Self-reported health problems, health care utilisation and unmet health care needs of elderly men and women in an urban municipality and a rural area of Bhaktapur District of Nepal

Abstract

The study aimed to identify the felt common health problems, utilisation of health services and unmet needs of urban and rural elderly people of Bhaktapur district, Nepal. It was a cross sectional population study of people aged 60 years or more where 204 respondents were interviewed in 2009. The common felt problems were pain and swelling of joints (65.7%), indigestion (63.7%), excessive tiredness (38.2%) and hypertension (35.8%). Pain and swelling of joints (72.5%) and back pain (40.4%) were higher in rural elderly population whereas indigestion (67.6%) and hypertension (37.85%) were higher in urban population. Pain and swelling of joints (66.7%) and indigestion (69.6%) were higher in males, and hypertension (50.0%), back pain (38.2%) and chronic bronchitis/asthma (39.2%) were higher in females. The unmet needs varied between different health problems. In general women had more unmet needs than men, where 80 unmet needs were identified for the 102 men compared with 105 for the 102 women, and these unmet needs increased dramatically with age. This approach yields new insights into the health care needs of the elderly and will be helpful to health care planners.

Keywords:

• Common health problems
• elderly
• health survey
• Nepal
• unmet needs

Introduction

Morbidity increases with age, and rise of proportion of elderly people also enhances the burden of health problems that results the new challenges for the healthcare systems to meet the additional demands. These needs should be carefully assessed and addressed for the welfare of those people. The information about the real situation of elderly people should be collected from local, regional, and national level to identify the actual needs in the process of need assessment. There can be various types of issues such as health problems, health care utilisation, physical and social care and others.

This study aims to develop the methods of assessing self-reported health problems, health care utilisation and the unmet health care needs of men and women aged over 60 years in urban and rural communities. This study was conducted in Bhaktapur Municipality and Sirutar Village Development Committee of Bhaktapur district of Nepal. Quantitative methods were applied to gather the information and self-administered questionnaires were used by the investigator in 2009. This study tries to illustrate the common health problems perceived by the respondents to identify the gap between consumer and service providers.

Methods

A descriptive cross-sectional study was conducted to assess the felt common health problems to identify the unmet health care needs of the elderly people. The study sites were selected in coordination with the staff of the District Health Office, Bhaktapur, local people and other concerned authorities. The selected urban sites were 6–14 wards (9 wards) of Bhaktapur Municipality and rural sites were from 1 to 9 wards of Sirutar Village Development Committee. During the study, the estimated population of Bhaktapur municipality was 83,556 and Sirutar Village development committee was 5319. Likewise, the estimated numbers of elderly people in Bhaktapur Municipality were 5431 and Sirutar Village Development Committee was 345. The study population was selected from the list of households provided by respective local authorities. The household having at least one person who had completed 60 years of age was included in this study. The sample size was 204 elderly people which were conveniently selected in equal numbers from urban and rural sites of either sex.

The sets of questions were developed from different sources depending upon the nature of study such as the socio-demographic questions were chosen from the Demographic Survey Questionnaire Module of World Health Organization [1], and felt common health problems from various other sources [2–4] and quality of life scale [5]. During the survey, the households of 286 elderly people were visited. However, face to face interviews were conducted with only 204 respondents to gather information. The representation of the males and females were equal in number from rural and urban study areas (n = 102). The health needs were identified by computing felt illness (health needs), taken consultation (demand) and performed medication (supply) with health professionals by respondents of both study areas. Unmet needs were determined by the gap between felt needs and utilisation of the available services.

For the purpose of ethical consideration, the proposal was submitted by researcher to Nepal Health Research Council which was duly approved. Informed consent was obtained from each respondent before administering the questionnaires. Those who were unable to respond the questionnaires themselves, the information were received from the either carer or family members with consent of the respondents. Those who denied to participate in the study or unavailable at the visits were not included in this study.

Results

According to the census 2001, the total population of Nepal was 23.1 million, of which 6% were aged 60 or over which is estimated to rise up to 14% by 2050 [2]. In 2009, the number of elderly people has increased to 6.5% (1.74 million) of total the estimated population of 27.5 million. In this study, 286 families of those individuals who have completed 60 years of age were visited. Among them only 204 respondents were interviewed. The response rate was 71.3%. Among them 109 (53.4%) were in the age group of 60–69 years, 72 (35.4%) in the age group of 70–79 years and 23 (11.2%) in the age group of 80+. The mean age of total respondents was 71.3 years. The respondents were equal in number in respect to gender and place of residence. The majority, 120 (58.8%) respondents were from Newar community where as 46 (22.5%) were Brahmins, 35 (17.2%) were Chhetris and remaining 7 (3.5%) respondents were from other ethnic groups. All of them were Hindus and only one-third were literate. Two-thirds of the respondents were living together with their spouses and remaining one-third were either widows or widowers.

Their economical needs were fulfilled by combination of the one or more resources such as 106 (51.9%) social security allowances, 74 (36.3%) family support, 63 (31.0%) agriculture and 45 (22.2%) old age allowance and 17 (8.3%) were pensioners. The remaining others 6 (2.9%) from urban area were engaged in business. Fourteen respondents (7.0%) were either physically or mentally unable to respond the administered questions. Almost equal proportions of the respondents were living either in a nuclear family (a family group consisting of only a father and mother and their children), joint family (a complex family, parents and their children's families often live under a single roof) or extended type of family (a nuclear family embracing the grandparents, aunts, uncles, cousins and sometimes more distant relatives).

Felt common health problems by the respondents

During the survey 16 possible common health problems of the elderly persons were asked with respondents to know whether they felt any problem in last 1 year. A total number of 705 different common health problems were reported by the respondents from both study areas of which 55.3% (390) were in urban and 44.7% (315) in the rural study area. The average number of felt common health problem was 3.4 episodes per person per year. Table I shows the prevalence of felt common health problem in which pain and swelling joints accounts for 134 (65.7%), indigestion 130 (63.7%) and excessive tiredness 78 (38.2%). The other felt common health problems which are not included in this table were 16 (7.8%) hearing impairment, 15 (7.4%) fall, 15 (7.4%) depression, 14 (6.9%) diabetes mellitus, 8 (3.9%) heart problems and 4 (2.0%) tuberculosis.

Table I.  Prevalence of felt common health problems by number of elderly people.

Felt common health problems*	n = 705	Percentage	Rank
Pain and swelling of joints	134	65.7	1
Indigestion	130	63.7	2
Excessive tiredness	78	38.2	3
Hypertension	61	35.8	4
Back pain	61	29.9	5
Chronic bronchitis/asthma	53	25.9	6
Visual impairment	39	19.1	7
Anxiety	30	14.7	8
Insomnia	28	13.7	9
Incontinence of urine	22	10.8	10

*The occurrence of more than one problem was possible in a respondent.

Felt common health problems by the place of residence

Table II shows the prevalence of felt common health problems of elderly people residing in urban and rural areas where some individuals reported more than one medical problems. The prevalence of felt common health problems of pain and swelling of joints, excessive tiredness, back pain, anxiety and insomnia were higher in the rural elderly people whereas indigestion, hypertension, chronic bronchitis/asthma, visual impairment and incontinence of the urine were higher in urban elderly people. The Chi square test showed a significant association between site of residence and reported high blood pressure (more in elderly people of urban areas) compared to rural people (p = 0.032), but the prevalence of back pain in rural elderly people was higher than in urban elderly people (p = 0.016).

Table II.  Felt common health problems by elderly people by place of residence.

Felt common health problems	n = 705	Place of residence
		Frequency (n)		Percentage (%)
		Urban	Rural	Urban	Rural
Pain and swelling of joints	134	63	71	63.7	72.5
Indigestion	130	69	61	67.6	59.8
Excessive tiredness	78	34	44	33.3	43.1
Hypertension	61	38	23	37.3*	22.5
Back pain	61	20	41	19.6	40.1*
Chronic bronchitis/asthma	53	31	22	30.4	21.7
Visual impairment	39	22	17	21.6	16.7
Anxiety	30	13	17	12.7	16.7
Insomnia	28	13	15	12.7	14.7
Incontinence of urine	22	12	10	11.8	9.8

Statistically significant *p < 0.05.

The distribution of common health problems in men and women by sex and age groups

Table III shows the prevalence of felt common health problems of elderly men and women in relation to gender and age group. The prevalence of felt common health problems between males and females shows indigestion (69.6%), chronic bronchitis/asthma (32.4%), visual impairment (21.6%) and incontinence of urine (14.7%) were more common in men whereas excessive tiredness (50.0%), hypertension (38.2%), back pain (39.2%), anxiety (15.7%) and insomnia (17.6%) were more frequent in female elderly people. Chi square test shows that there is a significant association between the gender of elderly people and felt common health problems with high blood pressure more likely in elderly females compared to elderly males (p = 0.014). Back pain in females was also significantly higher (p = 0.001) compared to males whereas excessive tiredness was more likely in females compared to male elderly people (p < 0.001). The frequency of pain and swelling of joints was similar in men and women. The prevalence of all felt health problems increased with age (Table III).

Table III.  Distribution of felt common health problems by gender and age group.

			Age groups
	Gender (n)		Male (%)			Female (%)
Felt health problems	Male	Female	60–69 years	70–79 years	80+ years	60–69 years	70–79 years	80+ years	Total no.
Pain and swelling of joints	66	68	59.3	75.7	80	54	74.3	76.9	134
Indigestion	71	59	64.4	75.8	80	48	64.1	76.9	130
Excessive tiredness	27	51*	16.9	36.3	50	46	48.7	69.2	78
Hypertension	22	39*	18.6	24.2	30	30	43.5	53.8	61
Back pain	21	40*	15.5	24.2	40	26	48.7	69.2	61
Ch. bronchitis/asthma	33	20	28.9	33.3	50	14	23.1	30.1	53
Visual impairment	22	17	10.1	27.2	70	4	12.1	84.6	39
Anxiety	14	16	8.5	18.2	30	10	15.3	38.5	30
Insomnia	10	18	3.4	15.5	30	4	17.9	69.2	28
Incontinence of urine	15	7	3.4	21.2	60	2	10.2	15.2	22
Total No.	102	102	59	33	10	50	39	13	204

Statistically significant *p < 0.05.

Unmet needs in the felt common health problems

Table IV shows the pattern of prevalence of different types of common felt health problems comparing the frequency of consultations as felt needs with sought consultations as demand and performed treatment as supply by respondents in both urban and rural study areas. It shows that of the total episodes of 134 (68.14%) felt pain and swelling of joints, 101 (75.4%) sought consultation and only 81 (60.4%) took treatment resulting in 33 (24.6%) who did not take any treatment. The range of unmet needs varies in number from minimum of 1 (4.5%) person in incontinence of urine to highest of 36 (46.20%) persons for excessive tiredness. In general women had more unmet needs than men, where 80 unmet needs were identified for the 102 men compared with 105 for the 102 women. Women had more unmet needs for 6 out of the 10 common health problems with similar rates for the other four conditions. Unmet needs increased dramatically with age; in the 60–69 year age group one in four men and one in two women reported an unmet health need compared to 1.1 health unmet needs per man and 1.6 unmet needs for women in the 70–79 year age group, and 3 unmet needs for every man and 1.9 unmet needs for every women in the 80 years and over age group.

Table IV.  Unmet needs of the felt common health problems.

Felt common health problems	Felt illness (need)	Sought consultation (demand)	Performed treatment (supply)	Unmet needs
	n (%)	n (%)	n (%)	n (%)
Pain and swelling of joints	134 (68.1)	101 (75.4)	81 (60.4)	33 (24.6)
Indigestion	130 (63.7)	91 (70)	76 (58.5)	39 (30)
Excessive tiredness	78 (38.2)	42 (53.8)	26 (33.3)	36 (46.2)
Hypertension	61 (35.8)	57 (93.4)	35 (57.4)	16 (26.2)
Back pain	61 (29.9)	54 (88.5)	34 (55.7)	7 (11.5)
Chronic bronchitis/ asthma	50 (26)	37 (74)	23 (46)	16 (32)
Visual impairment	39 (19.1)	29 (74.4)	24 (61.5)	10 (25.6)
Anxiety	30 (14.7)	19 (63.3)	14 (46.7)	11 (36.7)
Insomnia	28 (13.7)	12 (42.9)	8 (28.6)	16 (57.1)
Incontinence of urine	22 (10.8)	21 (95.5)	15 (68.2)	1 (4.5)

Discussion

This study aimed to identify the prevalence of common felt health problems and unmet health care needs of the elderly population of an urban and rural people of Bhaktapur district of Nepal. The available information related to health problems and health seeking behaviours of elderly people are very limited and inadequate for the policy makers in Nepal.

This study showed the prevalence of pain and swelling of joint in 65.7% and back pain in 29.9% of the respondents. Although, in a study conducted by Aacharya et al. [3] in Dharan Municipality of Nepal found 76% and 60% of the elderly people suffered from joint pain and back pain, respectively. In another study conducted by Swami et al. in India [4] also reported 36.5% of the respondents suffered from pain and swelling of joints. Likewise in another study conducted, jointly by the Government of India and WHO [6] also reported 36.1% of the elderly people suffered from joint pain. Another study conducted by Brochet et al. [7] people reported the prevalence of backache as 29.6% in the age group of 65+ years. In this study 61 (35.8%) respondents were hypertensive which is higher than the finding of Aacharay et al.'s [3] study who reported 50% with hypertension in an urban area of Nepal. A similar study conducted by WHO in India [6] found 38.2% of elderly people suffered from high blood pressure. Another study by Patnaik et al. in urban slum of Brahampur Orissa [8] also revealed the presence of hypertension in more than 50% of the elderly population. Aacharya et al. [3] in the same study reported the prevalence of insomnia in 43% of the elderly population, whereas in this study insomnia was reported in 13.7% of the elderly people.

These above findings from the different studies suggest and support that the elderly people are always prone to suffer from common health problems demanding additional care and support. The frequency of all felt health problems increased with age, and gender differences were observed for specific health problems. The analysis of unmet health needs identified more unmet needs in women than in men, and a dramatic increase in unmet needs with increasing age in both men and women.

Older people might consider joint pain as a minor problem, because they are able to perform their regular duties with some degree of discomfort and a little effect to physical mobility. They may think it is a minor problem in old age and do not require treatment. The reason for the higher frequency of pain and swelling of joints could be the consequence of physical work in both indoor and outdoor. In Nepalese tradition, females have to lift heavy objects, carrying water from source to house immediately after delivery, work in agricultural farms, bending and have to carry heavy objects with children on their back. The explanation for more high blood pressure in urban area compared to rural area could be due to less physical activity among urban people and availability of more frequent blood pressure measurement facilities in towns.

Conclusion

This study has provided an opportunity to develop methods to assess the health status of the elderly people describing the pattern of diseases in those urban and rural study areas. It has also helped to learn more about the actual needs, the priority of elderly people and highlighted areas of unmet needs. Future planning of the health services considering scarce resources needs information to help allocation of those limited resources. This will be helpful to describe the needs of elderly people. However, these findings can provide only a snap shot of the unmet needs of the elderly people of those study areas and which are also associated with social factors which require integrated multi-sectoral approaches. There is a need for further research and more extensive surveys in different regions of Nepal to be more realistic in long-term planning of required health services for the growing number of elderly people.

Declaration of interest: The authors do not have any conflict of interests and are responsible for the content and writing of this article.