Utilization of Health Services Among the Elderly in Medan City

Putranto Manalu

1,* a

, Ermi Girsang

, Santy Deasy Siregar

, Naomi Enzeli Manullang

and Nisa Apriyani Ginting

Departement of Public Health and Preventive Medicine, Universitas Prima Indonesia, Jl. Sampul No.3, Medan City,

Indonesia

Departement of Occupational Health and Safety, Universitas Prima Indonesia, Jl. Sampul No.3, Medan City, Indonesia

Departement of Healthcare Management, Universitas Prima Indonesia, Jl. Sampul No.3, Medan City, Indonesia

Keywords: Healthcare Utilization, Elderly, Distance.

Abstract: The low utilization of health services is a prevalent global issue, particularly in low- and middle-income

countries. As the elderly experience a decline in their overall body function and ability, they become more

vulnerable to degenerative diseases, which increases the demand for health services and the risk of mortality.

The present study aimed to analyze the determinants of health service utilization at the primary level. This

cross-sectional study was conducted at 41 community health center in Medan City, North Sumatra Province.

A proportional random sampling technique was used to select 485 participants. A structured questionnaire

was administered to collect the data. The data were analyzed using the chi-square test and logistic regression.

The findings revealed that health service utilization was affected by knowledge (0.002), insurance ownership

(0.006), distance (0.004), and family support (0.002). The logistic regression test demonstrates that distance

is the most influential factor (PR=10.067 (2.797-22.714)). Hence, it can be inferred that the utilization of

health services by older adults is affected by their knowledge, insurance ownership, distance, and family

support. Stakeholders are advised to guarantee convenient transportation access to overcome the challenge of

distance to healthcare centers.

1 INTRODUCTION

The increasing elderly population requires special

attention because their healthcare needs tend to rise

along with the growing risks of degenerative diseases

and healthcare costs (Abdi et al., 2019;

Sambamoorthi et al., 2015). The cumulative chronic

pathological processes in the elderly make it

challenging to recover from disease, and the growing

symptoms remaining from disease progression

contribute to the severity of other illnesses (Fan et al.,

2021). Declining memory, reduced hearing ability

(presbycusis), and vision impairment (presbyopia)

can limit physical mobility in older adults (Amarya et

al., 2018). Furthermore, psychological disturbances,

such as the loss of a life partner, can exacerbate the

above conditions, often leading to fatal outcomes

(Stahl et al., 2016).

https://orcid.org/0000-0002-2397-1067

https://orcid.org/0000-0003-4313-4941

https://orcid.org/0000-0003-0472-0331

The increase in the elderly population is occurring

globally as a consequence of technological and

healthcare advancements as well as improved

socioeconomic levels. It is estimated that by 2050, the

elderly population will double to 2.1 billion, with

80% residing in low- and middle-income countries

(WHO, 2022). Data from SUSENAS 2022 indicate

that the elderly population in Indonesia constitutes

10.48% of the total population with a dependency

ratio of 16.09 ((BPS, 2022). The demographic shift

among the elderly requires special attention from the

government, particularly regarding access to both

physical and mental healthcare (Chen et al., 2023).

The WHO mandated reforms in healthcare and long-

term care systems for the elderly in 2016, aiming to

enable them to optimize physical and mental health

throughout their lifetimes (WHO, 2016). Therefore,

efforts are needed to enhance the access and

Manalu, P., Girsang, E., Siregar, S. D., Manullang, N. E. and Ginting, N. A.

Utilization of Health Services Among the Elderly in Medan City.

DOI: 10.5220/0013666600003873

Paper published under CC license (CC BY-NC-ND 4.0)

In Proceedings of the 1st International Conference on Medical Science and Health (ICOMESH 2023), pages 101-106

ISBN: 978-989-758-740-5

101

affordability of healthcare services for the elderly and

address existing barriers.

Ease of access to healthcare is crucial for

improving healthcare service quality. Understanding

the factors with significant impacts is essential to

formulate effective strategies to overcome barriers to

accessing healthcare among the elderly. The

interactions among individuals, families, the

environment, and the healthcare system can be

explained by the concept of access to healthcare (Din

et al., 2014). Elderly people have specific needs in

terms of both the physical and psychological aspects

of daily activities. Limitations such as declining

physical abilities, income, and therapy needs can

affect the quality of life and self-actualization (Putri

& Lestari, 2018). Reduced physical capabilities in the

elderly can lead to decreased economic capacity,

subsequently limiting their social mobility (Quinn &

Cahill, 2016). Various factors influence healthcare

service utilization among the elderly, including

individual, family, community, and healthcare system

factors (Hlaing et al., 2020; Lin et al., 2020; Zeng et

al., 2022).

Previous studies have emphasized the importance

of knowledge in shaping health behavior changes and

health-seeking behavior (He et al., 2016; Teo et al.,

2021). Health insurance ownership has also been

reported as a predictor of healthcare service

utilization and can reduce inequality in the elderly

population (Dalinjong et al., 2017; Laksono et al.,

2023; Siongco et al., 2020). Healthcare service

disparities due to distance from healthcare facilities

have been reported in studies conducted in Yangon

and Texas ((Hlaing et al., 2020; Smith et al., 2019).

Research in Indonesia and China has concluded that

both financial and non-financial family support is a

crucial factor in encouraging the elderly to access

healthcare services (Cahyawati et al., 2020; Yuan et

al., 2022).

Medan is the third largest city in Indonesia and the

largest city on the island of Sumatra. Data gathered

from routine reports by the Medan City Health

Department indicate that the elderly population in the

city will amount to 186,196 people in 2022. Several

previous studies only involved one community health

center, thus having limitations in representing the

elderly population in the city of Medan as a whole

(Nasution, 2019; Siregar et al., 2015; Yollanda &

Zulfendri, 2018). This study will provide a more

comprehensive and representative overview of the

primary healthcare access challenges faced by the

elderly in the city of Medan. Therefore, the results of

this study can provide a deeper and more relevant

understanding in designing policies and intervention

programs that are in line with the real needs of the

elderly population in Medan. This study aimed to

analyze the relationship between knowledge, health

insurance ownership, distance to healthcare facilities,

family support, and healthcare service utilization

among the elderly in Medan

2 METHODS

2.1 Study Design

This cross-sectional study was conducted at 41

community health centers in Medan. This research

was conducted from June 2023 to August 2023.

2.2 Participant

The sample for this study consisted of 485 elderly

individuals obtained using the Lemeshow formula. In

recruiting research subjects, proportional random

sampling techniques were used to ensure that the

number of subjects was aligned with the population

size at each health center. The study included elderly

individuals aged ≥ 60 years, proficient in reading, and

willing to provide informed consent.

2.3 Data Collection

Data were collected using structured questionnaires

and observational sheets. The questionnaire was

divided into six sections: The first section contained

questions about the subjects' sociodemographic

information. The second section consisted of nine

questions on knowledge, and the third section

contained questions on health insurance ownership.

In the fourth section, the researcher inquired about the

distance (in kilometers) from the subjects' homes to

the community health center. The fifth section

comprises six questions about family support in

accessing healthcare. The sixth section included the

question: "Has the elderly person visited the

community health center in the last three months?".

All questionnaires were directly distributed to the

participants, and during data collection, the

researcher was accompanied by healthcare or local

officers to ensure the participants’ residential

addresses.

2.4 Data Analysis

All completed questionnaires were processed using

SPSS software version 26. The total scores of the

responses on each questionnaire were grouped into

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several categories relevant to the operational

definition of the variables. Data were statistically

analyzed using the chi-squared test and logistic

regression analysis. The test results are presented in

tables and in narrative form.

2.5 Ethical Consideration

Ethical clearance for this study was obtained from the

Research Ethics Commission of Universitas Prima

Indonesia with registration number:

090/KEPK/UNPRI/VII/2023.

3 RESULTS

In Table 1, it can be observed that the majority of the

elderly fell within the age range of 60-65 years

(47.58%), and over half of them were female

(67.22%). Only 16.08% of the elderly pursued higher

education, while 2.27% did not attend school. More

than half of the elderly did not have a monthly income

(61.03%), and only 18.76% still had an income

exceeding 1.5 million rupiahs per month.

Table 1: Elderly sociodemographic data (n=485)

Characteristic n %

Age

60-64 226 47.58

65-69 170 35.79

≥70 79 16.63

Sex

Male 159 32.78

Female 326 67.22

Education Status

No school 11 2.27

Primary school 92 18.97

Middle school 143 29.48

High school 161 33.20

College/Degree 78 16.08

Income per month (Rupiah)

Nil 296 61.03

< 750.000 31 6.39

750.000 – 1.500.000 67 13.81

>1.500.000 91 18.76

Table 2 shows the frequency distribution based on

knowledge, health insurance ownership, distance to

healthcare facilities, family support, and healthcare

service utilization. The majority of the subjects had

insufficient knowledge (75.26%) and possessed

health insurance (85.36%). More than half of the

respondents indicated that the distance to healthcare

facilities was quite far, exceeding 5 km (67.42%). A

total of 314 individuals stated that they had received

support from their families (64.74%). Only 17.94%

had utilized healthcare services in the last 3 months

Table 2: Frequency distribution of research variables

Variable n %

Knowledge

Less 365 75.26

Good 120 24.74

Insurance ownership

No 71 14.64

Yes 414 85.36

Distance

Far (>5 km) 327 67.42

Near (≤ 5 km) 158 32.58

Family support

No 171 35.26

Yes 314 64.74

Health service utilization

No 398 82.06

Yes 87 17.94

Furthermore, the researcher conducted a chi-

square test to determine the significance of the

relationship between the predictors and healthcare

service utilization (Table 3). Among subjects with

poor knowledge, 60.82% did not utilize healthcare

services, and only 14.43% did so. In contrast, among

respondents with good knowledge, 21.24% did not

use healthcare services. The test results indicated a

significant relationship between knowledge and

healthcare service utilization (0.002). Similarly,

concerning health insurance, the statistical test results

show a significant relationship between insurance

ownership and healthcare service utilization (0.006).

Of 71 elderly individuals without health insurance, 50

did not utilize healthcare services. By contrast, among

those with insurance, only 13.61% utilized healthcare

services.

In this study, distance to healthcare facilities was

associated with healthcare service utilization (0.004).

Of the 327 elderly individuals who indicated that their

distance to healthcare facilities was quite far, only 61

utilized healthcare services. Family support is also

related to healthcare service utilization (0.000).

Elderly individuals receiving family support are more

likely to utilize health care services.

Next, a logistic regression analysis was conducted

to determine the variables or factors that most

dominantly influenced healthcare service utilization.

From the bivariate analysis, it was evident that all

predictors met the criteria for inclusion in the logistic

regression analysis (p<0.250).

Utilization of Health Services Among the Elderly in Medan City

103

Table 3: Relationship between knowledge, insurance

ownership, distance, and family support with health service

utilization

Variable

Health service

utilization

No Yes

n (%) n (%)

Knowledge

0.002 Less 295 (60.82) 70 (14.43)

Good 103 (21.24) 17 (3.51)

Insurance

ownership

No 50 (10.31) 21 (4.33)

0.006

Yes 348 (71.75) 66 (13.61)

Distance

Far (>5 km) 266 (54.85) 61 (12.58)

0.004

Near (≤ 5 km) 132 (27.22) 26 (5.36)

Family support

No 146 (30.10) 25 (5.15)

0.000

Yes 252 (51.96) 62 (12.78)

The results of the analysis indicate that the most

dominant predictor influencing the utilization of

community health center services by the elderly in

Medan was distance. With a PR value of 10.067, it

can be projected that elderly individuals with a long

distance to healthcare facilities have a tendency to not

utilize healthcare services 10.067 times. This finding

underscores the significance of accessibility to

healthcare services.

Table 4: Dominant factor for health service utilization

Variable

PR 95% CI

Knowled

e 0.242 1.415 1.034

–

2.545

Insurance

ownership

0.007 8.469 2.797 – 22.714

Distance 0.002 10.067 2.455

–

44.714

Famil

ort 0.124 0.668 1.956

–

3.341

4 DISCUSSION

The utilization of health services by the elderly is an

important and complex topic. Ideally, primary

healthcare facilities such as community health centers

should provide comprehensive services for the

elderly. Beyond focusing on primary treatment and

rehabilitation, these centers need to offer both

physical and mental health education services as a

form of promotive and preventive care to enable the

elderly to manage their health independently.

Numerous factors can influence the elderly's

utilization of available health services. This study

focused on several aspects, such as the elderly's

knowledge about health services, health insurance

ownership, distance from their residence to health

facilities, and family support.

The results indicate that knowledge significantly

predicts health-service utilization. In this study,

elderly individuals with limited knowledge were less

likely to use health services. Knowledge is crucial for

motivating the elderly to explore and access health

information. This finding aligns with those of several

previous studies (Mosadeghrad, 2014; Rahmadani et

al., 2022; Vorrapittayaporn et al., 2021). Limited

information receipt may lead the elderly to lack

interest in visiting health facilities, even for medical

checkups. One study reported infrequent health

check-ups due to insufficient information (Chien et

al., 2020). Additionally, most older people in this

study had high school education. A study in the

Philippines reported an association between

education level and health knowledge (Hoffmann &

Lutz, 2019).

The elderly also need adequate health insurance to

cover health service costs. Statistically, there was a

significant relationship between health insurance

ownership and health service utilization. Although

most elderly individuals have health insurance, only

a few use health services. This is possibly due to

public concerns about disparities in medical services

provided by community health centers for patients

with social insurance (JKN). A study in Manado

reported community reluctance to use JKN for

treatment because of negative perceptions

(Rumengan et al., 2015). Another study mentioned

that patients with JKN complained about short

examination and consultation durations, giving a

rushed impression (Rochmah et al., 2020). The study

results also indicate that family support significantly

encourages the elderly to access health services.

Families can assist the elderly in various ways such

as escorting them to health facilities, helping them

understand medical information, and providing

emotional support(Schulz et al., 2020). Additionally,

families can engage in discussions with health care

professionals and make informed decisions about

elderly care, especially in managing chronic diseases

(Alqahtani & Alqahtani, 2022).

In this study, the distance to health facilities was

also significantly associated and was the most

dominant predictor of elderly health services

utilization. This finding is consistent with that of a

study conducted in Ethiopia (Girma et al., 2011).

Elderly individuals from health facilities find it

challenging to travel, especially if they have mobility

limitations or lack access to reliable and friendly

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transportation. Moreover, if transportation costs are

perceived as high, it becomes a consideration for the

elderly to seek health services. A study in China

reported barriers faced by the elderly despite the

reasonable distance to health facilities. Traffic

congestion, public transportation inconvenience, and

fare issues are the reasons for their lack of access to

health services (Li et al., 2022). Steps that can be

taken include encouraging the government to make

changes in an elderly friendly environment,

especially in public spaces and transportation

facilities, thus making them easily accessible.

Increasing the number of health facilities could be an

additional option, particularly in urban areas with

inadequate public transportation.

5 CONCLUSIONS

The results indicate that knowledge, health insurance,

distance, and family support are significantly

associated with the utilization of health services by

the elderly. Space emerged as the most dominant

predictor influencing the elderly to seek healthcare

services at health facilities. Elderly individuals with

good knowledge, health insurance, proximity, and

strong family support are more likely to use health

services than those without these factors. Community

health centers are recommended to enhance the

quality and availability of healthcare services for the

elderly, especially in terms of health information, and

promote family involvement in healthcare.

Additionally, the government is encouraged to

provide elderly friendly and cost-effective

transportation facilities.

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