Factors affecting access to health services by older adults in an urban community in Thailand: a cross-sectional study

Introduction

An older adult is defined by the United Nations as a person who is over 60 years of age. In 2017, the world had a population of 7.550 million people. Approximately 12.7% were older adults, meaning that our world has become an ‘aging society’. In 2017, older adults made up 17.1% of Thailand’s population,^1,2 and this expected to increase to 25.2% by 2030³ and 30% by 2035.² This changing population has a direct impact on public health policy and countries due older adults having different physical, mental, emotional, and social health issues to other demographics. The most common issues are related to economic, social and health issues, especially chronic health issues that require dependency from other people.

Due to chronic illnesses of older adults, health policies need to ensure that health services cover patient treatment and prevention of health issues, as well as providing a well-prepared health service system.⁴ The World Health Organization⁵ has suggested three concepts (factors of health, participation and security factors) to ensure that people will be covered by health services regardless of income, ethnicity gender and age. Their access to health services depends on financial factors, sufficient service and the organization of the health service. In 2002, Thailand’s government has implemented medical insurance rights⁶ with the goal of giving people access to health care services. However, medical insurance rights do not ensure that Thai people will have access to health services completely. Other related factors must be considered, such as socioeconomic factors, distance from habitation to service facilities, travel expenses, and presence of reliable caretakers.⁷

In 2013, Thailand’s urban population was 53.6% of the total population, with an increasing trend. Previous research has shown that people in the urban areas have limited access to health services.⁸ Good health service system management is significant to older adults in allowing them to access the service thoroughly. Therefore, the Ministry of Public Health’s primary objective is to ensure that people have access to health services when they need them. Previous studies in Thailand have shown that older adults have access to health services using health insurance rights through the Government (44%), the Universal Coverage Scheme (24%), or the Social Security Scheme (3%). It was also reported that use of health services was different dependent on the health insurance rights used and geographical region.⁹ Access to health services can be assessed by five dimensions: availability, accessibility, accommodation, affordability, and acceptability.¹⁰ However, an individual's access to and use of health services is considered to be a function of three characteristics as defined by Aday & Anderson¹¹: a) Predisposing Factors; b) Enabling Factors; and c) Need Factors. This study aimed to study the factors affecting access to health services for older adults in urban communities, as well as to perform a situation survey of health service utilization.

Methods

Results

A total of 886 older adults were included in this study. Of these 70.8% were women, the average age was between 60 and 69.9 years, and most (42.3%) participants were married and lived together. In total, 58% of participants had finished primary education and most (63.8%) were currently unemployed. Almost half of participants (45.5%) had an income less than 5,000 baht.; 58% of participants stated that their income was sufficient to cover monthly bills. Most participants came from the urban communities.

In addition, 56.5% of participants reported accessing health services in the past year for an illness or health problems that required medical treatment and most of them reported that their condition was minor. More than half of respondents reported accessing health services was necessary to them with awareness that their health conditions were minimal. Most (>60%) of participants went to health facilities by themselves, and 83.6% used health services with direct health insurance. Public health facilities were the preferred health services visited.

In terms of expenses, participants reported that transportation fares were mostly below 100 baht, while 79.5% had no fees relating to medical expenses and miscellaneous fees. Most of the transport services to public health facilities were taxis, motorcycle-taxis, tricycles and vans. A total of 45% of participants visited hospitals two or three times per month. In terms of distance, most participants reported less than 5 kilometers from home to public health services, with a travel time of less than 30 minutes most reported. Most of the medical insurances were Universal Coverage Scheme. Participant demographics are shown in Table 1.

Discussion

This study is a part of the Health Promotion Project under the Principle for the Elderly in the Urban Area of Bangkok Metropolitan, which is influenced by a well-known national practice guideline, the Philosophy of Sufficiency Economy, initiated by King Rama IX-Bhumibol Adulyadej. Previous studies have shown that the utilization of health services by older adults in urban areas does adhere to the five dimensions as described by Penchansky & Thomas.¹⁰ Firstly, based on previous data there is a high level of access to health service units at all levels from public to private sector, which are located across the country, and especially in the Bangkok Metropolis. In the Thailand’s capital city, there are a total of 4,687 health service units, and only 141 units are able to admit patients in the facility overnight. Approximately 56% of the units are in the public sector and 44% are in the private sector.¹³ This result is consistent with previous studies^14,15 which explored the factors that affect access to health services of older adults in Bangkok. However, a previous study has revealed that availability of health service at national level is relatively insufficient.¹⁶ Secondly, for the accessibility dimension, high level access has been shown by a previous study,¹⁴ but this result is inconsistent with some studies.^15,16 Obstacles in accessing health services have been reported as difficulties to travel to health facilities.¹⁷ However, in our study, most participants (60.4%) stated that the distance from home to health facilities was less than 5 kilometers, and it takes 76.2% of participants less than 30 minutes to travel to health facilities. This short distance enables participants to access health services easily, which are mostly public hospitals. Therefore, the participants are able to access and utilize the service conveniently.

Thirdly, for the accommodation dimension, data from our study indicates a high level of service access. A previous study¹⁷ revealed that the main problem in this dimension is the long duration between making an appointment and seeing general doctors or specialists. A study by Rahman et al.¹⁸ found that the long waiting time for doctors affected the satisfaction of patients. In addition, it was found that personal factors of patients, such as experience of previous medical care or expectation, affected satisfaction as well.¹⁹ Participants in our study had high satisfaction with appointment of doctors, as they easily made appointments. Therefore, the level of accommodation for our study is at a high level access. Fourthly, for the affordability dimension, our study revealed that there is a high level of access to services. The ability to pay a medical expense is one problem in accessing health services.²⁰ The constitution of the Kingdom of Thailand B.E. 2550²¹ states that “Everyone has equal rights in utilization of the public health service without medical expenses and able to received public health services thoroughly and efficiently”. Accordingly, the established health insurance rights for Thai people gives everyone the opportunity to access health services equally as prices are standardized by the state.²² Our study indicated that participants were satisfied with the rights and expenses at a high level because most of them used Universal Coverage Scheme rights, which has no payment. Therefore, the ability to access the service in the affordability dimension is at a high level. Fifthly, for the acceptability dimension, our study showed a high level service. A previous study²³ found that for this dimension service characteristics, such as attitude and expectations of service recipients, can hinder the acceptance of service quality. The concept of satisfaction of service quality is significant as patients as customers should be satisfied by the service and facility, particularly when they frequently use the health services.

This study found two factors affecting health service accessibility: a) visiting health service unit they registered at, and b) the need for the service. The former factor is aligned with Enabling Factor, the latter is aligned with Need Factor. For health insurance right factor, this study statistically found that participants that visited a health service unit that they were registered at were 1.9 times more likely to access to health service, compared to those who are not registered at the unit(95%Cl=1.214–3.094). In total 83.7% of public hospital patients visited hospitals they were registered at, which is four-times more than those who visited health service units they are not registered. This was consistent with a previous study¹⁵ that found that the relationship between accessibility to health services and utilization of health services was statistically significant (p<0.05). For this reason, if patients use their rights directly the health care service is free of charge for them, or only causes minimal payment. Besides, one of factors why people access public hospitals is no medical expenses.²⁴ It’s been shown that 61.6% of older adults used Universal Coverage Scheme rights, which effects accessibility to health services.²⁵ In addition, use of treatment services increase with the use of health insurance rights, especially in outpatients.^26,27 The lack of ability to pay for medical expenses has been shown to be an issue with utilization of health services of older adults.²⁰

For the second factor, necessity of health care, our study revealed that participants who perceived that they needed to be treated in a hospital increases access to health facilities by 1.5 times compared to those that consider it unnecessary to be treated in a hospital (95%Cl=1.013–2.340). The necessity was making people be aware of the importance in medical treatment. However, it has been observed that using health insurance rights with no payment leads to a more accessible health services. These health services are mostly free of charge, especially for those who registered their health insurance rights at the hospital. Even though patients do not have to pay for the health services, free services are not what they actually want; usually they visit health service units due to their illness and awareness on health conditions and not just because these are free. This finding is supported by previous research²⁴ that studied the needs for access to health services from the perspective of patients and doctors. It indicated that most patients came to access services at the outpatient department; 71.8% of them thought that it was necessary to access to health services and only 0.6% thought it was unnecessary. Nonetheless the viewpoint on treatment between patients and doctors could be different; perspective is important because different perspectives lead to different decisions about necessity in treatment. A previous study²⁸ revealed the patients assumed that they knew about their health and were able to decide whether they needed treatment. Lack of knowledge of health may lead them to not taking care of themself or lead them going to hospital. While doctors are likely to suggest them to initially get diagnosed by general practitioners at health service units.

Findings from our study suggested that the government should give the opportunity to get health insurance rights, so individuals can access health facilities nearest their habitation. Similarly the government should facilitate the ability to move health insurance rights to the health facility nearest their habitation. Due to the fact that receiving health services from health service units where patients do not have their health insurance causes extra payment for them. Instead, rights could be based on the use of identification card, as there are some older adults who do not have real address in urban communities as they may be renting a house etc. Medical facilities near the habitation will make it easier way to visit, with no payment, meaning that older adults could have access to more services. Both the public and private sectors should help raise awareness of basic health care, including health literacy to increase awareness of necessity for treatment. Indeed, a previous study indicated there is a correlation between health literacy and the quality of healthcare interactions.²⁹ Enhancing an understanding of the concept of health literacy will eventually increase patient participation in health care standard and quality in the country holistically.³⁰

There are a few limitations in our study, primarily the number of participants did not reach the set target due to accessibility to participants in urban communities. Also, participants were able to be contacted only via community leaders or public health volunteers for data collecting. A target number of 1,086 participants was missed by 18% - a final number of 886 participants were included in the study.

Conclusion

Among older adults in urban Bangkok, factors affecting access to health services were using health insurance rights for health care service, and concern about the necessity of health care. Encouraging older adults to change their health insurance rights to their nearest hospital and promoting the provision of public health information, will support older adults in accessing more health services to improve their health outcomes.

Data availability