System, institutional, and client-level factors associated with formal healthcare utilisation among older adults with low income under a social protection scheme in Ghana

The population of older adults is increasing at a pace that continues to engage policy attention worldwide. Currently, older people aged 60 years or above are estimated to be around 900 million across the globe and this subpopulation is expected to outnumber children for the first time in world history by 2047 [1]. Based on the current growth rates of older individuals, the geographical distribution of the ageing demographics is projected to reach 9% in Africa, 24% in Asia, and 25% in Latin America. The proportion of older adults in North America and Europe is expected to be 28% and 35%, respectively by 2050 [2]. In sub-Saharan Africa [SSA], Ghana is identified as one of the countries with the fastest ageing population. The proportion of the country’s older demographic (60+) is estimated to rise from 6.9% in 2015 to 12% by 2050 [3, 4]. The expanding segments of the older population have been attributed to factors such as declining fertility and mortality rates and advanced technology and biomedical breakthroughs that have led to increased life expectancy/longevity [5].

Ageing has been associated with an increased risk of chronic conditions and functional disabilities. Frailty, mobility challenges, multimorbidity, and mental health challenges are reported to be more prevalent in older adult population [6, 7]. Even though ageing is not synonymous with poor health or chronic conditions, it is associated with health conditions such as diabetes, cardiovascular diseases, kidney problems due to physiological changes and gradual biological decline along the life course [7]. Thus, population ageing and its associated higher risk of chronic morbidities place older adults on a greater need for health services to improve health outcomes and general well-being in later life [6, 8, 9]. Hence, older adults are higher users of health services compared to the younger age groups [10]. For example, while about 52% of the residents in Ghana utilise various healthcare services every year, older adults constitute about 52.41% of the annual health service users in the country [3, 11]. This presupposes that population ageing may exert additional pressure on healthcare resources as well as increase the cost burden of health service provision. In examining the relationship between ageing, health services use, and healthcare expenditure, Breyer and colleagues [12] reported a positive correlation between ageing and healthcare expenditure. A study by Ambagtsheer and Moussa [13] in Côte d’Ivoire revealed that frailty was associated with increased health service use and total health expenditure. Awoke et al. [11] indicated that ageing has a positive relationship with the use of formal healthcare services in Ghana. Similarly, Huang et al. [14] noted that major depressive symptoms predominantly common in older adults increased the healthcare utilization and cost in Sao Paulo. Older adults with comorbid physical and mental health conditions were more likely to be hospitalized or receive emergency services in the US [15]. Despite their higher health services demand, not all older adults can access required health services at the time of need, an idea suggesting determinants of health services use and outcomes [16].

Considerable literature has emerged describing demographic, biological, and socioeconomic factors that contribute to health services uptake among older adults [11, 17]. Older adults with better economic conditions tend to access and utilize health services easily and more desirably [17, 18]. This evidence suggests existential barriers to access and use of health services needed by older people with lower socioeconomic status. The inequality of access and use of desired health services, according to Van Doorslaer et al. [19, 20, 21] exacerbates for poor individuals in healthcare systems where users pay out-of-pocket for healthcare services and/or episode billing systems (payments at the point of accessing services) [20, 22]. Thus, the affordability of healthcare becomes prohibitive for lower socioeconomic groups, thereby preventing them from utilizing needed health services [23]. Socio-demographic factors such as age, gender, education, and marital status have been verified in several studies to predict health services use among older populations [24, 25]. In China, Gong et al. [10] examined the impact of marital status, gender, and age on healthcare resource use. The study observed a significant association between the study variables and healthcare utilisation. They specifically highlighted that married older females had higher odds than their male counterparts to access available health services. Moreover, another potential determinant of healthcare access by older adults is discrimination perpetuated by clinical staff or administrative and clerical staff. Discrimination can manifest in a form of unequal treatment in healthcare settings by virtue of an individual’s membership in a socially defined group [26, 27]. Communication gaps between providers and patients as well as the differential approach in physician referral behaviour may help in explaining the differences in patterns of health services uptake by older people [28].

Despite the expanding literature on determinants of health services utilisation among older individuals, studies on the subject in most developing countries such as Ghana have overly focused on demographic, economic and health-related factors, neglecting point of access and systemic factors that in concert, shape the help-seeking decisions by older people. To holistically understand healthcare use determinants and to strategically design policy frameworks to achieve healthy ageing, analysis of all the possible determining factors of health services use is desirable. Therefore, this study investigates the system, institutional and client-level factors associated with formal healthcare utilisation among older adults with low income in Ghana.

In recent decades, utilisation of formal healthcare by older adults, especially those with low income in developing countries has become a topical issue in international discussions. This cross-sectional study contributes to the debate by providing evidence of client, institutional and system-level factors associated with formal healthcare utilisation among older adults with low income under a social protection scheme in Ghana. In the final model, the study found that client-level factors(such as health insurance/social scheme subscription, autonomy on healthcare utilisation decision), institutional (such as communication problem with healthcare providers and attitudes of healthcare providers) and system-level factors (such as length of stay at the health facility), were associated with the use of formal healthcare among the participants. Our finding is relatively similar to evidence from previous studies [35‐37]. For instance, in Ghana, van der Wielen et al. [35] reported that enrollment in NHIS among older adults increased the utilisation of inpatient and outpatient care by 6% and 9%, respectively, compared to non-members. In a study by Singh et al. [36] in India, older adults explained that long waiting times acted as a barrier to the utilisation of formal healthcare. Agyemang-Duah et al. [37] indicated that communication with health providers was associated with the use of formal healthcare among older adults.

On the client level, having health insurance increased the odds of utilising formal healthcare services compared with the lack of health insurance. Previous studies have established a positive relationship between health insurance and healthcare utilisation [38‐41]. This indicates that older adults’ decision to use formal healthcare is to some extent influenced by access to health insurance considering the evidence that older adults with valid health insurance have a higher tendency to use formal healthcare compared with non-enrollees. This finding can be plausibly explained by several factors. For instance, health insurance to some extent replaces out-of-pocket payment for formal healthcare services, which enhances access to health services at a reduced or no cost. Because our study participants were older adults with low income, the removal or reduction of financial barriers to healthcare allows them to use services since the cost burden is either removed or diminished. This explanation is supported by previous assertions and observations by WHO [42] and Van der Wielen et al. [35] that social protection schemes such as health insurance promote healthcare utilisation among groups with low income including older adults. More importantly, our finding indicates that health insurance is a dominant client-level factor influencing the use of formal healthcare among older adults with low income. This is because the introduction of institutional and system-level factors such as waiting time, quality of care, satisfaction and communication problems did not significantly reduce the strength of association between health insurance enrolment and healthcare utilisation. This somewhat supports the proposition that financial constraints could be, perhaps, the major reason, for unmet needs for, and delays in, seeking healthcare and reduced well-being in later life [11, 43‐46]. Our finding, therefore, implies that policies and measures to improve the implementation and sustainability of Ghana’s health insurance scheme are imperative. This is in line with Gyasi et al. [47] observation that when well-resourced and systematically sustained, Ghana’s health insurance scheme could eventually lead to improvements in the health status of older persons due to the improvement in healthcare use, insofar as these two variables are positively associated.

The study revealed that autonomy concerning decisions as to when and where to seek healthcare as a client-level factor was also associated with healthcare utilisation among older adults with low income. Interestingly, those whose family/caregivers decided on where and when to use formal healthcare had a greater tendency to use formal healthcare compared to those who could decide for themselves. This finding is interesting and appears somewhat difficult to explain. However, it would relate well with the sociocultural practices in Ghana that promote collective decision making about health [48; 49]. Also, it is possible that most of the participants might have developed dementia and other forms of Alzheimer’s disease which keep their thought from the use of formal healthcare services [50], especially when they do not have any family/caregiver to determine when and where to utilise healthcare services. Again, it is possible that most of the participants have developed strong taste for traditional medicine as remedies for their health problems, hence autonomy concerning decisions as to when and where to seek help veer towards the use of tradional medicine. We however acknowledge that the above reasons may not be sufficient as there is the likelihood of other underlying factors to predict the lower odds of formal healthcare utilisation among the participants who have autonomy in relation to formal healthcare utilisation. However, because of the quantitative nature of this study, we were not able to look into this issue which will call for a further qualitative study.

Crucially, perceived communication barrier was an important institutional-level factor that influence formal healthcare utilisation among the participants. Older adults who did not encounter communication problems with healthcare providers had higher odds of utilising healthcare services compared to those who experienced communication problems with providers. Previous studies have highlighted the important roles of effective communication in health provision [51‐55]. Evidence shows that effective communication among patients and providers is essential in all healthcare settings and all aspects of healthcare, from prevention and health maintenance to illness diagnosis, treatment, and recovery [56‐58]. Research also shows that effective communication, grounded by core values, improves health outcomes, quality of care, and patient and clinician satisfaction [59]. Likewise, the link between poor communication and poor health outcomes has been extensively established [60]. Poor communication in healthcare leads to delayed treatment [60]. Without effective communication, messages and signals will be misinterpreted and misunderstood which can lead to unmet needs of patients [61]. This suggests that perceived communication problem with providers serves as a barrier to the use of formal healthcare services among older adults [62]. To facilitate greater use of formal healthcare by older adults, healthcare organisations and providers should identify ways to promote effective cross-cultural communication in healthcare settings [62].

Our study also found that another institutional-level factor associated with older adults’ formal healthcare use was perceived poor attitude of healthcare providers. Older adults who perceived the attitude of healthcare providers as poor had decreased odds of utilising formal healthcare compared to those who rated the attitude of healthcare providers as good. Healthcare providers’ attitude toward older adults has been previously mentioned as an important determinant of formal healthcare use [43, 62, 63]. Evidence suggests that the physiological and psychological conditions of older adults require that healthcare providers treat them with maximum care and respect [63]. However, many older adults mostly do not get the expected care and respect from providers, and this influences their decision to utilise formal healthcare [62]. This may explain why in our study older adults who perceived providers’ attitudes to be poor were less likely to utilise formal healthcare services. Personal experiences and previous encounters among our participants may also explain this finding. For instance, in Namibia, Aboderin and Beard [64] reported that older patients did not use commercial providers because of the unavailability, perceived poor quality, or age insensitivity of services in government facilities. Also, in a qualitative study by Agyemang-Duah et al. [62] in Ghana, older adults explained that non-respectful attitude, unapproachable interaction style and failure of formal healthcare providers to accord them the needed respect and care influence their decision to stay away from formal healthcare utilisation. Our finding, therefore, indicates that a change in providers’ attitudes may improve formal healthcare utilisation among older adults with low income in Ghana.

Again, this study found that system level factors such as waiting time was associated with formal healthcare utilisation among older adults with low income. Older adults who spent between 20 and 40 min at the healthcare facility had decreased odds of utilising formal healthcare compared with those who spent less than 20 min. Waiting time has been previously identified as a system-level issue that significantly influences healthcare utilisation [64, 65]. Our finding suggests that long waiting times at a health facility may influence older adults’ decision to utilise formal healthcare. To address long waiting times, healthcare providers should employ adequate and competent staff to care for patients [43, 66]. On the client level, older adults should visit health facilities near them, on days other than Mondays and in the afternoons to avoid long waits at health facilities [67].

To the best of our knowledge, this is one of the first studies that explore this important issue, especially for older adults with low income enrolled in a social protection scheme in Ghana. Despite the contributions of this study, some limitations are notable. Our findings may be exposed to a potential selective survival bias which may partly be attributed to the selection procedure of the sample and criteria for defining, conceptualising, or categorising our variables and key concepts in this study. Also, given the cross-sectional nature of the study, the direction of the causal relationship between healthcare use and factors influencing healthcare utilisation among older adults with low income cannot be determined. The results only show a significant association between these variables. Future studies should investigate the causality of the associations and the underlying mechanisms in more detail.