Unmet health care needs of elderly residing on urban areas of Sunsari District, Nepal. A Cross Sectional Study

Background : Global ageing population is in increasing trend. Morbidity increases with age and enhances the burden of health problems that results in new challenges to meet the additional demands. There can be various types of issues such as health problems, health care utilization, physical and social care which should be carefully assessed and addressed. Objective : This study aimed to assess the unmet health care needs among elderly. Methodology : A Community based, House to House, Cross sectional study was conducted in urban areas of sunsari district using face to face interview. Sample size of 530 elderly were selected by Systematic proportionate random sampling technique. Results : This study unfurled the prevalence of unmet need for consultation for Near vision 52.3%, Far vision 53.7%%, Hearing 79.7%, Dental 79.4%, Hypertension 6.7%, Diabetes 3.9%, CVD 5.3 %, and of at least one Unmet Health care need to be 64.9%. At least one unmet health need was significantly associated with higher odds among elderly of age more than 70, of dalit and janajati ethnicity, illiterate, poor, those with difficulty leaving home, distance of health facility > 30 mins, and those with depressive symptoms. Conclusion : The study highlighted higher prevalence and associated factors related to unmet health care needs among elderly. There is an urgent need to promote geriatric health services and make it available at the primary health care level.


INTRODUCTION
Ageing is universal and inevitable biological process that renders physical, psychological, and social transformation.(1) At the biological level accumulation of a wide variety of molecular and cellular damage over time results in ageing. (2) Morbidity increases with age resulting in new challenges to meet the additional demands thus enhancing the burden of health problems. (3) The life transitions such as retirement, relocation to more appropriate housing, and the death of friends and partners is also associated with ageing beyond biological change. (4) Elderly population comprises of 12% of the global population. Nepal is also witnessing an increasingly ageing population with its ageing population 8.1% in 2011. Life expectancy has increased from 41 years in 1971 to 68 years in 2012 and the growth rate of ageing population is around 3.5% and is in increasing trend while total population growth rate of Nepal is 1.4% and is declining. The increasing aging population and the sustained shift in population age structure poses an array of challenges to overall health services and policy makers to combat with different morbidity patterns among elderly residing in Nepal.(12,13)Also to fulfil the pledge of the 2030 agenda for sustainable development that "no one will be left behind" it is essential to prepare for the economic and social shifts associated with an ageing population with implications from all sectors of society.
(14) Unmet health care needs can be defined as the difference between the health care services deemed necessary to deal with a health problem and the actual services received.(8) The problems that are not being addressed by the existing service delivery system can be highlighted by assessment of unmet needs, also it considers both health status and the receipt of assistance.(15) Through assessment of the factors that influence health care utilization and unmet needs of the elderly prevalent in society it will be helpful to inform the policy as the social protection is limited and many of the needs of elderly are unmet with a lack of sensitivity and awareness regarding the rights and protection of the elderly.(5)

Primary Objective:
To assess the unmet health care needs among elderly residing in urban areas (Itahari and Dharan) of Sunsari district.

Materials and Method
This was a Community Based Cross Sectional Study within a period of one year from September 2017 to August 2018 in selected areas of Itahari and Dharan. People of Age 60 years and above willing to participate in the study were included in the study and those with diagnosed mental health problems under medication, severely ill who needed emergency care were excluded from the study. Sample Size was calculated at 95% confidence interval and 85% power taking the prevalence of unmet health care needs in people suffering with hypertension from study done in Bhaktapur District was 26.2%.(3) The total calculated sample size was 530.
Systematic proportionate random sampling was done to obtain the representative sample. The proportion was based on total population of metropolitian and population in each selected ward. Wards were selected randomly using lottery method. Selected ward was visited and bottle was rotated at the middle junction and first household was chosen in the direction that bottle pointed. Then every 3rd house was taken for the study until the desired sample size was fulfilled. In case sample criteria, didn't meet in the selected household the adjacent household with sample criteria was taken for the data collection.
Semi-structured pre-tested Questionnaire were used to gather information regarding demographics and other variables. Participants reporting a chronic disease were asked to identify their problem(s) in a list of 5 chronic diseases used by package for IRC/1163/017) The permission to coduct study in respective areas were obtained from municipality office.

Data Management and Statistical analysis
Statistical analysis was done using Statistical package for social sciences. For Descriptive analysis is presented in frequency, percentage and bi-variate analysis was done using appropriate test of significance (chi-square test). Multivariate binary logistic regression was then further done to find the adjusted odds ratio for the determinants. Statistical significance is tested with 95% confidence interval and p value less than 0.05 is considered significant.

Operational Definitions:
The term elderly has been used as a Senior citizen where "Senior Citizen" means a citizen of Nepal having completed the age of Sixty years. (19) Common Health problems were sensory functional limitations (Near vision, Far vision, Hearing and Chewing).(8) Common presenting symptoms symptoms in elderly were inquired by asking if they have any problems from a list of common presenting symptoms in elderly obtained by study in chandigarh. (20) Depressive symptoms was referred to as scores above 20 in BDI-II. (18) Ethnicity was categorized as per HMIS classification of ethnicity, which was based In the study participants 63.8% were currently married, (47.4%) were living in pukka house, 2.6% of elderly were living alone. More than half (56.0%) participants were below poverty line and 20.4% of the participants had per capita income less than NRs 43,200 (USD -375$). Most of the participants (67.7%) had no any schooling, and regarding work status majority (49.2%) were not working. (Table 1)

Felt needs and unmet health care needs for common health problems
The felt need for common health problem was highest for those with difficulty in near vision out of which 52.3% have not consulted and 55.1% of those who consulted didn't get required treatment. Similarly, higher proportion of unmet need for consultation with felt need (79.7%) and unmet need for treatment in those who consulted (90.6%) was seen in those complaining hearing impairment. In common health symptoms majority (58.1%) complained of pain and swelling of joint and unmet need for consultation was higher among those with Giddiness and fainting (56.6%). In chronic illnesses 34% reported to have hypertension which was highest.
( Table 2) This study found the prevalence of at least one unmet health care need to be 64.9% among elderly population. (Table 3) The higher proportion of participant with at least one unmet health care need was seen among the age group of 80 years and above (76.7%), female gender (69.2%), ( Table 4) In binary logistic regression analysis the participants of age group 80 years, dalit by ethnicity, illiterate, those with lesser income, those complaining of difficulty leaving home without help, those going nowhere taking home remedy, those reporting more than 30 minutes time to reach health facility and those with depressive symptoms were found at higher odds of having unmet health care needs with significant association. The participants visiting their respective welfare camps for their illness were seen to be protective with odds of 0.138. (Table 5)

Discussion
Elderly are the dependent population of the country and taking care of them is the responsibility of country as well as their children but developing countries like our's, lack an effective way to cope with such problems of elderly. We should explore the resources to make it easier and compatible for fulfillment of needs of elderly population.

Prevalence of Unmet Health Care Needs
Unmet health care need was reported by 64.9% and prevalence increased with age, reaching 76.7% in people of age 80 years and older. Similar to this in a study done in French elderly the prevalence increased with increasing age and unmet health care needs were reported by 23.0% of the study population and prevalence increased with age, reaching 46.1% in people aged 95 and older. (8) There was a marked differences in findings of similar study done in another city of Nepal regarding the proportion of unmet health care needs for different health needs and it may be due to the study location, study design and also our study constituted almost double sample size. (3) Also our country Nepal is a home of cultural diversity so there can be difference in the way population act and take responsibilities about their health.
The prevalence of unmet need was more in our study compared to study in French elderly which reported 23% have at least one unmet health care needs but similar in a way that study also reported unmet needs for visual impairment, hearing care and dental care to be 44.2%, 88.0% and 76.4% respectively.(8) In our study 1.9% (3/158) of those with hearing problem were found using hearing aid similar to the study which reported use of hearing aids was very low-only 1.47% (6/257) of the hearing impaired were using a hearing aid. (26)

Predictors of Unmet health care needs
Similar to our study French study revealed age, regular homebound status, tobacco smoking, A poor economic situation, a low level of former employment, limitations in IADL and depressive status as the risk of having unmet health care needs. (8) Similar to our study in a study done in Serbia the probability for those least reporting unmet health care needs included those with higher education and who belong to the richest quintile but differ in work status as unemployed were seen protective and unemployed elderly in our study were seen with higher odds of having unmet health care needs.

Consent for publication:
There is no any personal identification or information in this study.
Data Availability: Data used in generating result of this study can be made available from author whenever needed on request.
Competing Interest: The authors declare that they have no competing interest for this study.
Funding: There is no any source of funding and the expenses of study was carried out by author.

Authors Contribution: Every author has contributed in the study. Dr Mukesh Poudel and Mrs
Asmita Ojha were involved from proposal writing, data collection to data analysis, result generation and writing of manuscript. Professor Dr Anup Ghimire, Dr Deepak Kumar Yadav, Dr Ram Bilakshan Sah and Mr Avaniendra Chakravarrty were involved in supervising and edition of the article and helped in every step from proposal writing, obtaining ethical approval to fulfillment of this research.