policy improvement in terms of increasing the Livelihood Empowerment Against Poverty grants. For instance, it will be important for policymakers and policy implementers to ensure adequate and regular cash transfers to these poor older adults so that they can access quality healthcare service and ensure that they can express their right to receive quality healthcare. Such a policy action would ensure that the inefficiencies of the health insurance coverage are dealt with since these poor older adults have incomes to pay for the services they need satisfactorily, especially the ones not covered under the national health insurance scheme.

The results further suggest that there is a disparity in healthcare use dissatisfaction among older adults based on marital status. Study participants who are married are less likely to be dissatisfied with the formal healthcare services utilised as compared to those who are not married. This finding suggests that companionship is an important aspect of dissatisfaction with healthcare utilisation. A similar finding has been reported in a previous study in Lebanon which revealed that those married are significantly less likely to be dissatisfied with the formal healthcare service they utilise (Hemadeh et al., 2019). This finding is attributed to the fact that unmarried participants appear more likely to experience emotional stress and poor health outcome due to marital breakdown (Gyasi & Phillips, 2020). This, therefore, increases their dissatisfaction with the utilisation of formal healthcare as they may present higher healthcare needs compared with those who are married. However, in a related study in Turkey, Uğurluoğlu et al. (2019) found that married women are significantly less likely to be satisfied with healthcare services utilisation. These differences in the study outcome may likely be as a result of the differences in the type of services requested by users and the quality of service offered.

This study is the first to have measured the demographic and socio-economic factors associated with the dissatisfaction with formal healthcare utilisation among older adults with very low incomes surviving under a social protection programme in Ghana. Despite the usefulness of these findings, some limitations need to be highlighted. First, this study did not consider other variables such as health-related factors, lifestyle factors, health system, health literacy levels, and cultural norms in relation to dissatisfaction with formal healthcare utilisation. The above factors can contribute to formal healthcare use dissatisfaction among older adults with very low incomes in Ghana. Second, due to the cross-sectional design used, we could not establish a causal relationship between and among the study variables. Third, our study findings could also be exposed to a potential selective survival bias which may partly be attributed to the selection procedure of the sample and criteria for defining or conceptualising older adults with very low incomes in this study. Fourth, the small sample size used in this study could have implications for the representativeness and generalisability of the findings. Lastly, measuring the dependent variable which is dissatisfaction with formal healthcare use as a dichotomous variable limits this study. However, this baseline study provides a basis for a nationally representative study on demographic, socio-economic, health-related, health literacy levels, cultural norms, health system, and lifestyle factors associated with formal healthcare use dissatisfaction among older adults with very low incomes.

6. Conclusion

This study highlights formal healthcare use dissatisfaction and associated demographic and socio-economic factors among older adults with very low incomes in Ghana. Our findings provide evidence that few of the older adults with very low incomes are dissatisfied with the use of formal healthcare. The study has shown that demographic and socio-economic factors particularly, gender, income, marital status, and education are significant drivers of dissatisfaction with formal healthcare utilisation among older adults with very low incomes in Ghana. The implications of the study have been extensively discussed to inform policy, practice, and future research. Key among them is the call for incorporation of these significant demographic and socio-economic variables in the design of policies and programmes aimed at reducing formal healthcare use dissatisfaction among older adults with low incomes.

List of abbreviation

AHLHS-	=	Ageing, Health, Lifestyle and Health Services Survey
AOR-	=	Adjusted Odd Ratio
CHRPE-	=	Committee on Human Research and Publication Ethics
SPSS-	=	Statistical Package for Social Sciences

Ethics approval and consent to participate

All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Furthermore, ethics approval for this study was granted by the Committee on Human Research Publication and Ethics (CHRPE), School of Medical Sciences, Kwame Nkrumah University of Science and Technology and Komfo Anokye Teaching Hospital, Kumasi, Ghana (Ref: CHRPE/AP/311/18). Also, the purpose of the study was explained to the study participants before their informed written and verbal consents were obtained. Again, they were assured of the strict confidentiality and anonymity of the data they provided. They were further assured that their participation in the study was voluntary and that they were free to opt out at any time.

Data and material availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Authors contribution

WA-D conceived the study. JAB, JOA, DA, JO-A, AAM and WA-D contributed to the design. WA-D collected the data. WA-D and JOA analysed the data. JAB, WA-D, JOA and DA drafted the manuscript. AAM, JOA, JO-A and DA reviewed the draft. All authors accept final responsibility for the paper. All authors read and approved the final manuscript.

Acknowledgements

We acknowledge our study participants for providing the study data and the authors and publishers whose works were consulted.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors

Notes on contributors

Joseph Asumah Braimah

Dr. Joseph Asumah Braimah is currently a postdoctoral researcher at the Department of Public Health Sciences, Queen’s University, Canada. His research interests include Environment and Health; Ageing and Health; Health Disparities, Maternal Health, and Food Security.

Joseph Oduro Appiah

Dr. Joseph Oduro Appiah is an Assistant Professor of Sustainability at the Department of Sustainability, Western Oregon University, United States. His research interests are Land Change, Environmental Change, Human-Environment Interactions, Geographies of Health and Healthcare, Human-Dimension of Resources and Sustainability.

Dina Adei

Dr. (Mrs) Dina Adei is an Associate Professor at the Department of Planning, Kwame Nkrumah University of Science and Technology, Ghana. Her research interest covers areas such as Health Services Planning, Occupational Health and Safety, Macroeconomic Policy and Planning, and Human-Environment Interactions.

Justice Ofori-Amoah

Justice Ofori-Amoah is currently working with the Ghana Health Service as a District Director of Health Services. His research interests are Disease Outbreak Investigation, Epidemiology, Neglected Tropical Disease (NTDs) and Health Services Research.

Anthony Acquah Mensah

Anthony Acquah Mensah holds an MPhil in Planning from the Department of Planning, Kwame Nkrumah University of Science and Technology, Ghana. His research interests cover Land Governance, Smart Cities, Urban Planning and Health Systems.

Williams Agyemang-Duah

Williams Agyemang-Duah is currently a PhD Candidate at the Department of Geography and Planning, Queen’s University, Canada. His research interests include Geographies of Health and Healthcare, Geographies of Ageing, Geographies of Care, Human-Environment Interactions.