Morbidities, health problems, health care seeking and utilization behaviour among elderly residing on urban areas of eastern Nepal: A cross-sectional study.

BACKGROUND: Morbidity increases with age and enhances the burden of health problems that result in new challenges to meet additional demands. In the ageing population, health problems, and health care utilization should be assessed carefully and addressed. This study aimed to identify chronic morbidities, health problems, health care seeking behaviour and health care utilization among the elderly.
METHODS: We conducted a community based, cross-sectional study in urban areas of the Sunsari district using face-to-face interviews. A total of 530 elderly participants were interviewed and selected by a simple proportionate random sampling technique.
RESULTS: About half, 48.3%, elderly were suffering from pre-existing chronic morbidities, of which, 30.9% had single morbidity, and 17.4% had multi-morbidities. This study unfurled more than 50.0% prevalence of health ailments like circulatory, digestive, eye, musculoskeletal and psychological problems each representing the burden of 68.7%, 68.3%, 66.2%, 65.8% and 55.7% respectively. Our study also found that 58.7% preferred hospitals as their first contact facility. Despite the preferences, 46.0% reported visiting traditional healers for treatment of their ailments. About 68.1% reported having difficulty seeking health care and 51.1% reported visits to a health care facility within the last 6 months period. The participants with pre-existing morbidity, health insurance, and an economic status above the poverty line were more likely to visit health care facilities.
CONCLUSION: Elderly people had a higher prevalence of health ailments, but unsatisfactory health care seeking and health care utilization behaviour. These need further investigation and attention by the public health system in order to provide appropriate curative and preventive health care to the elderly. There is an urgent need to promote geriatric health services and make them available at the primary health care level, the first level of contact with a national health system.

Introduction

Ageing is an inevitable biological process that renders physical, psychological, and social transformation with an increasing possibility of complex and expensive diseases [1]. The global ageing population is on the increasing trend, hence to fulfil the pledge of the 2030 agenda, “leave no one behind,” it is essential to prepare for an effective way to deal with the contextual health needs of the ageing population [2].

Morbidity increases with age, thus health care systems need to continually update in order to adequately cater for these additional demands [3]. Studies report the existence of inequalities in health services with sustained unmet needs for healthcare among the elderly population [4-6]. Lower survival probabilities for individuals with unmet health care needs are reported. Moreover, unmet health needs conferred a higher risk of mortality, with excess risk ranging from 10% to 155% [7].

Achieving healthy ageing relates to the adequate maintenance of functional ability by appropriately addressing the health care needs of the elderly [8]. Health needs assessments typically rely on the measurement of the health status and assessment of the services that are required in a community to highlight the key problems. Needs assessment enables the identification of the unmet needs to address the gaps in receipt of assistance for healthful ageing [9].

In Nepal, the elderly refers to a senior citizen who has completed the age of sixty years [10]. The elderly population of Nepal is 8.1% in 2011 and is in an increasing trend with the growth rate of the ageing population around 3.5% [11, 12]. The Global Age Watch Index of Help age International 2015 proclaimed Switzerland as the most suitable country for the old to live whereas Nepal ranks 70 among 96 in the index [13]. The increase in the ageing population and the sustained shift in population age structure pose an array of challenges to overall health services and policymakers to combat different morbidity patterns among the elderly residing in Nepal [14]. There is a lack of awareness in addressing the concerns of the ageing population in Nepal. Social protection is limited and most of the needs of the elderly are unmet with a lack of sensitivity and awareness regarding the rights of the elderly [12].

The assessment of the chronic morbidities, health problems among the elderly of Nepal, their health care seeking and utilization behaviour prevalent in society will be helpful to plan relevant interventions focusing on healthy ageing. This study aims to identify the preexisting chronic morbidities, health problems, health care seeking and utilization behaviours among the elderly population.

Materials and methods

Study design

This was a community-based cross-sectional study involving a face-to-face interview with elderly people residing in two metropolitan cities of Sunsari district during 2017 and 2018.

Study setting

General setting

Nepal is a landlocked country in South Asia that borders China in the north and India in the east, west and south. It is a federal republic comprising seven provinces with a population of 30.2 million as per the ongoing census 2021 [15]. The elderly people constitute 8.14% with an increase in life expectancy to 68 years in 2012. The total population growth rate of Nepal is about 1.4% while the growth rate of the ageing population is around 3.5% [11, 12].

Specific setting

Among the seven provinces of Nepal, Province one is the easternmost part. It consists of 14 districts, one metropolitan city, two sub-metropolitan cities, 46 municipalities and 88 rural municipalities. Itahari and Dharan are the second and third largest cities and two sub-metropolitan cities of Province one located in Sunsari District [16]. Both consist of 20 wards each [17, 18]. We conducted the study from September 2017 to August 2018 in randomly selected 16 wards of Itahari and Dharan (eight wards from each city).

Participants

We selected the household by stratified proportionate random sampling method. The two sub-metropolitan cities of Sunsari district were considered urban areas and constituted the sampling frame for our study. Eight wards selected randomly from each sub-metropolitan city were considered strata. The ward-wise population of the sub-metropolitan city was collected from the administrative office and the number of participants from each ward was calculated proportionately [17, 18]. Subjects above the age group of 60 years and older and willing to participate in the study were included following approval of detailed informed consent. We took a bottle and rotated it at a centrally located spot in each ward. The first household was the direction pointed by the bottle. Thereafter, we visited every third house until the desired sample size was fulfilled. In case of unavailability of the sample population in selected households, the adjacent household was considered for data collection. If more than one member from the same household met the sample criteria, one member was chosen by the lottery method.

The sample size was calculated at a 95% confidence interval and 85% power based on one proportion sample size formula n = Z2PQ/D2. The prevalence of unmet health care needs in people suffering from hypertension was 26.2% in a study done in Bhaktapur District [3]. This prevalence suggests the scenario of health care seeking practice with one of the common morbidity among the elderly. The value of Z is 1.96 at a 95% confidence interval, p was 26.2, q was 73.8(100-p) and d is 15% of p at 85% power. The total calculated sample size after adding a 10% to adjust for potential non-responders was 530.

Variables studied

We did a face-to-face interview using a semi-structured pre-tested questionnaire to gather information regarding demographics and other variables. A questionnaire intended to fulfil the study objective was developed based on different studies among the elderly. The questions were discussed among authors for validity. The translation of questions into the local language was done. The elderly visiting the BP Koirala Institute of Health Sciences was interviewed. The authors reviewed the acquired answers with an amendment to the questionnaire. Participants identified their pre-existing chronic morbidity from a list of five chronic diseases used by the package for essential non-communicable diseases in Nepal [19].

Participants went through a series of questions about their ability to see newspaper print, the ability to see the face of someone four-meter away clearly, the ability to hear clearly in a conversation with one other person, and the ability to chew hard foods without difficulty to identify the problems in physical and sensory functions [4].

Moreover, we asked the participants if they had any additional health problems from a list of common presenting symptoms in the elderly identified by a study in Chandigarh [20].

Blood pressure was measured by the interviewer using a calibrated aneroid sphygmomanometer on the right arm with the participant sitting on a chair with their arm resting on the table at heart level, using an appropriately sized cuff [21]. Hypertension was classified according to the seventh report of the joint national committee in not previously diagnosed cases [22].

We assessed depression using the BDI-II scale translated into Nepali which is a validated tool for use in Nepal [23]. In non-clinical populations, scores above 20 indicate depression. The Cronbach’s alpha of the BDI-II scale has shown good consistency of 0.76 [24]. Depression is one of the most common psychological problems in the elderly population [25]. The findings are presented as a psychological problem in the result section.

The interviewer performed a general physical examination to assess pulse rate and identify pallor, icterus, lymphadenopathy, cyanosis, clubbing, oedema and dehydration.

The complaints and findings were then stratified into various health problems according to the International classification for primary care (ICPC) [26].

Ethnicity was categorized per the Health Management Information System (HMIS) based on the central bureau of statistics population monograph of Nepal [27].

The poverty line was according to the world bank global poverty line revised in October 2015 (US$1.90 per day) [28]. The exchange rate used is the one fixed by Nepal Rastra bank at the time of analysis on 1st October 2018. USD 1$ = 115 NRs [29].

Current tobacco users are those using any form of tobacco daily or had used it in the past 30 days. Past tobacco users are those who said they had used tobacco once for a few months or years in the past [21].

Physical activity was termed as an adequate amount if the participant does at least 150 minutes of moderate-intensity aerobic physical activity in one week or does at least 75 minutes of vigorous-intensity aerobic physical activity throughout the week or an equivalent combination of moderate and vigorous-intensity activity [30].

Fruit and vegetable intake was said to be adequate if the participant consumes more than five servings of fruit and vegetable in one day [21].

Self-reported health status is the self-rating of the participant’s health status in terms of good, average, and poor.

Statistical analysis

Statistical analysis was done using the statistical package for social sciences (SPSS version 16). Data are described using frequency and percentage for categorical data, while continuous data are presented in mean and standard deviation. The association of independent variables with difficulty in health care seeking and health care utilization was assessed using the chi-square test in bivariate analysis. Multivariable analysis was done using conditional logistic regression [backward] to calculate the adjusted odds ratio of the independent variables. All the variables with a p-value less than 0.25 were considered for multivariable analysis and were tested for collinearity (to include those with VIF < 2). All the analysis was done at a 5% significance level considering a p-value of less than 0.05 as significant.

Ethical clearance

The Institutional Review Committee of B.P Koirala Institute of Health Sciences (Code No. IRC/1163/017) provided the approval for the study. The permission to conduct the study in the communities was obtained from the respective metropolitan office.

Results

Socio-demographic and behavioural characteristics

This study constituted 49.1% of females. The mean age of the participant in this study was 72.2 years with a standard deviation of 8.1 years. The participants were in-between ages ranging from 60 years to 101 years. The highest proportion of participants belonged to the age group 60–69 years (41.1%), Brahmin/Chettri ethnicity (45.6%) and Hindu religion (85.7%). Among the study participants, 63.8% were currently living as a couple, and 87.0% of the elderly were living with their families. More than half (56.0%) of the participants were below the poverty line. More than two-thirds of the participants in our study (67.7%) were not able to read and write. In our study, 36.8% and 35.5% reported current tobacco and alcohol use respectively. Approximately, a quarter (26.8%) reported adequate consumption of fruit and vegetable, and 60.0% performed adequate physical activity (Table 1).

Table 1

Sociodemographic and behavioural characteristics of participants [n = 530].

Characteristic	Categories	Frequency (n)	Percentage (%)
Age Distribution	60–69 years	218	41.1
	70–79 years	209	39.5
	80 years and above	103	19.4
	Mean ± SD (min, max)	72.2 ± 8.1 (60, 101)
Gender	Male	270	50.9
	Female	260	49.1
Ethnicity	Dalit	53	10.0
	Janajati	224	42.3
	Madhesi/ Muslim	11	2.1
	Brahmin/Chettri	242	45.6
Relationship status	Single*	192	36.2
	Couple	338	63.8
Living arrangement #	With family	461	87.0
	By themselves	69	13.0
Economic status	Below Poverty Line	297	56.0
	Above Poverty line	233	44.0
Ability to read and write	No	359	67.7
	Yes	171	32.3
Tobacco use	Current user	195	36.8
	Past user	199	37.5
	Never user	136	25.7
Alcohol Use	Current Drinker	188	35.5
	Past 12 months abstainer	107	20.2
	Lifetime abstainer	235	44.3
Fruit and veg intake	Adequate	142	26.8
	Inadequate	388	73.2
Physical Activity	Low activity	212	40.0
	Adequate activity	318	60.0
Self-reported health status	Good	92	17.4
	Average	275	51.9
	Poor	163	30.8

* Single constituted 3 never married, 185 widowed, 2 separated and 2 divorced participants

# Participants living with their son or daughter were considered living with family and those living alone or with a spouse were considered living by themselves.

Our study identified that about half (48.3% elderly were suffering from pre-existing chronic morbidities, of which, 30.9% had single morbidity, and 17.4% had multimorbidity. Hypertension was the most common morbidity reported by 34.0% followed by diabetes mellitus among 14.3%. Hypertension with diabetes mellitus was the commonest multimorbidity reported by 9.4% of respondents. Almost, all the participants except three reported having health needs for different ailments at the time of the interview, of which problem relating to the circulatory system was the commonest (68.7%) followed by digestive problems (68.3%). Moreover, the prevalence of problems with the eye, musculoskeletal and psychological was more than 50 per cent (Table 2).

Table 2

Self-reported pre-existing chronic morbidities and health problems among the elderly [n = 530].

Characteristics	Categories	Frequency	Percentage
Pre-existing Morbidities	None	274	51.7
	Single condition	164	30.9
	Multimorbidity	92	17.4
Chronic Morbidities	Hypertension	180	34.0
	Diabetes	76	14.3
	Cardiovascular Disease	57	10.8
	COPD/Asthma	52	9.8
	Cancer	4	0.8
Health Problems	Circulatory problem	367	69.3
	Digestive problem	362	68.3
	Eye problem	351	66.2
	Musculoskeletal problem	349	65.8
	Psychological problem	295	55.7
	Urological problem	164	30.9
	Ear problem	158	29.8
	Skin problem	128	24.2
	Respiratory problem	111	20.9
	Neurological problem	110	20.8
	General unspecified problem	94	17.7
	Endocrine / metabolic problem	76	14.3
	Genital problem	31	5.8

Health problems are classified according to the complaints/ symptoms and examination findings as per the International Classification of primary care [ICPC-2]

Health care seeking and utilization behaviour

In this study, 19.2% reported difficulty in performing daily activities and 87.0% were able to leave home without help. Approximately half, 51.9% of the participants reported having average health status. The majority of the participants (58.7%) preferred to visit a hospital in the case of need while 6.2% reported a preference for traditional healers and 5.1% hesitated to go anywhere confining themselves in their houses. Despite the lower preference for first contact, almost half of the participants (46.0%) reported visiting traditional healers for their illnesses. Table 3 lists various health care seeking behaviour and health service utilization characteristics among the elderly.

Table 3

Health care seeking and utilization behaviour among the participants [n = 530].

Characteristic	Category	Total [n]	Percentage [%]
Preferred health facility for first contact	Hospital	311	58.7
	Pharmacy	55	10.4
	Private Clinic	51	9.6
	Traditional healer	33	6.2
	PHC/Health post	30	5.7
	Pension camp*	23	4.3
	Nowhere/Home Remedy	27	5.1
Walking distance to the nearest health facility	30 minute or less	345	65.1
	More than 30 minute	185	34.9
Last visit to any health facility	Less than six months	271	51.1
	Six to less than 12 months	56	10.6
	one to three years	57	10.8
	More than three years	99	18.7
	Never	47	8.9
Number of health facility visits in last six months	None	257	48.5
	Once	112	21.1
	Twice	93	17.5
	Thrice or more	68	12.8
Sought emergency care in last six months	Yes	55	10.4
	No	475	89.6
Admitted for inpatient care in last six months	Yes	50	9.4
	No	480	90.6
Health insurance	Insured	114	21.5
	Not Insured	416	78.5
Difficulty in seeking health care	Yes	361	68.1
	No	169	31.9
Perception about health services	Satisfactory	382	72.1
	Non-satisfactory	148	27.9
Awareness of the government geriatric health scheme	Yes	256	48.3
	No	274	51.7

* Pension camp is the common term used by people for pension paying office for the Ex Gurkha army officials, which also have a health facility with medical personnel and doctor which provides health care service free of cost.

Table 4 list the association of different variables with difficulty in seeking health care and health care utilization within six months. The studied variables like age, current occupation, economic status, ability to read and write, self-reported health status, health insurance and awareness of the government geriatric health scheme were significant contributors to the difficulties in seeking health care, and health care utilization among the elderly. Moreover, gender, relationship status and walking distance of the nearest health facility had a measurable impact on difficulty seeking health care while preexisting morbidities were related to health care utilization (Table 4).

Table 4

Bivariate analysis of different variables with difficulty in seeking health care and health care utilization within six months.

	Difficulty in seeking health care			Health care utilization within six months
	Yes 361(68.1%)	No 169(31.9%)	p-value	Yes 271(51.1%)	No 259(48.9%)	p-value
Age in years
Less than 70	134[61.5%]	84[38.5%]	0.01	104[47.7%]	114[52.3%]	0.04
70 to 79	147[70.3%]	62[29.7%]		121[57.9%]	88[42.1%]
80 and above	80[77.7%]	23[22.3%]		46[44.7%]	57[55.3%]
Gender
Male	151[55.9%]	119[44.1%]	0.00	133[49.3%]	137[50.7%]	0.4
Female	210[80.8%]	50[19.2%]		138[53.1%]	122[46.9%]
Living arrangement
Living with family	312[67.7%]	149[32.3%]	0.60	243[52.7%]	218[47.3%]	0.06
Living by themselves	49[71.0%]	20[29.0%]		28[40.6%]	41[59.4%]
Relationship status
Couple	210[62.1%]	128[37.9%]	0.00	173[51.2%]	165[48.8%]	0.98
Single	151[78.6%]	41[21.4%]		98[51.0%]	94[49.0%]
Current occupation
Paid Job	11[50.0%]	11[50.0%]	0.00	7[31.8%]	15[68.2%]	0.03
Agriculture	23[51.1%]	22[48.9%]		16[35.6%]	29[64.4%]
Business	23[48.9%]	24[51.1%]		25[53.2%]	22[46.8%]
Homemaker/Retired	304[73.1%]	112[26.9%]		223[53.6%]	193[46.4%]
Economic status
Below Poverty Line	223[75.1%]	74[24.9%]	0.00	120[40.4%]	177[59.6%]	<0.01
Above Poverty line	138[59.2%]	95[40.8%]		151[64.8%]	82[35.2%]
Ability to read and write
Yes	89[52.0%]	82[48.0%]	0.00	100[58.5%]	71[41.5%]	0.02
No	272[75.8%]	87[24.2%]		171[47.6%]	188[52.4%]
Self-reported health status
Good	34[37.0%]	58[63.0%]	0.00	39[42.4%]	53[57.6%]	0.2
Moderate	183[66.5%]	92[33.5%]		145[52.7%]	130[47.3%]
Poor	144[88.3%]	19[11.7%]		87[53.4%]	76[46.6%]
Pre-existing morbidity
None	186[67.9%]	88[32.1%]	0.15	97[35.4%]	177[64.6%]	<0.01
Single Condition	119[72.6%]	45[27.4%]		99[60.4%]	65[39.6%]
Multimorbidity	56[60.9%]	36[39.1%]		75[81.5%]	17[18.5%]
Health Insurance
Yes	66[57.9%]	48[42.1%]	0.01	86[75.4%]	28[24.6%]	<0.01
No	295[70.9%]	121[29.1%]		185[44.5%]	231[55.5%]
Walking distance to the nearest health facility
30 minutes or less	213[61.7%]	132[38.3%]	0.00	173[50.1%]	172[49.9%]	0.5
More than 30 minutes	148[80.0%]	37[20.0%]		98[53.0%]	87[47.0%]
Awareness of the government geriatric health scheme
Yes	151[59.0%]	105[41.0%]	0.00	173[67.6%]	83[32.4%]	<0.01
No	210[76.6%]	64[23.4%]		98[35.8%]	176[64.2%]

Tables 5 and 6 show the results of multivariable analyses of different variables associated with difficulty in health-seeking care and health care utilization respectively. In our study, female gender, those below the poverty line, those with average to poor self-reported health status, non-availability of the nearest health facility within 30 minutes of walking distance and those who were not aware of government geriatric health schemes significantly reported difficulty in seeking health care. The elderly with a poor self-reported health status were approximately 9.6 times more likely to face difficulty in seeking health care. (Table 5) Expectedly, elderly of economic status above the poverty line, insured for health and those who were aware of government geriatric health schemes were more likely to visit health care facilities within six months. Moreover, among the elderly with pre-existing morbidity, those with single morbidity and multimorbidity were at 2.4 and 6.2 higher odds of health care utilization respectively (Table 6).

Table 5

Multivariable logistic regression analysis of different variables with difficulty in health-seeking behaviour.

Characteristic	Categories	AOR	95% C.I.for Adjusted Odds Ratio (AOR)		p-value
			Lower	Upper
Gender	Male	REF			<0.01
	Female	2.492	1.544	4.022
Relationship status	Couple	REF			0.09
	Single	1.536	0.929	2.54
Economic Status	Above poverty line	REF			0.01
	Below Poverty line	1.751	1.13	2.712
Self-reported health status	Good	REF			<0.01
	Average	3.585	2.076	6.193
	Poor	9.86	4.92	19.759
Walking distance to the nearest health facility	30 minutes or less	REF			<0.01
	More than 30 minutes	3.609	2.182	5.971
Aware of the government geriatric health scheme	Yes	REF			<0.01
	No	3.161	2.002	4.989

Variables adjusted with age, gender, relationship Status, occupation, economic status, ability to read and write, self-reported health status, preexisting morbidity, health insurance, walking distance to the nearest health facility, awareness of the government geriatric health scheme.

Table 6

Multivariable logistic regression analysis of different variables with health service utilization in the last months.

Characteristics	Category	AOR	95% C.I. for Adjusted odds ratio (AOR)		p-value
			Lower	Upper
Age group	80 years and above
	60–69 years	1.511	0.874	2.612	0.14
	70–79 years	1.873	1.078	3.252	0.02
Economic status	Below poverty line				<0.01
	Above poverty line	2.286	1.538	3.397
Pre-existing morbidities	None				<0.01
	Single morbidity	2.435	1.581	3.751
	Multimorbidity	6.156	3.306	11.463
Health Insurance	No				<0.01
	Yes	2.244	1.329	3.789
Awareness of the government geriatric health scheme	No				<0.01
	Yes	2.553	1.713	3.805

Variables adjusted with age, gender, occupation, economic status, ability to read and write, self-reported health status, preexisting comorbidities, health insurance, awareness of the government geriatric health scheme, living arrangements.

Discussion

This study identified the self-reported chronic morbidities, health problems and health care seeking and utilization behaviour among the elderly population residing in two sub-metropolitan cities of Province one, Nepal. These two cities are polarized in culture, ethnicity, religion, education, socioeconomic status, and lifestyle; therefore, the findings of this study represent the scenario of urban areas of the country. The availability of health care facilities in these two cities is also relatable to other urban areas of Nepal [31]. This study found a significant proportion of the elderly suffering from preexisting chronic morbidities. In the health problems, the highest prevalence was circulatory problems, and multiple health ailments were common among the elderly. This study found that 68.1% of the elderly people were facing difficulty in seeking health care and only 61.7% of the elderly have visited a health care facility within a year duration, only 35.5% had a regular visit to a doctor, and 8.9% reported never visited health facility till the study period.

Chronic morbidities

This study found that almost half of the participants (48.3%) had pre-existing chronic morbidity at the time of the study, of which 30.9% had single morbidity and 17.4% had multimorbidity. A study done in eastern Nepal has reported a prevalence of preexisting morbidity to be 66.5%, of which 43.8% had single morbidity and 22.8% had multimorbidity [32]. Another study done in eastern Nepal has also found a significant burden of morbidity among the elderly which is higher than our study [33]. It may be the result of the inclusion of osteoarthritis as chronic morbidity in this study while our study has not considered osteoarthritis in preexisting morbidity.

Consistent with our study finding, a multinational study including low and middle-income countries has also discovered a similar burden of hypertension [34]. Expectedly, the findings of our study reflect the similar burden of hypertension and diabetes found by a study done in eastern Nepal among the elderly [33]. The finding of our study shows a slight increment in the prevalence of hypertension and diabetes but a decrease in cases of chronic obstructive pulmonary diseases (COPD) compared to the study done in Dharan municipality in 2007 which represents the increasing trend of hypertension and diabetes in the elderly community [35]. A study analyzing the worldwide trend of hypertension has concluded that the burden of hypertension among 30–79 years doubled from 1990 to 2019 [36]. The reduction in COPD may have resulted due to decreased use of biomass fuel with the introduction of clean energy [37]. The study from Bhaktapur, Nepal also reports a similar burden of hypertension, but a higher burden of COPD than our study [3]. This discrepancy may be due to the variation in sample size, geographical distribution, ethnicity and cultural practices. Other studies have reported a prevalence of hypertension ranging from 27–57% among the elderly [35, 38–45]. The prevalence of hypertension in the STEPS survey 2019 has shown a higher burden of hypertension among the increasing age group [46]. Like our study, a study done in Pune and Karnataka India reported the highest burden of hypertension followed by diabetes, heart disease and the lowest in asthma among the chronic morbidities in the elderly [39, 47]. A multinational study done in 29 low-middle-income countries has stated an overall prevalence to be 7.5% which is almost half of the findings of our study [48]. This may be due to the difference in sample population as this study has included participants of 25 years and above.

Health problems among the elderly

Health problems like circulatory problems, digestive problems, musculoskeletal problems and psychological problems as reported in this study are the common problems of the ageing population [8]. Moreover, cardiovascular diseases are the leading cause of death globally [49]. The prevalence of eye problems reported by our study was higher than the findings of a study done in Bhaktapur but lower than the findings of studies done in Dharan and India [3, 35, 39]. Hearing impairment among the elderly in this study was complained by 29.8% akin to a study done in Dharan but different from a study done in India which reported a relatively higher prevalence [35, 39]. Dental problem reported by our study was relatively higher than that reported by a study done in India [39]. These discrepancies in findings may be the result of tools used for identifying these health problems in different studies. Moreover, the questionnaires of our study were more focused on exploring the relative needs of the elderly but confirming the real need is the limitation of the study.

Consistent with our finding, a study done in Bhaktapur and Dharan has reported a similar burden of musculoskeletal problems among the elderly [3, 35]. A study in Nepal has found musculoskeletal problems to be the most common morbidity among the elderly [45]. Moreover, a study done in Nepal has also reported an association between joint pain and advancing age [50]. A multinational study has also stated low back pain to be the leading cause of years lived with disability in 2017 [1].

Health seeking behaviour and health care utilization

The health service utilization, emergency visits and admission rate differ in our study from than findings of a study done in Butwal city in west Nepal, which may be due to differences in sample sizes, geographical differences and health facility availability. Regarding the utilization of the traditional healing system both the study reported a significant proportion of elderly visiting traditional healing which suggest a common belief and cultural alignments [51]. Similarly, a study done in the Ilam district of Nepal reported one-fifth of the population sought a traditional healer’s service, supporting a strong belief in the traditional healing system [52]. In contrast to our findings, a study exploring health care utilization for headache disorders found the majority of visiting paramedical professionals for their problems [53]. This may be due to differences in accessibility of health services, health information, and the perceived credibility and trustworthiness of studied participants [54].

In our study gender, economic status, walking distance of health facility, self-reported health and perceived geriatric health policy had a major role in difficulty in seeking health care. Similarly, economic status, health insurance, preexisting chronic morbidities and perceived geriatric health policy constituted a major contributor influencing health care utilization among the elderly. Other studies of Nepal have also recognized the difference in household economic status, family income, chronic disease, educational status and self-rated health as significant determinants of health service utilization [52, 55]. A study done in eastern Nepal has shown a significant association between preexisting morbidity with difficulty in seeking health care and acquiring medication [32]. Another study in Nepal has found an increasing health care utilization proportional to symptom severity [53]. A study done in China has reported a crucial role of the need factor in determining health service utilization among the elderly. This same study has reported financial difficulties as a barrier and education, having social security and poor health status as a facilitator to use health services [56]. Similar to our finding, a study done in India among the elderly has found health care utilization to increase significantly with multimorbidity [57]. Moreover, studies from outside Nepal have also reported frailty multimorbidity and disability to impact doctor visits [58-60]. Similarly, a study done in Norway found medium- and high-risk patients more likely to healthcare utilization compared with low-risk patients [61]. An all of Us nationwide survey have reported financial concerns and lack of access to transportation as a reason for the delay in seeking care [62]. A study in North Carolina also stated several geographic and spatial behaviour factors, including having a driver’s license, use of provided rides, and distance for regular care was significantly related to health care utilization [63].

Conclusion

Our study unveiled a high burden of chronic morbidities and other health ailments among the elderly population as about half reported to have a preexisting chronic condition and almost all reported having some sort of health problems. Despite substantial health needs, the participants did not adequately visit health care providers. The economic status and awareness of the government geriatric health scheme were the significant contributor to both health seeking behaviour and health care utilization among the elderly. Moreover, health insurance and pre-existing morbidities increased the odds of health care utilization. Continuous intervention and health education programs incorporating components like geriatric health policy, health insurance and other factors focusing on healthy ageing should be conducted to motivate elderly people for healthy behaviours, adequate health care seeking and utilization. The health policies should prioritise the ageing population and health services should be made available at the primary level with a geriatric specialized one-door policy capable of addressing common health problems among the elderly.

This study tried to explore the common health problems among the elderly population yet missed one of the major issues of cognitive impairment.

Mental health self-reports are sometimes subject to bias because of a general community stigma towards mental illness in Nepal [64].

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11 Nov 2021

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Reviewer #2: Yes

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Reviewer #1: Dear authors,

Thank you for addressing an important issue concerning the older population in Nepal. Although the topic is important, it is not novel. It is not clear what is new in comparison to similar studies conducted in Nepal in the past. You may also consider conducting multivariate logistic/linear regression or other higher analysis (as appropriate) as this study only has descriptive data. Higher analyses will also make your study stronger. Please find my detailed comments below.

Line 57: What are the challenges and additional demands?

Lines 60-63: It is not clear what the unmet needs were and the purpose/objective of follow-up.

Line 96: Numbers less than ten should be spelled out in academic writing

Line 122: Check the spelling of “than” or “then”. “the complaints and findings were then….”

Line 166: Check spellings

Lines 165-169: Logistic regression is missing in the result section.

Proteinuria as a variable is not mentioned in the methods section.

Line 236: The term “developing country” may not be appropriate. The authors may consider using another term and also instead of using “like ours”, it is preferable to use “like/such as Nepal”.

Lines 235-239: The first paragraph of the discussion should mention the major findings of the study.

Discussion: Do not repeat sentences from the result section in discussion.

Discussion of major findings is lacking in general.

The conclusion section is weak and can be improved.

Academic writing:

1. Avoid use of unnecessary capitalizations

2. Use past tense to report methods and results

3. Use hyphenation where necessary (e.g.: face-to-face)

4. Inconsistent use of percentage (example: 53%, 27. 2%, 56.9% etc.)

5. Inconsistent use of the Oxford comma before “and”.

6. Commas missing in many sentences.

7. Check spellings

8. Inconsistent use of the words “aging” and “ageing”; “elderly” and “older people”. Use the same term throughout the text.

9. Recheck the text. The flow of paragraphs can be improved.

Hope the suggestions are useful. Best wishes.

Reviewer #2: �  The topic is interesting and explores an important area of public health research. The article is good. However, there are some changes that need to made to make the article even better.

Overall Suggestions:

o There are minor errors in grammar/language. Please kindly proofread the article.

o Also some rearranging and adding of text may be necessary.

o Please make sure that the numbers in tables are correct. Details are in my comments below.

�  Title page:

o Line 10: Please use the correct spelling of ‘Hetauda’

�  Abstract:

o Line 50: Keywords not in alphabetical order

�  Materials and Methods:

o Line 86: What do you mean by structured interview? You have mentioned that the questionnaire itself is semi-structured. Do you mean face to face interview?

o Line 102: Please explain how this was a stratified proportionate random sampling? Did you have a sampling frame? If yes, please mention it.

o Line 134: The term elderly is defined here. As this study is about elderly people, it should be moved it up in the text so that reader can understand the context

o Line 165: Please specify which version of SPSS was used

o 167-169: Where are the results of multivariate analysis? Where is the Chi-square test used?

�  Results

o Line 182: In Table 1: for Age distribution, the percentage does not sum up to 100.0%. Please correct it.

o Line 184-186: Not clear what the author wants to say and may be confusing for the readers. Please re-write to bring clarity.

o Line 200-203: How did you assess the blood pressure at the time of visit? Did you measure the blood pressure yourselves? It is not mentioned in the methodology or tools used.

o Line 209: Measurement of proteinuria by the researcher and the tools used for this process is not mentioned in the methodology.

�  What you are trying to present as health needs is not clearly depicted in the results and discussion section.

�  References:

o Some of the references are not according to the journal guidelines. Please make required changes.

**********

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Reviewer #2: No

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22 Feb 2022

Dear Editor,

Warm Regards

Sub: Submission of the revised manuscript

Sir,

I would like to heartily thank you for reviewing our manuscript and allowing us to submit a revised manuscript. We have considered all the comments received for this revision. In addition, we have made some changes (rewording of some terms) to the title and objectives to ensure consistency of our focus and improve the storyline in the manuscript. We have extensively revised the results section and also added some new tables. The title now reads, Morbidities, health problems, health care seeking and utilization behaviour among elderly residing on urban areas of eastern Nepal: a cross-sectional study.

We have also added an author who had contributed to the manuscript throughout but was not available to consent for authorship during the first submission. We now have an agreement from the author. We have completed the ‘Authorship Changes’ form and attached it with this revision. We hope you consider this change in line with PLOS guidelines. We appreciate the time and effort that you and the reviewers have dedicated to providing your valuable feedback on this manuscript. We are grateful to the reviewers for their insightful comments on our paper. We have also attached a point-by-point response to the reviewers’ comments and concerns as required.

I will upload my study’s minimal underlying data and survey questionnaire used as a supporting file. I confirm that this work does not constitute dual publication. Some of the findings of this work can be found in a preprint available on: https://assets.researchsquare.com/files/rs-9433/v2/fc5b8b50-f3de-4f1e-a1b0-6042ee5da034.pdf?c=1631830880.

Dear reviewers, I would like to thank you for your time and effort towards improvement of the manuscript. Below are the response to the specific points raised by reviewers in this manuscript.

Reviewer 1:

Thank you for the constructive comments.

R1 Comment 1: Line 57: What are the challenges and additional demands?

Response: The challenges are to respond to the increasing health care demand and needs of elderly with increasing age. This line now reads as, “Morbidity increases with age, thus health care systems need to continually update in order to adequately cater for these additional demands.” 54-55.

R1 Comment 2: Lines 60-63: It is not clear what the unmet needs were and the purpose/objective of follow-up.

Response: The unmet needs are defined as no health care consultation despite of persistent health needs. I have edited this line and it now reads as “Lower survival probabilities for individuals with unmet health care needs are reported. Moreover, unmet health needs conferred a higher risk of mortality, with excess risk ranging from 10% to 155%” in line 57 - 59.

R1 Comment 3: Line 96: Numbers less than ten should be spelled out in academic writing Line

Response: This has been edited and the numbers are written in text accordingly.

R1 Comment 4: 122: Check the spelling of “than” or “then”. “the complaints and findings were then….”

Response: This has been edited in line 139.

R1 Comment 5: Line 166: Check spellings

Response: We have checked all the spellings accordingly.

R1 Comment 6: Lines 165-169: Logistic regression is missing in the result section. Proteinuria as a variable is not mentioned in the methods section.

Response: We have added new tables with regression. Proteinuria is removed from methods as we are not reporting it in results.

R1 Comment 7: Line 236: The term “developing country” may not be appropriate. The authors may consider using another term and also instead of using “like ours”, it is preferable to use “like/such as Nepal”.

Response: We have edited the text accordingly and rephrased the paragraph.

R1 Comment 8: Lines 235-239: The first paragraph of the discussion should mention the major findings of the study. Discussion: Do not repeat sentences from the result section in discussion. Discussion of major findings is lacking in general. The conclusion section is weak and can be improved.

Response: We have edited the discussion and conclusion section as advised.

R1 Comment 9: Academic writing:

1. Avoid use of unnecessary capitalizations

Response: This has been checked and edited throughout.

2. Use past tense to report methods and results

Response: This has been checked and edited throughout.

3. Use hyphenation where necessary (e.g.: face-to-face)

Response: This has been checked and edited throughout

4. Inconsistent use of percentage (example: 53%, 27. 2%, 56.9% etc.)

Response: This has been checked and edited throughout

5. Inconsistent use of the Oxford comma before “and”.

Response: This has been checked and edited throughout

6. Commas missing in many sentences.

Response: This has been checked and edited throughout

7. Check spellings

Response: This has been checked and edited throughout

8. Inconsistent use of the words “aging” and “ageing”; “elderly” and “older people”. Use the same term throughout the text.

Response: This has been checked and edited throughout

9. Recheck the text. The flow of paragraphs can be improved. Hope the suggestions are useful.

Best wishes.

Response: This has been checked and edited throughout. Thank you so much.

Reviewer #2:

Thank you for the constructive comments.

R2 Comment 1: �  The topic is interesting and explores an important area of public health research. The article is good. However, there are some changes that need to made to make the article even better.

Response: Thank you so much. We have revised this manuscript considering all the comments.

R2 Comment 2: Overall Suggestions: There are minor errors in grammar/language. Please kindly proofread the article.

Response: This has been checked and edited throughout

R2 Comment 3: o Also some rearranging and adding of text may be necessary.

Response: This has been checked and edited throughout

R2 Comment 4: o Please make sure that the numbers in tables are correct. Details are in my comments below.

Response: This has been checked and edited throughout

R2 Comment 5: �  Title page:

o Line 10: Please use the correct spelling of ‘Hetauda’� 

Response: We have corrected it now

R2 Comment 6: Abstract:

o Line 50: Keywords not in alphabetical order

Response: We have now kept keywords in alphabetical order.

R2 Comment 7: �  Materials and Methods:

o Line 86: What do you mean by structured interview? You have mentioned that the questionnaire itself is semi-structured. Do you mean face to face interview?

Response: Yes, we meant face to face interview with semi-strucured questionnaire. We have corrected that.

R2 Comment 8:

o Line 102: Please explain how this was a stratified proportionate random sampling? Did you have a sampling frame? If yes, please mention it.

Response: The sampling frame was elderly people residing two sub-metropolitan cities. Eight wards from each sub-metropolitan selected randomly were strata in this study. The population of wards were identified from administrative office and number of participants from each ward was calculated proportionately.

We have mentioned it in line 99 – 104.

R2 Comment 8: o Line 134: The term elderly is defined here. As this study is about elderly people, it should be moved it up in the text so that reader can understand the context

Response: I have moved the text above in the introduction part and it is now in line 66 – 67.

We have ensured this in the revision.

R2 Comment 9: o Line 165: Please specify which version of SPSS was used

Response: We have specified the version of SPSS used. I used SPSS version 16. It is stated in line 159 -160.

R2 Comment 10: o 167-169: Where are the results of multivariate analysis? Where is the Chi-square test used?

Response: We have added the tables with the results for chi-square test and multivariate analysis. Table 4 shows the bivariate analysis and table 5 and 6 states the finding of multivariable analysis.

R2 Comment 11: �  Results

o Line 182: In Table 1: for Age distribution, the percentage does not sum up to 100.0%. Please correct it.

Response: This has been checked and corrected. Thank you.

R2 Comment 12: o Line 184-186: Not clear what the author wants to say and may be confusing for the readers. Please re-write to bring clarity.

Response: We have edited this to two categories, with family or by themselves.

R2 Comment 13: o Line 200-203: How did you assess the blood pressure at the time of visit? Did you measure the blood pressure yourselves? It is not mentioned in the methodology or tools used.

Response: As a qualified physician, the PI measured the blood pressure. This is now mentioned in methodology and is in line 129 – 133.

R2 Comment 14: o Line 209: Measurement of proteinuria by the researcher and the tools used for this process is not mentioned in the methodology.

Response: Based on this revision after adding and rearranging the findings to match the objectives, we have removed proteinuria from results hence not mentioned it in methods.

R2 Comment 15: �  What you are trying to present as health needs is not clearly depicted in the results and discussion section.

Response: We have revised the title as ‘ Morbidities, health problems, health care seeking and utilization behaviour among elderly residing on urban areas of eastern Nepal: a cross-sectional study’ to improve the focus and enhance clarity. We have ensured this is reflected in the objectives as well as presented in a similar manner in results and discussion,

R2 Comment 16: �  References: Some of the references are not according to the journal guidelines. Please make required changes.

Response: We have made these changes in the references.

Thank you ever so much for all the comments.

Submitted filename: Response to reviewers.docx

Click here for additional data file.

13 Jun 2022

23 Jul 2022

Dear reviewer,

I kindly appreciate all your constructive comments and effort in making this manuscript better. I have tried my best to respond to all your comments.

Reviewer 2

Thank you for the appreciation.

Reviewer 3

Thank you for the constructive comments.

R3 Comment 1: The article is very well written and the enormous effort undertaken during the study design, data analysis and writing of the manuscript is greatly appreciated. Indeed, the issues of elderly is an important issue and in developing countries like Nepal, more such research and articles are appreciated.

Response: Thank you for the appreciation. We will continuously look forward to explore the issues of elderly and are motivated to conduct research in this area

R3 Comment 2: Line 26 (abstract) inconsistent use of hyphenation in ‘health care seeking’

Response: I have removed the hyphenation and the word now reads as health care seeking behaviour in line 26.

R3 Comment 3: Line 216 ‘6’ to be written as six

Response: This has been edited and number is written in text in line 221.

R3 Comment 4: Line 276 comma missing.

Response: This has been edited.

R3 Comment 5: Yes, the manuscript is well written. However, the data shared is coded and codes for limited variables are given so reviewer is unable to decide with full confidence. Eg GD column in data sheet reads as ‘multimorbidity’ which has 271 rows coded as 1 (51.13%). Reviewer cannot be sure what this implies. Most of the conclusions seem possible when the questionnaire is reviewed.

Response: Thank you. We shared a basic excel sheet and a SPSS data set. The excel sheet being a basic data set we tried various outcomes. The multimorbidity stated in that data set includes the relative health problem also. But later for the analysis the morbidity and multimorbidity was classified based upon preexisting health condition. The SPSS data set has been recoded again for analysis and it gives more clarity on data analysis.

R3 Comment 6: Line 99 Sampling method has been explained and eight wards have been selected as per the manuscript but data sheet shows missing data in 45 participants and there are 9 wards in one of the cities i.e. Dharan (if the number allotted after Dharan is the ward no in the data sheet). More clarity would be there if authors showed the number in sampling frame and ward wise population as reviewer believes this is a great strength of this article.

Response: The ward wise population has been cited accordingly in the methodology section in line 104. The data representing ward number has been revised and corrected accordingly.

R3 Comment 7: Line 112-116 Calculation of sample size: The formula used one proportion sample size seems fine, but in the stated formula, I am not sure where the power (85%) is used. The rationale for choosing prevalence of unmet health care needs in people suffering with ‘hypertension’ along with the full calculation would clarify readers.

Response: The calculation of sample size is elaborated accordingly in line 112-118. The rationale of choosing prevalence of unmet health care need is now stated which reads as “This prevalence suggests the scenario of health care seeking practice with one of the common morbidity among elderly” in line 114-115.

R3 Comment 8: Line 118 onwards in “variables studied’’ there is inconsistent writing style with some of the variables being described in paragraph and some with heading.

Response: This has been edited and variables are now described in paragraph.

R3 Comment 9: Line 119 The questionnaire is ‘pre-tested’. Elaborating the pre-testing technique would strengthen the article as the questionnaire shared is in great detail with translation to local language. This work is not reflected in the manuscript.

Response: The pretesting was done among the elderly visiting the BP Koirala Institute of Health Sciences. We have added about pretesting in the manuscript as “A questionnaire intended to fulfil the study objective was developed based on different studies among the elderly. The questions were discussed among authors for validity. The translation of questions into the local language was done. Elderly visiting the BP Koirala Institute of Health Sciences were interviewed. Authors reviewed the acquired answers with an amendment to the questionnaire.” In line 122-126.

R3 Comment 10: Line 134-136 BDI II scale used for depression but the result of this has not been expressed in ‘Results’ section. If authors are not publishing this, maybe they can omit from methods section too. It also raises a question why only ‘depression’ was assessed and not other mental health issues.

Response: It has been presented in result section as psychological problem. The rationale of assessing this mental health problem is now included and it reads as “Depression is one of the most common psychological problem in elderly population” in line 142-143.

R3 Comment 11: Line 140-141 ICPC is used for health problems which is a standard in itself so the sentence following it with Ref 30 seems only to add to the authors long list of references (study among inmates vs study of elderly)

Response: By citing the paper on inmates, our intentions were to show that ICPC has been used for research in Nepal. However to avoid confusion the reference has been revised and removed in line 148.

R3 Comment 12: Line 149 Reference for this variable (if provided) would be good.

Response: The reference for tobacco users has now been provided to that variable in line 156.

R3 Comment 13: Table 3 Mentions “Pention camp’’, the terminology might not be clear to many people so elaboration below table on what kind of ‘health facility’ would add to clarity.

Response: The footnote in the table now describes in a brief about the pension camp which reads as “Pension camp is the common term used by people for pension paying office for the Ex Gurkha army personnel, which also have a health facility with medical personnel and doctors which provides health care service free of cost” in line 216 – 218.

R3 Comment 13: In ‘Last visit to any health facility’, one of the options reads as ‘Never’ with 47 responders choosing it. Does it mean in their 60 years, they never visited a health facility?

Response: Yes, it was the response from those 47 participants. The added response of these participant was taking home remedies and seeking traditional healer.

R3 Comment 14: Discussion Section: Overall slightly weak. Authors have compared their findings with other researches but they have not explained why the variations are there. Eg for HTN, eye (66.2 vs 19.1), dental issues etc

Response: We have revised the discussion and added explanation for such variations in line 312 -315.

R3 Comment 15: Line 257 The article including the title of the article refers the study setting as urban eastern Nepal, while in this line the article claims to represent whole Nepal in terms of culture, ethnicity, religion, education, socioeconomic status, lifestyle which seems contradictory in itself.

Response: We have revised it and edited as “represent urban areas of the country” in line 264.

R3 Comment 16: Flow of article in chronic morbidities section needs to be worked out. Eg

- Line 271-275 Manuscript is describing articles

- Line 276-277 Manuscript gives a broad comment

- Line 277 onwards manuscript starts to describe individual articles

- When discussing, it is better to discuss one variable and then start others, broad statements are better at beginning of discussion to start a variable discussion or the end.

Response: We have revised the discussion and edited as per the comments in line 273-301.

R3 Comment 17: Line 277 The prevalence of HTN is 34% in this study. The manuscript reports a ‘similar’ range of 27-57% in other studies. Maybe the authors should reconsider the term ‘similar’ considering the expressed range.

Response: This has been revised and edited. Similarly has been removed and it has been stated as “Other studies have reported a prevalence of hypertension ranging from 27-57% among the elderly” in line 293 - 294.

R3 Comment 18: References in discussion section is missing. Eg Line 280, Line 291, Line 303. It gives more clarity to readers if reference is given immediately after a particular article is discussed and not at the end of the paragraph. Author is advised to check this throughout the discussion section.

Response: We have revised this and edited accordingly. The references is now provided after each statement.

R3 Comment 19: References:

One Ref 37 is of the year 2022 while most others are relatively not recent so maybe the author can add more recent articles in discussion section while revising the manuscript. Author has 56 references; some references might need reconsideration for citation as stated above.

Response: This has been revised and we have tried to include the recent articles in discussion section.

Submitted filename: Response to reviewers.docx

Click here for additional data file.

3 Aug 2022

Morbidities, health problems, health care seeking and utilization behaviour among elderly residing on urban areas of eastern Nepal: a cross-sectional study

PONE-D-21-29483R2

Dear Dr. Poudel,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Reviewers' comments:

26 Aug 2022

PONE-D-21-29483R2

Morbidities, health problems, health care seeking and utilization behaviour among elderly residing on urban areas of eastern Nepal: a cross-sectional study

Dear Dr. Poudel:

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Dr. Pranil Man Singh Pradhan

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