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Poudel et al. BMC Public Health (2025) 25:1512
https://doi.org/10.1186/s12889-025-22693-5 BMC Public Health
*Correspondence:
Sujan Poudel
poudelsujan15@gmail.com
Full list of author information is available at the end of the article
Abstract
Background The increasing trend of senior citizens and their complex healthcare needs demands the improvised
provision of healthcare services and strategies to improve health service utilization to ensure health for all. Although
health service provision has been prioritized, health service utilization is also a prime aspect that should be addressed
to target the chronic needs of senior citizens. This study aims to assess the status of health service utilization and its
inuencing factors among senior citizens in rural municipalities of the Kaski district, Nepal.
Methods A cross-sectional study was carried out in selected wards of all rural municipalities of Kaski District
(Annapurna, Machhapuchre, Madi and Rupa). The study included a sample size of 392 senior citizens. Data were
collected using a semi-structured interview schedule based on the Andersen‒Newman behavioral model using
the Study on Global Aging and Adult Health (SAGE) questionnaire to assess health service utilization. Data analysis
included descriptive statistics to summarize participant characteristics and health service utilization patterns.
Additionally, bivariate and multivariable logistic regression analyses were performed to identify key determinants of
healthcare utilization, adjusting for potential confounders. All statistical analyses were conducted using Statistical
Package for Social Sciences version 20, with a signicance threshold set at p < 0.05.
Results More than half (54.6%) of the senior citizens in the study visited healthcare facilities in the 12 months. Health
service utilization was signicantly associated with awareness of free healthcare services, membership in social health
insurance, family support, self–perceived health status, independence in activities of daily living, and having a chronic
disease with a p-value less than 0.05 and 95% condence interval. After controlling for confounders, membership
in social health insurance (aOR = 3.85, 95% CI: 2.31–6.40, p < 0.001), family support (aOR = 2.06, 95% CI: 1.01–4.15,
p < 0.05), and the presence of chronic disease (aOR = 2.92, 95% CI: 1.70–4.98, p < 0.001) were statistically signicant
with health service utilization among the senior citizens.
Social health insurance, family support,
and chronic diseases as determinants
of health service utilization among senior
citizens in rural Nepal
SujanPoudel1,2* , AnushaParajuli3, NirmalDuwadi2, Bal KrishnaBhatta2, ShishirPaudel4, DhurbaKhatri4, Damaru
PrasadPaneru5 and Yam PrasadSharma6
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Poudel et al. BMC Public Health (2025) 25:1512
Introduction
e landscape of health service utilization is nuanced,
particularly when examining the critical role that sup-
portive systems play in enhancing access and eective-
ness [1]. Regardless of race, gender, socioeconomic
status, and educational background, healthcare needs
among an elderly population become more complex with
age [2, 3]. e World Health Organization (WHO) esti-
mated that the proportion of people aged 60 years and
above almost doubled, from 12 to 22%, between 2015 and
2050 [4] and these are amongst the vulnerable popula-
tions that are signicantly more prone to chronic condi-
tions such as cardiovascular disease (CVD), respiratory
disease, diabetes, hypertension, etc.
e healthcare system in low- and middle-income
countries (LMICs), including Nepal, relies heavily on out-
of-pocket payments (OOPs) for service provision, further
burdening rural households [5]. As a strategy to improve
healthcare utilization and prevent households from fall-
ing into poverty due to catastrophic health expenses,
social health insurance systems have gained popularity in
LMICs [6–8], and Nepal is not an exception. In the con-
text of Nepal, over 85% of aging population lives in rural
areas that seem to have poor access to general healthcare
services [5]. In rural regions senior citizens are unedu-
cated, have limited sources of income, and have poor
health and nutrition, resulting in an elevated burden of
both infectious and chronic illnesses [9–11] which is also
claimed by the WHO as unmet healthcare needs due to
nancial or accessibility barriers within the same group.
is gap hinders progress toward achieving the Universal
Health Coverage (UHC) Service Coverage Index target of
80 by 2030 [12].
While geriatric health has long been overlooked in
Nepal, recent government eorts aim to improve elderly
welfare through policies like free essential healthcare,
subsidies for chronic illnesses, social security which are
also addressed by the Senior Citizens by Act (2006) and
Regulation (2008) [13, 14]. Additionally, the Geriatric
Health Service Strategy (2021–2030) has addressed the
provoke to equitable, integrated elderly care through
strengthened health systems, chronic and other disease
management by establishment of an eective and e-
cient system of medication delivery and response system
for the prevention and mitigation of the health risks of
senior citizens, and improved social protection [15].
Similarly, the Social Health Insurance (SHI) also known
as National Health Insurance program aims to provide
equitable health care services through a risk-pooling
mechanism, oering senior citizens a free premium of
Rs. 3500 (US $25), enabling them to access up to Rs. 1
lakh (US $713) in healthcare services with exempt from
co-payments [16]. Implementation gaps and insucient
legal frameworks hinder adequate support for the grow-
ing elderly population, underscoring unmet healthcare
demands.
Despite these initiatives, rural households face signi-
cant challenges that hinder healthcare utilization among
senior citizens. Since the life expectancy of senior citi-
zens has been increasing in recent years, their quality of
life also needs to be considered by focusing on the fac-
tors associated with increased healthcare utilization to
mediate their chronic conditions promptly [17]. While
previous studies have explored healthcare coverage and
utilization, the specic dynamics of healthcare-seek-
ing behavior in rural settings remain underexamined.
Although previous studies were focused on health-
care coverage, this study addresses the gap by assessing
healthcare utilization behavior in rural settings through
the study of predisposing, enabling, and need factors.
us, this study aims to assess the status of health service
utilization and its inuencing factors among senior citi-
zens in rural municipalities of Kaski district, Nepal.
Method
Study design and setting
A community-based cross-sectional study was conducted
among senior citizens residing in all the rural munici-
palities (Annapurna, Machhapuchchhre, Madi, Rupa) of
Kaski District between February to March 2023. ere
are one metropolitan and four rural municipalities inside
Kaski District, Nepal. ese four rural communities
cover 14.8% of the district accommodations and 11,680
senior citizens above the age of 60 [18].
Sample size and sampling
e sample size of 392 was determined via Cochran’s for-
mula for the estimation of the proportion for nite popu-
lation, n= (NZ2pq)/ (d2(N-1) + Z2pq) where z = standard
normal variate, with a value of 1.96 at 95% CI, p = preva-
lence of health service utilization among senior citizens
at 70% based on previous study conducted in neighbor-
hood areas in 2019 [19]; q = 1-p and d = allowable error
(5%); N = total number of senior citizens above age of 60
Conclusions Many senior citizens did not utilize the healthcare services. Enrollment in social health insurance,
awareness of free health services, family support and presence of chronic conditions were signicantly associated
with higher health service utilization. This suggests that to increase health service utilization awareness about health,
including social health insurance, and fostering a sense of security and well-being is crucial.
Keywords Health service utilization, Senior citizen, Utilization, Rural area
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Poudel et al. BMC Public Health (2025) 25:1512
inside selected wards (11680). e sample was adjusted
for a 1.2 design eect and a 5% non-response rate.
e required samples were drawn in multiple stages,
where initially, from each of the four rural municipali-
ties. ree or four wards were selected at random via
lottery methods, considering the total number of wards
in each of the rural municipalities. en the detailed list
of senior citizens residing in those wards was prepared
and a sample to be drawn from each selected ward was
calculated on the basis of a proportion of senior citizens
residing in each of the wards. After the required samples
were identied, the individual households were selected
using the WHO epi-method [20] by starting at a central
point, choosing a random direction, and systematically
visiting every household until the desired sample size was
achieved (Fig.1). In cases where there was more than one
senior citizen in the selected household, only one senior
individual was selected through the lottery method. All
senior citizens who were 60 years and above, and who
permanently resided in the rural municipalities were
eligible to participate in the study. Senior citizens with
severe mental health disorders, hearing impairments, or
speech disabilities were excluded from the study.
Data collection and variables
Data were collected via face-to-face interviews using a
semi-structured interview schedule, at the residency of
each selected senior citizen by the principal investiga-
tor while strictly adhering to the ethical guidelines. e
study was grounded in the Andersen Newman Behav-
ioral Model, which posits that the utilization of health
services is determined by predisposing, enabling, and
need factors [21]. e Study on Global Aging and Adult
Health (SAGE) questions were adapted to assess health
care utilization [22]. e tool was developed in English
language and translated into Nepali language and back-
translated in the English language to maintain translation
validity. All the interviews were taken in Nepali language.
e Nepalese version of the questionnaire was pre-tested
among 10% (n = 40) of the total sample in Rupa rural
municipality ward no. 4, which was not included in the
study sample and shared a similar characteristics.
e outcome variable of this study was health service
utilization. Participants were initially assessed regard-
ing their pre-existing medical conditions or comorbidi-
ties over the past year, their self-perceived health status,
and whether they sought any kind of healthcare services
(e.g., consultations, treatments or screening) to address
Fig. 1 Sampling process
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Poudel et al. BMC Public Health (2025) 25:1512
health concerns during the preceding 12-month period.
Furthermore, participants were asked to provide some
information on the nature of the healthcare facilities vis-
ited, the services received, and their satisfaction with the
services to validate if they had utilized any healthcare
services.
e independent variables included predisposing,
enabling, and need factors as suggested by the Andersen
model. Predisposing factors included age, gender, ethnic-
ity, marital status, family type, education, occupation,
awareness about free healthcare services, and preference
for seeking care. Enabling factors such as membership
in national health insurance, household wealth measure
through International Wealth Index [23], distance to the
health facility, and family support were also measured.
e family support was assessed by assessing family func-
tioning based on the Family APGAR Index [24]. Family
APGAR scale covers ve areas adaptability, partnership,
growth, aection, and resolve in three-point Likert scale
with total score ranging between 0 and 10. A score of 7 to
10 suggested a highly functional family, 4 to 6 suggested
a moderately dysfunctional family and < 4 suggested a
severely dysfunctional family [24]. Similarly, need factors
such as self-perceived health status, presence of diag-
nosed chronic diseases, and dependency status. e
dependency status was assessed through the Katz Index
of Independence in Activities of Daily Living (ADL) [25].
Katz index assesses a person’s independence in six basic
daily living activities where each activity is scored on a
binary scale and a total score ranging between 0 and 6. A
score of 6 indicates full function while a score of < 6 was
considered functional impairment [25].
Data analysis
e data were entered into EpiData 3.1 software and
exported to the Statistical Package for Social Sciences
(SPSS) version 20 for analysis. Descriptive statistics were
used to summarize the data: categorical variables were
presented as frequencies and percentages, while the con-
tinuous variable (age) was described using mean and
standard deviation. e normality of age was assessed
using the Shapiro-Wilk test, and its distribution was visu-
ally examined using histograms and boxplots. Pearson
chi-square tests were performed to assess the associa-
tion between categorical independent variables (e.g., age
category, gender, ethnicity, education level, social health
insurance membership, presence of chronic disease, and
family support) and the dependent variable (health ser-
vice utilization). Binary logistic regression was applied
for multivariable analysis, as the outcome variable was
binary (utilized vs. not utilized health services). All vari-
ables with p < 0.05 in chi-square tests were included in
the multivariable model to control for confounding.
Adjusted odds ratios (aOR) with 95% condence level
were calculated.
Results
Among the 392 senior citizens, 214 (54.6%) visited
healthcare facilities in the past 12 months. Among those
utilizing healthcare facilities, the primary reasons for
seeking health services were acute conditions, joint/
arthritic pain, and hypertension, collectively represent-
ing 11.2% of all reported healthcare services. Similarly,
among senior citizens who did not access healthcare ser-
vices, the most prevalent reason was the absence of a per-
ceived need for care (55.1%), followed by transportation
barriers (23.6%), and uncertainty regarding healthcare
facility locations (12.4%) (Table1).
In Table2, the age of the participants ranges between
61 and 99 years with a mean ± SD of 69.9 ± 7.8 years. e
gender was almost equally distributed in the sample as
56.4% were females. Most of senior citizen were of upper
caste (48.5%) and lives with their spouse (64.03%). More
than half (64.3%) belongs to non- nuclear family and
almost half senior citizens were Illiterate All these fac-
tors are not signicantly aected health service utiliza-
tion. However, awareness of free health care services
Table 1 Health service utilization patterns and barriers
Variables Frequency Percentage
Health service utilization (n = 392)
Yes 214 54.6
No 178 45.4
Main reason to seek health (n = 214)
Hypertension 24 11.2
Chronic pain in joints/arthritis 24 11.2
Acute conditions 24 11.2
Diabetes or related complication 22 10.3
Unexplained pain in the chest 14 6.5
Depression or anxiety 13 6.1
Generalized pain 10 4.7
Surgery 10 4.7
Problems with mouth, teeth or swelling 6 2.8
Occupational or work-related injury 6 2.8
Stroke or sudden paralysis 6 2.8
Injury 6 2.8
Sleeping problems 4 1.9
NTD and heart disease 3 1.4
Problems with breathing 3 1.4
Cancer 3 1.4
Other 2 0.9
Reason for not visiting health Facility
(n = 178)
Was not sick 98 55.1
Lack of transportation cost 42 23.6
Did not know where to go 22 12.4
Inadequate drugs or equipment in health
facility
10 5.6
Others 6 3.4
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Poudel et al. BMC Public Health (2025) 25:1512
signicantly inuenced utilization (p = 0.019), with 62.9%
of those aware utilizing services compared to 50.4% of
those unaware. Preference for public or private health
care showed a non-signicant trend (p = 0.073), with
slightly higher utilization among those preferring private
care (62.9%). Although preference for seeking health care
services showed a non-signicant trend, with 52.1% of
those preferring public and 62.9% of those preferring pri-
vate health care utilizing services (Table2).
Membership in social health insurance (SHI) signi-
cantly inuenced health service utilization (p < 0.001),
with 74.3% of SHI members utilizing services compared
to only 43.7% of non-SHI members. Among SHI mem-
bers, those who paid premiums themselves had higher
utilization rates (82.9%) compared to those who had
their premiums paid by government entities or NGOs
(64.1%) (p = 0.011). Economic status did not signicantly
impact utilization, as all quintiles showed similar utiliza-
tion rates (p = 0.182). Distance to the health facility also
had no signicant eect on utilization (p = 0.482). Family
support was a signicant factor, with severely dysfunc-
tional families showing the lowest utilization (35.8%), and
highly functional families having the highest utilization
(p = 0.006). Similarly, self-perceived health status, inde-
pendence in daily activities, and the presence of chronic
diseases signicantly inuence health service utilization,
with poorer health, dependence, and multiple chronic
conditions being associated with greater utilization
(p < 0.05) (Table3).
Multivariate analysis indicated that membership in SHI
was strongly associated with increased health service
utilization, with those enrolled in SHI being nearly four
times more likely to utilize services compared to those
not enrolled (aOR: 3.85, 95% CI: 2.31–6.40, p < 0.001).
Table 2 Predisposing factors and health service utilization
Characteristics n (%) Health Service Utilization χ² p-value
Yes n (%) No n (%)
Age of senior citizens
< 70 209 (53.3) 115 (55) 94 (45) 0.340 0.854
≥ 70 183 (46.7) 99 (54.1) 84 (45.9)
x ± SD 69.9 ± 7.8
Gender
Male 171 (43.6) 92 (53.8) 79 (46.2) 0.076 0.782
Female 221 (56.4) 122 (55.2) 99 (44.8)
Ethnicity
Dalit 91 (23.2) 52(57.1) 39 (42.9) 4.169 0.384
Disadvantaged Janajati 34 (8.7) 14(41.2) 20 (58.8)
Relatively Advantaged Janajatis 61 (15.6) 32 (52.5) 29 (47.5)
Religious minorities 16 (4.1) 7(43.8) 9(56.2)
Upper caste 190 (48.5) 109 (57.4) 81 (42.6)
Marital Status
With Spouse 251(64.03) 141 (56.2) 110 (43.8) 0.706 0.401
Without Spouse 141(35.97) 73(51.8) 68(38.2)
Family type
Nuclear 140 (35.7) 84(60) 56 (40) 2.57 0.109
Non-nuclear 252 (64.3) 130 (51.6) 122 (48.4)
Educational Level
Illiterate 193 (49.2) 96 (49.7) 97 (50.3) 4.258 0.235
Primary level 126 (32.1) 72 (57.1) 54 (42.9)
Secondary level 41 (10.5) 26 (63.4) 15 (36.6)
Graduate and above 32 (8.2) 20 (62.5) 12 (37.5)
Economic Dependency
Dependent 124 (31.63) 68 (54.8) 56 (45.2) 0.004 0.947
Independent 268 (68.37) 146 (54.5) 122 (45.5)
Awareness about free health care services
Yes 132 (33.67) 83 (62.9) 49 (37.1) 5.513 0.019*
No 260 (66.33) 131 (50.4) 129 (49.6)
Preference for seeking health care services
Public Health care 303 (77.30) 158 (52.1) 145 (47.9) 3.223 0.073
Private health care 89 (22.70) 56 (62.9) 33 (37.1)
*statistic ally signicant at p < 0.05, **stat istically signican t at p < 0.001
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Poudel et al. BMC Public Health (2025) 25:1512
e presence of chronic diseases also signicantly inu-
enced service utilization: individuals with multiple
chronic diseases were nearly six times more likely to
utilize health services (aOR: 5.94, 95% CI: 3.17–11.10,
p < 0.001), while those with single chronic diseases were
approximately three times more likely to use services
compared to those with no chronic conditions (aOR:
2.92, 95% CI: 1.70–4.98, p < 0.001). Additionally, individu-
als from highly functional families were twice as likely to
utilize health services compared to those from severely
dysfunctional families (aOR: 2.06, 95% CI: 1.01–4.15,
p = 0.045). Furthermore, independence in activities of
daily living was associated with lower health service uti-
lization, with those who were independent being half as
likely to use health services than those who were depen-
dent (aOR: 0.49, 95% CI: 0.99–4.25, p = 0.053) (Table4).
Discussion
is study identied the determinants of health service
utilization among the Senior citizen living in the rural
Municipalities of Kaski District. Six factors were found
to have a statistically signicant relationship with health
service utilization in these rural settings, including all
three predisposing, enabling factors, and need factors.
Membership in SHI, awareness about free healthcare
services, family support, self-perceived health status,
independence in activities of daily living and presence of
chronic diseases were the signicant factors that play a
pivotal role in utilizing the health service among senior
citizens. All these factors relate to increasing accessibility
of healthcare services for all rural senior citizens which
serves as key components for universal health coverage
(UHC) which aims to ensure that everyone, regardless of
wealth, gender, or other conditions, has access to high-
quality healthcare as a key goal of the Sustainable Devel-
opment Goals (SDGs) is to improve [26].
Table 3 Enabling and need factors and health service utilization
Determinants n (%) Health Service Utilization χ² p-value
Yes n (%) No n (%)
Membership in Social health insurance (SHI)
Yes 140 (35.7) 104 (74.3) 36 (25.7) 34.073 < 0.001**
No 252 (64.3) 110(43.7) 142(56.3)
Premium payern = 140
Paid by self or family member 76 (54.28) 63 (82.9) 13 (17.1) 6.45 0.011*
Paid by Government entities and NGOs/CBOs 64(45.71) 41(64.1) 23 (35.9)
Economic Status of family
Lowest quintile 78 (19.9) 33 (42.3) 45 (57.7) 6.236 0.182
Second quintile 80 (20.4) 48 (60) 32 (40)
Third quintile 77 (19.6) 44 (57.1) 33 (42.9)
Fourth quintile 79 (20.2) 44 (55.7) 35 (44.3)
Highest quintile 78 (19.9) 45 (57.7) 33 (42.3)
Distance to health facility
≤ 30min 173 (44.1) 91 (52.6) 82 (47.4) 0.495 0.482
> 30min 219 (55.9) 123 (56.2) 96 (43.8)
Family support
Severely dysfunctional family 53 (13.5) 19 (35.8) 34 (64.2) 10.344 0.006*
Moderately dysfunctional family 89 (22.7) 46 (51.7) 43 (48.3)
Highly functional family 250 (63.8) 149 (59.6) 101 (40.4)
Self–perceived health status
Poor 113 (28.8) 70 (61.9) 43 (38.1) 15.805 < 0.001**
Moderate 152 (38.8) 93 (61.2) 59 (38.8)
Good 127 (32.39) 51 (40.2) 76 (59.8)
Independence in activities of daily living
Dependent 51 (13.0) 21 (41.2) 30 (58.8) 4.256 0.039*
Independent 341 (87.0) 193 (56.6) 148 (43.4)
Presence of Chronic Disease
No 162 (41.3) 58 (35.8) 104 (64.2) 42.625 < 0.001**
Single 128 (32.6) 80 (62.5) 48 (37.5)
Multiple 102 (26.1) 76 (74.5) 26(25.5)
*statistic ally signicant at p < 0.05, **stat istically signican t at p < 0.001
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Poudel et al. BMC Public Health (2025) 25:1512
is study revealed that slightly more than half (54.6%)
of the rural senior citizens utilized health services in the
past 12 months, whereas 45.4% did not access any health-
care. Translating this rate to the senior citizens of Kaski’s
rural municipalities (total 11,680), this equates to approx-
imately 5,303 seniors who did not receive healthcare ser-
vices [18]. e observed health service utilization is lower
than the utilization reported in the past study based on
the rural setting of the same province, which reported
utilization of health service among the senior citizens at
65% [27]. e past studies from Nepal assessing health
service utilization among the ageing population (60 years
and above) suggested that the health service utilization
lies between 63.3 − 80.0% [19, 27–30]. Diverse enabling
factors, such as geographical access and socioeconomic
conditions, may inuence these variations in health ser-
vice utilization. However, comparing this utilization rate
with urban areas in Nepal shows that rural seniors face
distinct challenges, likely due to limited accessibility,
workforce shortages, and higher disease burdens [19, 28].
Despite these variations, the substantial proportion of
seniors who did not seek healthcare suggests that those
without prominent disease symptoms may miss neces-
sary care.
ose who did not attend health facilities (45.4%)
stated the reason was that they did not believe they were
sick enough (55.1%), followed by a lack of transporta-
tion cost (23.6%) and a lack of knowledge (12.4%). Many
seniors have agricultural-based incomes, which often
cover only basic expenses, and lack social support for
healthcare visits. Similar studies in India found compa-
rable barriers, including distance and the perception of
illness as a natural part of aging [31, 32]. Furthermore,
previous research shows that urban seniors have better
access to services and healthcare workers, which aligns
with higher urban health service utilization rates [33].
ese ndings suggest that eorts to increase utilization
could focus on educational programs that address com-
mon misconceptions about aging and promote preven-
tive healthcare. Further research should investigate the
nancial and social support systems that could facilitate
routine healthcare access for seniors.
Among the predisposing factors examined, awareness
of free healthcare services was positively linked to utiliza-
tion, with those aware being more likely to seek services.
is is in line with past studies sharing observations that
senior citizens who knew about free health care services
were more likely to utilize health services than those who
didn’t know about it [10, 28, 34]. However, it is impor-
tant to note that the Nepal government provides free
medical care services for senior citizens suering from
Alzheimer’s and geriatric-related diseases such as Par-
kinson, heart disease, kidney disease, asthma, and cancer.
ere is a government provision to construct and operate
a special hospital care room for senior citizens in all the
hospitals with more than 50 bed capacity and establish
Table 4 Multivariate analysis of the determinants of health service utilization among senior citizens
Characteristics Heath service utilization
uOR (95% CI) p-value aOR (95% CI) p-value
Awareness about free health care services
Yes 1.67 (1.08–2.56) 0.019* 1.20 (0.72–1.98) 0.471
No Ref Ref
Membership in SHI
Yes 3.72 (2.37–5.86) < 0.001** 3.85 (2.31–6.40) < 0.001**
No Ref Ref
Family support
Highly functional family 1.91 (0.95–3.84) 0.006* 2.06 (1.01–4.15) 0.045*
Moderately dysfunctional family 2.64 (1.42–4.88) 0.002* 1.67 (0.76–3.66) 0.199
Severely dysfunctional family Ref Ref
Self–perceived health status
Poor 1.09 (0.35–3.33) 0.001* 1.10 (0.29–4.12) 0.891
Moderate 1.60 (0.99–2.55) 0.001* 1.13 (0.71–2.34) 0.390
Good Ref Ref
Independence in activities of daily living
Independent 0.54 (0.29–0.97) 0.039* 0.49 (0.99–2.25) 0.053
Dependent Ref Ref
Presence of Chronic Disease
Multiple 5.24 (3.02–9.07) < 0.001** 5.94 (3.17–11.10) < 0.001**
Single 2.99 (1.84–4.83) < 0.001** 2.92 (1.70–4.98) < 0.001**
None Ref Ref
Logistic regression model adjusted for all variables in the table *statistically signicant at p < 0.05**s tatistical ly si gnicant at p < 0.001 AOR, adjusted OR; UOR,
unadjusted OR
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Poudel et al. BMC Public Health (2025) 25:1512
a geriatric ward in the health institution having a capac-
ity of more than 100 beds [15]. Similarly, membership in
social health insurance (SHI), now known as the National
Health Insurance scheme, was an important predictor
for health service unitization. Similar observations were
shared by the studies from Nepal [34–36], rural Tanza-
nia [37], and China [38, 39] observing the connection
between insurance coverage and health service utiliza-
tion, which signies the utilization of medical services by
the older population. In contrast, a Tanzanian and Chi-
nese study found that uninsured senior citizens utilized
outpatient and inpatient services more eectively than
insured seniors, suggesting that insurance may some-
times limit access to comprehensive care, respectively
[40, 41]. ese ndings suggest that insurance could play
an important role in health service utilization but the
policies should be evaluated to ensure insurance schemes
cater eectively to senior needs, and awareness cam-
paigns could better promote the availability of free and
insured services. In this regard, the government devel-
oped the policy regarding the establishment of social care
units and geriatric services to provide free and subsidized
health care to senior citizens with improved social pro-
tection [15].
While family support was signicantly linked to ser-
vice use in our study, some Nepalese studies have found
no association between family support and health service
utilization, underscoring possible regional and temporal
variations [33, 42]. However, a prior study from Nige-
ria found that family support had been associated with
health service utilization among senior citizens [43].
Notably, enabling factors such as household income and
proximity to health facilities did not show signicant
associations in our study, contrasting with other studies
where income and distance were identied as barriers
or facilitators of service use [19, 30, 42, 44]. is could
reect urban-rural disparities, as urban areas often pro-
vide greater access and nancial means for healthcare.
To enhance our understanding of social determinants
of health in rural settings, future studies could examine
dynamic socio-economic factors that inuence fam-
ily support for senior healthcare access. Community
engagement strategies might also address gaps in social
and economic factors to ensure adequate family or nan-
cial resources.
In terms of health-related factors, senior citizens who
were independent in activities of daily living (ADL) were
signicantly more likely to use health services. is
nding is consistent with a study from eastern Nepal,
although a western Nepal study reported no signicant
association between ADL independence and service use,
possibly due to dierent regional social expectations and
support systems [45]. Although self-perceived health
status was not linked to utilization in our study, other
studies, particularly in urban settings like Pokhara, have
found that self-perceived health is a strong predictor of
service use, suggesting possible dierences in health per-
ceptions between rural and urban seniors [19, 28]. is
variation may reect diering attitudes toward health
based on geographical and cultural factors. Programs
that educate seniors on managing daily health tasks could
promote earlier healthcare-seeking behaviors.
e presence of chronic disease was a signicant deter-
minant of healthcare use, with seniors having multiple
chronic conditions being more likely to seek care. ese
observations have been shared by multiple studies [19,
28, 33, 34, 42, 46], indicating that seniors often priori-
tize healthcare when faced with chronic health issues,
whereas the habit of utilizing screening services is low
[47, 48]. ese observations suggest the need for public
health interventions that could emphasize the benets
of regular check-ups, and motivate the senior citizens to
assess health care services even for those without current
symptoms.
is study has several strengths and limitations that
should be considered when interpreting the ndings.
is is one of the rare studies examining health service
consumption among Nepal’s elderly population, par-
ticularly in rural areas. In addition, we analyzed the free
essential health care and the social health insurance plan,
both of which had never been extensively researched.
While our ndings are focused on rural areas in the Kaski
district, they oer insights relevant to similar rural set-
tings but may not fully reect urban contexts. Some of
the information was based on self-reported data, which
may introduce recall bias, particularly when participants
reported on their health service utilization over the past
12 months. Due to the time constraints considering the
lengths of the questionnaire and the senior citizens, we
did not capture specic information on healthcare qual-
ity or satisfaction, which could further inuence utili-
zation patterns. Additionally, a design eect of 1.2 was
applied, aligning with common practice in community-
based health surveys. While variations in design eect
exist across studies, future research could further rene
estimations using context-specic data. Future research
could build on these ndings by incorporating longitu-
dinal designs to explore changes in health service uti-
lization over time and by including qualitative methods
to capture participants’ perceptions of healthcare qual-
ity and satisfaction. Despite these limitations, this study
makes an important contribution by highlighting key
determinants of healthcare utilization among an under-
served rural population.
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 9 of 10
Poudel et al. BMC Public Health (2025) 25:1512
Conclusion
is study highlights critical barriers to healthcare uti-
lization among senior citizens, revealing that more than
half of the senior citizens accessed healthcare services.
e key factors inuencing healthcare-seeking behavior
included enrollment in social health insurance, family
support, and the presence of chronic diseases, highlight-
ing their importance as predictors of healthcare utiliza-
tion. Additionally, awareness of free health services and
the ability to perform daily activities independently were
identied as signicant, though modest, contributors to
healthcare access. To increase the healthcare utilization
of senior citizens, policymakers and healthcare practi-
tioners should consider the above-mentioned signicant
factors to promote equal equitable access to healthcare
services for all senior citizens, particularly those from
rural areas, by which they can increase their awareness
of health, including social health insurance, and foster a
sense of security and well-being.
Abbreviations
aOR Adjusted Odds Ratio
CBOs Community Based Organizations
CI Condence Intervals
GoN Government of Nepal
IWI International Wealth Index
IRC Institutional Review Committee
NGO Non-Governmental Organizations
SDGs Sustainable Development Goals
SPSS Statistical Package for the Social Sciences
WHO World Health Organization
Acknowledgements
The authors acknowledge Aging Nepal for providing nancial support to
conduct the study. All authors are also grateful to the ocials of all the rural
municipalities of the Kaski district and all the senior citizens, who gave us
permission and support during data collection.
Author contributions
Sujan Poudel: Conceptualization, data collection, analysis of data, writing of
initial manuscript, editing and nalization of the manuscript. Anusha Parajuli:
Conceptualization, data collection, analysis of data, supervision of the research
methodology, editing and nalization of manuscript. Bal Krishna Bhatta:
Data validation and editing of the manuscript. Nirmal Duwadi: Editing and
nalization of the manuscript. Shishir Paudel: analysis of data, supervision of
the research methodology, and editing and nalization of the manuscript.
Dhurba Khatri: Data validation and editing and nalization of the manuscript.
Damaru Paneru: Data validation and editing of the manuscript. Yam Prasad
Sharma: Editing and nalization of the manuscript. All authors reviewed the
manuscript.
Funding
The study was carried out with nancial support from Aging Nepal as a
Research Fellowship Award awarded to the Principal Investigator.
Data availability
The data generated during and/or analyzed during the current study are
available from the corresponding author upon reasonable request.
Declarations
Ethical approval
This study adheres to the Declaration of Helsinki. Ethical approval was
obtained from the Institutional Review Committee (IRC), Nobel College, which
is aliated with Pokhara University (Ref. no. 079/080/139). Formal permission
was obtained from the selected rural municipalities for the conduct of
the study. Verbal and written informed consent were obtained from the
participants in the form of signatures or thumbprints before the initiation of
the interview sessions.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Author details
1HERD International, Lalitpur, Nepal
2Nobel College, Pokhara University, Kathmandu, Nepal
3College of Public Health, University of South Florida, Tampa, USA
4Kathmandu Institute of Child Health, Hepali Height, Kathmandu, Nepal
5School of Health and Allied Sciences, Pokhara University, Pokhara, Nepal
6Government of Nepal, Health Oce, Gorkha, Nepal
Received: 20 December 2024 / Accepted: 8 April 2025
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