The Open Public Health Journal




ISSN: 1874-9445 ― Volume 12, 2019
SYSTEMATIC REVIEW

The Social Determinants of Healthcare Access for Rural Elderly Women - A Systematic Review of Quantitative Studies



Mohammad Hamiduzzaman*, Anita De Bellis, Wendy Abigail, Evdokia Kalaitzidis
College of Nursing and Health Sciences, Flinders University of South Australia, Adelaide, Australia

Abstract

Objective:

This review aimed to explore and analyze the social determinants that impact rural women’s aged 60 years and older healthcare access in low or middle income and high income countries.

Methods:

Major healthcare databases including MEDLINE and MEDLINE In-Process, PsycINFO, PubMed, ProQuest, Web of Science, CINAHL and ERIC were searched from April 2016 to August 2016 and a manual search was also conducted. A rigorous selection process focusing on the inclusion of rural elderly women in study population and the social determinants of their healthcare access resulted in 38 quantitative articles for inclusion. Data were extracted and summarized from these studies, and grouped into seven categories under upstream and downstream social determinants.

Results:

Prevailing healthcare systems in combination with personal beliefs and ideas about ageing and healthcare were identified as significant determinants. Socioeconomic and cultural determinants also had a statistically significant negative impact on the access to healthcare services, especially in developing countries.

Conclusion:

Potentially, improvements to healthcare access can be achieved through consideration of rural elderly women’s overall status including healthcare needs, socioeconomic determinants and cultural issues rather than simply establishing healthcare centers.

Keywords: Healthcare access, Rural elderly women, Social determinants of health, Systematic review, Socioeconomic, Population.


Article Information


Identifiers and Pagination:

Year: 2017
Volume: 10
First Page: 244
Last Page: 266
Publisher Id: TOPHJ-10-244
DOI: 10.2174/1874944501710010244

Article History:

Received Date: 4/07/2017
Revision Received Date: 17/10/2017
Acceptance Date: 01/11/2017
Electronic publication date: 22/11/2017
Collection year: 2017

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© 2017 Hamiduzzaman et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: https://creativecommons.org/licenses/by/4.0/legalcode. This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


* Address correspondence to this author at the College of Nursing and Health Sciences, Flinders University of South Australia, Adelaide, Australia; Tel: 00962-796383002; E-mail: hami0185@flinders.edu.au




1. INTRODUCTION

The prevalence of morbidity, comorbidities and premature deaths associated with rural elderly women (REW) is related to access to modern healthcare services (MHS) [1Marengoni A, Angleman S, Melis R, et al. Aging with multimorbidity: A systematic review of the literature. Ageing Res Rev 2011; 10(4): 430-9.
[http://dx.doi.org/10.1016/j.arr.2011.03.003] [PMID: 21402176]
, 2UN. World Population Ageing. 2015 New York, Department of Economic and Social Affairs, Population Division, United Nations 2015.]. Elderly women are classified as 60 years of age and over [2UN. World Population Ageing. 2015 New York, Department of Economic and Social Affairs, Population Division, United Nations 2015.], and generally represent a higher proportion of all elderly people as they tend to live several years longer than men [3WHO. World report on ageing and health. 2015 World Health Organization: Geneva 2015.]. For example, elderly women accounted for 54% of the total elderly population worldwide in 2015 and 52% of these women live in rural areas [2UN. World Population Ageing. 2015 New York, Department of Economic and Social Affairs, Population Division, United Nations 2015., 3WHO. World report on ageing and health. 2015 World Health Organization: Geneva 2015.]. Many REW lack access to MHS and underutilization of MHS is identified as a major reason for premature and preventable deaths [4Palangkaraya A, Yong J. Population ageing and its implications on aggregate health care demand: Empirical evidence from 22 OECD countries. Int J Health Care Finance Econ 2009; 9(4): 391-402.
[http://dx.doi.org/10.1007/s10754-009-9057-3] [PMID: 19301123]
, 5WHO. Women and health: Today's evidence tomorrow's agenda. World Health Organization: Geneva 2009.]. This underutilization is skewed toward a lower rate of hospitalzation is skewed toward a lower rate of hospital visits, diagnosis, hospitalizations and complete treatment [2UN. World Population Ageing. 2015 New York, Department of Economic and Social Affairs, Population Division, United Nations 2015.]. Thus, inadequate healthcare access for REW presents a challenge to all countries that value good health outcomes for REW, especially low and middle income countries as defined by World Bank.

The social determinants of health (SDoH) are directly related to healthy ageing for REW, and they range from social to healthcare to individual sphere [6Nagata JM, Hernández-Ramos I, Kurup AS, Albrecht D, Vivas-Torrealba C, Franco-Paredes C. Social determinants of health and seasonal influenza vaccination in adults ≥65 years: A systematic review of qualitative and quantitative data. BMC Public Health 2013; 13(1): 388.
[http://dx.doi.org/10.1186/1471-2458-13-388] [PMID: 23617788]
, 7Palangkaraya A, Yong J. Population ageing and its implications on aggregate health care demand: Empirical evidence from 22 OECD countries. Int J Health Care Finance Econ 2009; 9(4): 391-402.
[http://dx.doi.org/10.1007/s10754-009-9057-3] [PMID: 19301123]
]. The determinants of REW’s access to healthcare sphere include inadequate services, a shortage of professionals, a lack of medical equipment and medications, the cost of services and long waiting times [6Nagata JM, Hernández-Ramos I, Kurup AS, Albrecht D, Vivas-Torrealba C, Franco-Paredes C. Social determinants of health and seasonal influenza vaccination in adults ≥65 years: A systematic review of qualitative and quantitative data. BMC Public Health 2013; 13(1): 388.
[http://dx.doi.org/10.1186/1471-2458-13-388] [PMID: 23617788]
, 7Palangkaraya A, Yong J. Population ageing and its implications on aggregate health care demand: Empirical evidence from 22 OECD countries. Int J Health Care Finance Econ 2009; 9(4): 391-402.
[http://dx.doi.org/10.1007/s10754-009-9057-3] [PMID: 19301123]
]. A number of other determinants, originate from social, economic and cultural contexts, have specific impact on REW’s MHS utilization [6Nagata JM, Hernández-Ramos I, Kurup AS, Albrecht D, Vivas-Torrealba C, Franco-Paredes C. Social determinants of health and seasonal influenza vaccination in adults ≥65 years: A systematic review of qualitative and quantitative data. BMC Public Health 2013; 13(1): 388.
[http://dx.doi.org/10.1186/1471-2458-13-388] [PMID: 23617788]
]. For example, poverty has a negative impact on the REW’s MHS access and use because of their dependency on household economy, as well as literacy levels [2UN. World Population Ageing. 2015 New York, Department of Economic and Social Affairs, Population Division, United Nations 2015.]. As such, having a high level of health illiteracy, in low, middle and high income countries, means a better access to MHS for REW as it is related with care seeking beliefs and behaviors [3WHO. World report on ageing and health. 2015 World Health Organization: Geneva 2015.]. Some evidences also show that close, personal characteristics, social relationships and transportation difficulties also impact MHS use, and that typically, healthcare policy and practice ignore these aspects of daily life for REW [3WHO. World report on ageing and health. 2015 World Health Organization: Geneva 2015., 6Nagata JM, Hernández-Ramos I, Kurup AS, Albrecht D, Vivas-Torrealba C, Franco-Paredes C. Social determinants of health and seasonal influenza vaccination in adults ≥65 years: A systematic review of qualitative and quantitative data. BMC Public Health 2013; 13(1): 388.
[http://dx.doi.org/10.1186/1471-2458-13-388] [PMID: 23617788]
, 8Hamiduzzaman M, De Bellis A, Kalaitzidis E, Abigail W. Factors impacting on elderly women’s access to healthcare in rural Bangladesh. Indian J Gerontol 2016; 30(2): 235-60.].

Evidence about the access to MHS exclusively by REW is scant [6Nagata JM, Hernández-Ramos I, Kurup AS, Albrecht D, Vivas-Torrealba C, Franco-Paredes C. Social determinants of health and seasonal influenza vaccination in adults ≥65 years: A systematic review of qualitative and quantitative data. BMC Public Health 2013; 13(1): 388.
[http://dx.doi.org/10.1186/1471-2458-13-388] [PMID: 23617788]
, 7Palangkaraya A, Yong J. Population ageing and its implications on aggregate health care demand: Empirical evidence from 22 OECD countries. Int J Health Care Finance Econ 2009; 9(4): 391-402.
[http://dx.doi.org/10.1007/s10754-009-9057-3] [PMID: 19301123]
]. Present literature either lost their focus on REW as a population group or investigated the SDoH affecting the utilization of MHS by REW concentrating on different aspects [3WHO. World report on ageing and health. 2015 World Health Organization: Geneva 2015.]. None of the study has assessed the determinants systematically and comprehensively. A systematic review of quantitative studies was, therefore, conducted to understand the SDoH impacting on healthcare access among REW in low/middle income and high income countries.

2. METHODS

2.1. Search Strategy

Literature search was undertaken (PROSPERO: CRD42016046605) across major electronic databases including MEDLINE and MEDLINE In-Process, PsycINFO, PubMed, ProQuest, Web of Science, CINAHL and ERIC. A combination of several key words along with their synonyms was used in the search including ‘healthcare access’, ‘healthcare utilization’, ‘healthcare resources’, ‘access barriers’, ‘socioeconomic factors’, ‘healthcare’, ‘health seeking behavior’, ‘elderly’, ‘older women’, ‘rural women’, ‘rural health’, and ‘remote areas’. This search was conducted from April 2016 to August 2016. A manual search was also conducted of the relevant references of retrieved articles, citations by authors, hand searched articles and experts’ opinions. The search and selection strategy was developed by the principal author and reviewed and checked by the other authors and one librarian [9Hamiduzzaman M, De-Bellis A, Kalaitzidis E, Abigail W. Addressing the factors and issues impacting on healthcare access for rural elderly women: A systematic review of the literature. CRD42016046605 Centre for Review and Disseminations 2016; University of York, York: UK 2016.].

2.2. Data Selection Strategy

Only peer reviewed empirical quantitative studies published from January 2000 to August 2016 in English were considered. To be included in this review, a study had to have REW as research participants. Additionally, studies were included if they investigated determinants of healthcare access in relation to preventive measures, communicable and non-communicable diseases, and reported at least one of the MHS access related outcomes. Studies on interventions targeted at the identification of the determinants and its association with healthcare utilization for REW were included. Studies that were excluded included literature reviews, secondary analyses of data and if the data were not specific to determinants of REW’s healthcare access. Studies were also excluded if they reported healthcare access from non-relevant aspects or specialized care such as the use of complementary and alternative medication, exercise, pre-natal care and pregnancy, reproductive healthcare, childbirth and post-natal care, dental care, cancer care, HIV and palliative care. No country or follow-up study restrictions were applied.

2.3. Data Extraction Process

The initial literature search identified 6899 citations. There were 473 articles of potential interest and, after examination of the full texts, 38 quantitative studies met all inclusion criteria apart from the provision of explicit healthcare outcomes for REW (See Fig. 1). A checklist was used based on the guidelines from the Centre for Reviews and Dissemination (CRD) for assessing the quality of each study [10CRD. Systematic reviews: CRD’s guidance for undertaking reviews in health care. Centre for Reviews & Dissemination. University of York, York: UK 2009.]. The data synthesis and analysis processes followed the CRD guidelines. Each article was assessed for methodological quality following several criteria namely: relevance to this systematic review; validity and appropriateness of methodology and instruments used; quality of research evidence such as generalizability of the findings; reporting quality in terms of data analysis process; and stated limitations in the study and how these limitations were adjusted [10CRD. Systematic reviews: CRD’s guidance for undertaking reviews in health care. Centre for Reviews & Dissemination. University of York, York: UK 2009.].

Fig. (1)
PRISMA flow chart.


Information was extracted from each study about authors, years, settings, participants, research methods and findings on the stated determinants in relation to healthcare access and healthcare seeking (See Table 1). Most of the studies included different population groups in their investigation and only one study identified that solely investigated REW’s healthcare access in USA. Thus, the authors selected the studies that included at least 10% REW of the total study population and reported the determinants of the REW’s healthcare access differently. These determinants were related to: (i) the REW such as literacy; (ii) the economic condition such as poverty; (iii) the medical treatments including health seeking beliefs and behaviors; (iv) the healthcare system including accessibility and adequacy of healthcare facilities; and (v) sociocultural status including mobility and social relationships.

2.4. Data Analysis Process

Meta-analysis of the data was inappropriate because of the heterogeneity in the studies including socioeconomic and cultural differences in low, middle and high income countries, the collected data, designs and settings. Extracted information from the selected studies was tabulated and significant SDoH were included. Multifaceted relationships between the SDoH were identified and grouped into themes using a combination of thematic and content analysis. The model developed by Braveman, Egerter & Williams in 2010 was employed because of its categorization of the SDoH that can provide structure to the identified evidence in the discussion chapter. Two broad categories in the SDoH were identified focusing on healthcare inequalities and disadvantages, including downstream and upstream SDoH [11Braveman P, Egerter S, Williams DR. The social determinants of health: Coming of age. Annu Rev Public Health 2011; 32: 381-98.
[http://dx.doi.org/10.1146/annurev-publhealth-031210-101218] [PMID: 21091195]
]. Downstream SDoH mean the factors that impact on healthcare at macro level, and they include health knowledge, perceived healthcare seeking behaviors and healthcare support [11Braveman P, Egerter S, Williams DR. The social determinants of health: Coming of age. Annu Rev Public Health 2011; 32: 381-98.
[http://dx.doi.org/10.1146/annurev-publhealth-031210-101218] [PMID: 21091195]
]. Upstream SDoH mean the inequalities in socioeconomic and cultural circumstances, which are fundamental causes of low healthcare access [11Braveman P, Egerter S, Williams DR. The social determinants of health: Coming of age. Annu Rev Public Health 2011; 32: 381-98.
[http://dx.doi.org/10.1146/annurev-publhealth-031210-101218] [PMID: 21091195]
]. Applying this model distinguished the determinants, often intertwined in personal, healthcare, socioeconomic and cultural factors.

Table 1
Characteristics of studies predicting SDoH of REW’s access to MHS.


3. RESULTS

Of the 38 studies, 19 were conducted in high income and 19 in middle/low income countries. Each study used varying research paradigms and designs and included; cross sectional research methods (n = 23), longitudinal research methods (n = 5), comparative descriptive methods (n = 2), an evaluation method (n = 1) and a survey method (n = 2). Other studies used different healthcare research processes from human ecology and behavioral approach. The data collection method in the studies was mostly via. interviews (n = 23) and surveys (n = 13) and one study was clinical assessment and another study used a combination of survey and interviews. Sample sizes across all of these studies ranged from 100 to 8387 participants. Synthesizing the evidence based on the SDoH model resulted in an identification of seven categories (see Table 2) and included the downstream SDoH category such as health literacy and education, passive healthcare seeking behaviour and lack of healthcare support, and also the upstream SDoH category comprising financial constraints, transportation difficulties, relationship matters and a culture of restriction as represented in the diagrammatic model seen in Fig. (2). The synthesized categories are described in detail in the following section.

Table 2
Summary of significant SDoH in MHS access for REW.


3.1. Health Literacy and Education

The association of the health literacy of REW and their healthcare access was significant, which was closely related to a lack of general education and lack of knowledge about health and healthcare among REW [12Ameh S, Gómez-Olivé FX, Kahn K, Tollman SM, Klipstein-Grobusch K. Predictors of health care use by adults 50 years and over in a rural South African setting. Glob Health Action 2014; 24(7): 771., 13Ruthig JC, Hanson BL, Ludtke RL, McDonald LR. Perceived barriers to health care and health behaviours: Implications for Native American elders’ self-rated health. Psychol Health Med 2009; 14(2): 190-200.
[http://dx.doi.org/10.1080/13548500802459892] [PMID: 19235078]
]. Nineteen studies found that schooling was a statistically significant determinant in REW’s access to MHS. The REW with formal education were more likely to visit MHS early and regularly than women with no formal education in low/middle and high income countries [14Abdulraheem IS. Health needs assessment and determinants of health-seeking behaviour among elderly Nigerians: A house-hold survey. Ann Afr Med 2007; 6(2): 58-63.
[http://dx.doi.org/10.4103/1596-3519.55715] [PMID: 18240704]
-18Iecovich E, Carmel S. Differences in accessibility, affordability, and availability (AAA) of medical specialists among three age-groups of elderly people in Israel. J Aging Health 2009; 21(5): 776-97.
[http://dx.doi.org/10.1177/0898264309333322] [PMID: 19282268]
]. In contrast, education attainment showed a weak positive relationship with the utilization of MHS among Filipino elderly women (r = 0.152), while 66.78% had at least a high school level of education [19De-Guzman AB, Lores KV, Lozano MC, et al. Health-Seeking preferences of elderly filipinos in the community via conjoint analysis. Educ Gerontol 2014; 40(11): 801-15.
[http://dx.doi.org/10.1080/03601277.2014.882110]
]. Differences in the level of education among the REW living in South Africa [six and more years of education had a twofold increased odds of using healthcare compared to those with no formal education: p < 0.05 (p = 0.001) (OR: 2.49; CI: 1.27 - 4.86)] and Israel [3% in the variability among the age groups] were identified as significant in using MHS [12Ameh S, Gómez-Olivé FX, Kahn K, Tollman SM, Klipstein-Grobusch K. Predictors of health care use by adults 50 years and over in a rural South African setting. Glob Health Action 2014; 24(7): 771., 18Iecovich E, Carmel S. Differences in accessibility, affordability, and availability (AAA) of medical specialists among three age-groups of elderly people in Israel. J Aging Health 2009; 21(5): 776-97.
[http://dx.doi.org/10.1177/0898264309333322] [PMID: 19282268]
]. As such, education levels of REW was a strong indicator in access and utilisation of MHS.

Three studies indicated that the utilization of MHS by REW increased with the knowledge about health and healthcare services [12Ameh S, Gómez-Olivé FX, Kahn K, Tollman SM, Klipstein-Grobusch K. Predictors of health care use by adults 50 years and over in a rural South African setting. Glob Health Action 2014; 24(7): 771., 20Pullen C, Fiandt K, Walker SN. Determinants of preventive services utilization in rural older women. J Gerontol Nurs 2001; 27(1): 40-51.
[http://dx.doi.org/10.3928/0098-9134-20010101-12] [PMID: 11915096]
]. Knowledge about health conditions and availability of MHS was a determinant for REW [0.6%] in MHS use in low/middle income countries like South Africa [12Ameh S, Gómez-Olivé FX, Kahn K, Tollman SM, Klipstein-Grobusch K. Predictors of health care use by adults 50 years and over in a rural South African setting. Glob Health Action 2014; 24(7): 771.]. Less than one-third (28.7%) of the REW were aware of their health needs in Nigeria [14Abdulraheem IS. Health needs assessment and determinants of health-seeking behaviour among elderly Nigerians: A house-hold survey. Ann Afr Med 2007; 6(2): 58-63.
[http://dx.doi.org/10.4103/1596-3519.55715] [PMID: 18240704]
]. Pullen, Fiandt, & Walker (2001) also highlighted that there was a lack of information about the existing availability of MHS among REW, where healthcare practiners’ recommendations made significant contribution to regression equation [Beta weight - 69] in a high income country like USA, which impacted on visits to the healthcare centres and also influenced healthcare seeking behaviours.

3.2. Passive Healthcare Seeking Behavior

A significant relationship between passive healthcare seeking behavior of REW and healthcare access was identified in several studies, and these behaviors included: a feeling of not being ill enough, self-treatment tendencies, mistrust of modern healthcare services, depression and perceived stigma.

Six studies found that the reason women did not seek assistance from MHS for ailments was because the women did not consider their ailment sufficiently serious until they appeared as physical symptoms. In their view, they were not feeling unwell enough [12Ameh S, Gómez-Olivé FX, Kahn K, Tollman SM, Klipstein-Grobusch K. Predictors of health care use by adults 50 years and over in a rural South African setting. Glob Health Action 2014; 24(7): 771., 21Cheng G, Tolhurst R, Li RZ, Meng QY, Tang S. Factors affecting delays in tuberculosis diagnosis in rural China: A case study in four counties in Shandong Province. Trans R Soc Trop Med Hyg 2005; 99(5): 355-62.
[http://dx.doi.org/10.1016/j.trstmh.2004.07.005] [PMID: 15780342]
-24Onwubiko SN, Eze BI, Udeh NN, Arinze OC, Okoloagu MN, Chuka-Okosa CM. Mapping the pathways to eye care in a rural south-east Nigerian population: Any implications for practice, eye care programs and policy? Rural Remote Health 2014; 14(4): 2729.
[PMID: 25382094]
]. Cheng et al. (2005) identified that 25% of REW living in China did not know whether their health problems were serious enough to visit a hospital. In Nigeria, 57% of REW indicated the non-seriousness of the ailment was a reason to not use a MHS [24Onwubiko SN, Eze BI, Udeh NN, Arinze OC, Okoloagu MN, Chuka-Okosa CM. Mapping the pathways to eye care in a rural south-east Nigerian population: Any implications for practice, eye care programs and policy? Rural Remote Health 2014; 14(4): 2729.
[PMID: 25382094]
]. Additionally, REW who did receive healthcare were less likely to use medication in a timely manner as prescribed [21Cheng G, Tolhurst R, Li RZ, Meng QY, Tang S. Factors affecting delays in tuberculosis diagnosis in rural China: A case study in four counties in Shandong Province. Trans R Soc Trop Med Hyg 2005; 99(5): 355-62.
[http://dx.doi.org/10.1016/j.trstmh.2004.07.005] [PMID: 15780342]
, 22Gopalan SS, Durairaj V. Addressing women’s non-maternal healthcare financing in developing countries: What can we learn from the experiences of rural Indian women? PLoS One 2012; 7(1): e29936.
[http://dx.doi.org/10.1371/journal.pone.0029936] [PMID: 22272262]
]. Studies by Onwubiko et al. (2014) and Nipun et al. (2015) established that the feeling of not being ill enough substantially increased the chances of REW’s reluctance to visit healthcare centers and use medications in two low income countries (i.e., Nigeria and India).

Three studies identified a significant relationship between self-treatment tendency and the utilization of MHS [25Jordan S, Wilson A, Dobson A. Management of heart conditions in older rural and urban Australian women. Intern Med J 2011; 41(10): 722-9.
[http://dx.doi.org/10.1111/j.1445-5994.2011.02536.x] [PMID: 21627742]
-27Weaver A, Gjesfjeld C. Barriers to preventive services use for rural women in the Southeastern United States. Soc Work Res 2014; 38(4): 225-34.
[http://dx.doi.org/10.1093/swr/svu023]
]. Jordan, Wilson, & Dobson (2011) indicated, in Australia, that only 48% REW received advice about diet, 20% about exercise and 10% having been advised to weigh them daily. This resulted in an interest in home remedies, traditional healers and over-the-counter medications for self-treatment rather than visiting hospitals, especially in low income country like Bangladesh [26Ahmed SM, Tomson G, Petzold M, Kabir ZN. Socioeconomic status overrides age and gender in determining health-seeking behaviour in rural Bangladesh. Bull World Health Organ 2005; 83(2): 109-17.
[PMID: 15744403]
]. The tendency of self-care was also statistically evident in USA [p < 0.05], however, not as significant as in low income countries like Nigeria [P < 0.05; OR: 1.7 (95% CI= 0.38-0.67] [14Abdulraheem IS. Health needs assessment and determinants of health-seeking behaviour among elderly Nigerians: A house-hold survey. Ann Afr Med 2007; 6(2): 58-63.
[http://dx.doi.org/10.4103/1596-3519.55715] [PMID: 18240704]
, 27Weaver A, Gjesfjeld C. Barriers to preventive services use for rural women in the Southeastern United States. Soc Work Res 2014; 38(4): 225-34.
[http://dx.doi.org/10.1093/swr/svu023]
]. This healthcare seeking behavior in combination with a mistrust of MHS had a negative impact on REW’s access to MHS.

Several studies demonstrated that mistrust was directly related with a decrease in the use of MHS [19De-Guzman AB, Lores KV, Lozano MC, et al. Health-Seeking preferences of elderly filipinos in the community via conjoint analysis. Educ Gerontol 2014; 40(11): 801-15.
[http://dx.doi.org/10.1080/03601277.2014.882110]
, 24Onwubiko SN, Eze BI, Udeh NN, Arinze OC, Okoloagu MN, Chuka-Okosa CM. Mapping the pathways to eye care in a rural south-east Nigerian population: Any implications for practice, eye care programs and policy? Rural Remote Health 2014; 14(4): 2729.
[PMID: 25382094]
, 28Byles J, Powers J, Chojenta C, Warner-Smith P. Older women in Australia: Ageing in urban, rural and remote environments. Australas J Ageing 2006; 25(3): 151-7.
[http://dx.doi.org/10.1111/j.1741-6612.2006.00171.x]
-31Xu KT, Borders TF. Characteristics of rural elderly people who bypass local pharmacies. J Rural Health 2003; 19(2): 156-64.
[http://dx.doi.org/10.1111/j.1748-0361.2003.tb00557.x] [PMID: 12696852]
]. Rural elderly women living in Australia who visited healthcare centers stated a lower satisfaction with GP, specialist or allied health professional than urban women and this was significantly associated [p < 0.01] with their access to MHS [28Byles J, Powers J, Chojenta C, Warner-Smith P. Older women in Australia: Ageing in urban, rural and remote environments. Australas J Ageing 2006; 25(3): 151-7.
[http://dx.doi.org/10.1111/j.1741-6612.2006.00171.x]
]. In India, REW most often visited healthcare professionals who were well-known to them and were perceived as having a simple approach and being culturally competent [6.0% reported as a barrier] [30Sharma D, Mazta SR, Parashar A. Morbidity pattern and health-seeking behavior of aged population residing in Shimla hills of north India: A cross-sectional study. J Family Med Prim Care 2013; 2(2): 188-93.
[http://dx.doi.org/10.4103/2249-4863.117421] [PMID: 24479077]
]. Additionally, there was a positive belief among REW women about the use of spiritual healing in low/middle income countries such as Nigeria [20.2% reported as a barrier], South Africa [p < 0.001], and India [15.8% reported as a barrier] [24Onwubiko SN, Eze BI, Udeh NN, Arinze OC, Okoloagu MN, Chuka-Okosa CM. Mapping the pathways to eye care in a rural south-east Nigerian population: Any implications for practice, eye care programs and policy? Rural Remote Health 2014; 14(4): 2729.
[PMID: 25382094]
, 29Peltzer K. Health beliefs and prescription medication compliance among diagnosed hypertension clinic attenders in a rural South African Hospital. Curationis 2004; 27(3): 15-23.
[http://dx.doi.org/10.4102/curationis.v27i3.994] [PMID: 15777026]
, 30Sharma D, Mazta SR, Parashar A. Morbidity pattern and health-seeking behavior of aged population residing in Shimla hills of north India: A cross-sectional study. J Family Med Prim Care 2013; 2(2): 188-93.
[http://dx.doi.org/10.4103/2249-4863.117421] [PMID: 24479077]
]. This lack of faith in doctors and nurses and the positive beliefs about spiritual healing led REW to visit traditional healers rather than MHS.

The mental health of REW also had an influence on healthcare access with those suffering from depression less likely to use MHS [32Chan EY, Griffiths S. Comparision of health needs of older people between affected rural and urban areas after the 2005 Kashmir, Pakistan earthquake. Prehosp Disaster Med 2009; 24(5): 365-71.
[http://dx.doi.org/10.1017/S1049023X00007159] [PMID: 20066635]
-36Judd F, Komiti A, Jackson H. How does being female assist help-seeking for mental health problems? Aust N Z J Psychiatry 2008; 42(1): 24-9.
[http://dx.doi.org/10.1080/00048670701732681] [PMID: 18058440]
]. In Pakistan, depression of elderly women was also evident which contributed to not using MHS [p < 0.001], but this depression was related to natural calamity [32Chan EY, Griffiths S. Comparision of health needs of older people between affected rural and urban areas after the 2005 Kashmir, Pakistan earthquake. Prehosp Disaster Med 2009; 24(5): 365-71.
[http://dx.doi.org/10.1017/S1049023X00007159] [PMID: 20066635]
]. Living with depression increased a sense of helplessness for REW in seeking MHS even in high income countries such as Switzerland [p = 0.008 (OR 6.4, 95% CI 1.6 - 24.8] and Australia [P value is not reported] and in USA [p < .001] [33Ingold BB, Yersin B, Wietlisbach V, Burckhardt P, Bumand B, Büla CJ. Characteristics associated with inappropriate hospital use in elderly patients admitted to a general internal medicine service. Aging (Milano) 2000; 12(6): 430-8.
[PMID: 11211952]
-35Sudore RL, Mehta KM, Simonsick EM, et al. Limited literacy in older people and disparities in health and healthcare access. J Am Geriatr Soc 2006; 54(5): 770-6.
[http://dx.doi.org/10.1111/j.1532-5415.2006.00691.x] [PMID: 16696742]
]. This state of depression resulted in REW not seeking MHS.

Three studies identified that perceived stigma was involved in access to MHS and this stigma is associated with having any illness impacted on the REW healthcare access to MHS in Nigeria [20.2% reported as a barrier] and India [49.6% reported as a barrier] [24Onwubiko SN, Eze BI, Udeh NN, Arinze OC, Okoloagu MN, Chuka-Okosa CM. Mapping the pathways to eye care in a rural south-east Nigerian population: Any implications for practice, eye care programs and policy? Rural Remote Health 2014; 14(4): 2729.
[PMID: 25382094]
, 30Sharma D, Mazta SR, Parashar A. Morbidity pattern and health-seeking behavior of aged population residing in Shimla hills of north India: A cross-sectional study. J Family Med Prim Care 2013; 2(2): 188-93.
[http://dx.doi.org/10.4103/2249-4863.117421] [PMID: 24479077]
]. Discrimination of REW in the form of dominance and disempowerment contributed to perceive stigma in these low income countries. The REW who attributed stigma as a factor in not seeking healthcare at a MHS significantly related this stigma as being the reason for a lack of healthcare support.

Fig. (2)
Thematic model of social determinants that impact REW’s access to MHS.


3.3. Lack of Healthcare Support

The prevailing healthcare system played a statistically significant role in restricting REW’s use of MHS. Determinants identified in relation to MHS included limited care services, inadequate healthcare professionals, a scarcity of medical equipment and medications, long waiting times, poor attitudes of care workers and lack of health insurance coverage. Each of the determinants had an association with limited access for REW.

Studies showed that healthcare access was associated with the availability of services for REW and acknowledged the limitation of healthcare centres and services for REW [27Weaver A, Gjesfjeld C. Barriers to preventive services use for rural women in the Southeastern United States. Soc Work Res 2014; 38(4): 225-34.
[http://dx.doi.org/10.1093/swr/svu023]
, 31Xu KT, Borders TF. Characteristics of rural elderly people who bypass local pharmacies. J Rural Health 2003; 19(2): 156-64.
[http://dx.doi.org/10.1111/j.1748-0361.2003.tb00557.x] [PMID: 12696852]
, 37Heinrich S, Luppa M, Matschinger H, Angermeyer MC, Riedel-Heller SG, König HH. Service utilization and health-care costs in the advanced elderly. Value Health 2008; 11(4): 611-20.
[http://dx.doi.org/10.1111/j.1524-4733.2007.00285.x] [PMID: 18179660]
, 38Young AF, Dobson AJ, Byles JE. Access and equity in the provision of general practitioner services for women in Australia. Aust N Z J Public Health 2000; 24(5): 474-80.
[http://dx.doi.org/10.1111/j.1467-842X.2000.tb00496.x] [PMID: 11109683]
]. In contrast, only one quantitative study conducted in Nigeria reported that most REW [89.4%] received treatment with the availability of MHS for themselves [14Abdulraheem IS. Health needs assessment and determinants of health-seeking behaviour among elderly Nigerians: A house-hold survey. Ann Afr Med 2007; 6(2): 58-63.
[http://dx.doi.org/10.4103/1596-3519.55715] [PMID: 18240704]
]. Whilst two seperate studies conducted in a USA [p < 0.01] and Germany [p < 0.05 (p = 0.023)] reported a lack of pharmacies and outpatient non-physician services, studies conducted in low income countries confirmed that there were a small number of hospitals or clinics in rural areas of Nigeria [2.8% reported as a barrier] and Ghana [47.8% reported as a barrier] [14Abdulraheem IS. Health needs assessment and determinants of health-seeking behaviour among elderly Nigerians: A house-hold survey. Ann Afr Med 2007; 6(2): 58-63.
[http://dx.doi.org/10.4103/1596-3519.55715] [PMID: 18240704]
, 15Adu-Gyamfi AB, Abane AM. Utilization of health care facilities among residents of Lake Bosomtwe basin of Ghana. EIJST 2013; 2(4): 131-42., 31Xu KT, Borders TF. Characteristics of rural elderly people who bypass local pharmacies. J Rural Health 2003; 19(2): 156-64.
[http://dx.doi.org/10.1111/j.1748-0361.2003.tb00557.x] [PMID: 12696852]
, 37Heinrich S, Luppa M, Matschinger H, Angermeyer MC, Riedel-Heller SG, König HH. Service utilization and health-care costs in the advanced elderly. Value Health 2008; 11(4): 611-20.
[http://dx.doi.org/10.1111/j.1524-4733.2007.00285.x] [PMID: 18179660]
]. Rural elderly women who lived near a rural care centre were more likely to access and receive adequate healthcare than the women without a close healthcare centre in both low/middle and high income countries [15Adu-Gyamfi AB, Abane AM. Utilization of health care facilities among residents of Lake Bosomtwe basin of Ghana. EIJST 2013; 2(4): 131-42., 32Chan EY, Griffiths S. Comparision of health needs of older people between affected rural and urban areas after the 2005 Kashmir, Pakistan earthquake. Prehosp Disaster Med 2009; 24(5): 365-71.
[http://dx.doi.org/10.1017/S1049023X00007159] [PMID: 20066635]
]. Healthcare services not being close by and a shortage of doctors and nurses in healthcare centres were identified in the studies as impacting negatively on healthcare access for REW.

Inadequate numbers of doctors and nurses in rural healthcare centers were attributed to the use of MHS [12Ameh S, Gómez-Olivé FX, Kahn K, Tollman SM, Klipstein-Grobusch K. Predictors of health care use by adults 50 years and over in a rural South African setting. Glob Health Action 2014; 24(7): 771., 21Cheng G, Tolhurst R, Li RZ, Meng QY, Tang S. Factors affecting delays in tuberculosis diagnosis in rural China: A case study in four counties in Shandong Province. Trans R Soc Trop Med Hyg 2005; 99(5): 355-62.
[http://dx.doi.org/10.1016/j.trstmh.2004.07.005] [PMID: 15780342]
, 32Chan EY, Griffiths S. Comparision of health needs of older people between affected rural and urban areas after the 2005 Kashmir, Pakistan earthquake. Prehosp Disaster Med 2009; 24(5): 365-71.
[http://dx.doi.org/10.1017/S1049023X00007159] [PMID: 20066635]
, 38Young AF, Dobson AJ, Byles JE. Access and equity in the provision of general practitioner services for women in Australia. Aust N Z J Public Health 2000; 24(5): 474-80.
[http://dx.doi.org/10.1111/j.1467-842X.2000.tb00496.x] [PMID: 11109683]
]. A shortage of healthcare professionals identified impacted on REW’s access to MHS in Nigeria [2.8% reported as barrier], Ghana [54.2% reported as a barrier] [14Abdulraheem IS. Health needs assessment and determinants of health-seeking behaviour among elderly Nigerians: A house-hold survey. Ann Afr Med 2007; 6(2): 58-63.
[http://dx.doi.org/10.4103/1596-3519.55715] [PMID: 18240704]
, 15Adu-Gyamfi AB, Abane AM. Utilization of health care facilities among residents of Lake Bosomtwe basin of Ghana. EIJST 2013; 2(4): 131-42.]. Moreover, there was a reported significant shortage of specialist doctors and nurses in rural healthcare centers in the USA [p < 0.001 ] and they were rarely available in low income countries like Ghana [61.7% reported it as a barrier] and South Africa [3.4% reported as a barrier] [12Ameh S, Gómez-Olivé FX, Kahn K, Tollman SM, Klipstein-Grobusch K. Predictors of health care use by adults 50 years and over in a rural South African setting. Glob Health Action 2014; 24(7): 771., 15Adu-Gyamfi AB, Abane AM. Utilization of health care facilities among residents of Lake Bosomtwe basin of Ghana. EIJST 2013; 2(4): 131-42., 39Borders TF. Rural community-dwelling elders’ reports of access to care: Are there Hispanic versus non-Hispanic white disparities? J Rural Health 2004; 20(3): 210-20.
[http://dx.doi.org/10.1111/j.1748-0361.2004.tb00031.x] [PMID: 15298095]
]. As such, a shortage of healthcare professionals impacted on healthcare access for REW and this access was further hindered by the supply of medical equipment and medications.

A number of the studies identified an association between the lack of supply of medical equipment and medications and the use of MHS. Rural elderly women living in low income countries like Ghana [54.2% reported as a barrier] and South Africa [7.3% reported as a barrier] were less likely to use local healthcare services due to a lack of medical equipment and medications [12Ameh S, Gómez-Olivé FX, Kahn K, Tollman SM, Klipstein-Grobusch K. Predictors of health care use by adults 50 years and over in a rural South African setting. Glob Health Action 2014; 24(7): 771., 15Adu-Gyamfi AB, Abane AM. Utilization of health care facilities among residents of Lake Bosomtwe basin of Ghana. EIJST 2013; 2(4): 131-42.]. Healthcare utilization was also impacted on by a poor supply of medications in rural healthcare centers in Germany [p < 0.05 (p = 0.019)] [15Adu-Gyamfi AB, Abane AM. Utilization of health care facilities among residents of Lake Bosomtwe basin of Ghana. EIJST 2013; 2(4): 131-42.]. Living in rural areas of low income countries was positively affected by an inadequate supply of equipment and medications that in turn resulted in a poor utilization of MHS.

Association of waiting a long time to be seen and treated in care centers also affected the use of MHS. The experience of long waiting times impacted negatively on REW’s visits to local public healthcare centers in Nigeria [3% reported as a barrier], India [16% reported as a barrier], USA [p < 0.05] and China [24% empty nesters reported as a barrier] [14Abdulraheem IS. Health needs assessment and determinants of health-seeking behaviour among elderly Nigerians: A house-hold survey. Ann Afr Med 2007; 6(2): 58-63.
[http://dx.doi.org/10.4103/1596-3519.55715] [PMID: 18240704]
, 23Nipun A, Prakash SV, Kumar SA, Danish I. Healthcare services utilization by geriatric population in rural area of District Bareilly, India. Int J Curr Microbiol Appl Sci 2015; 4(5): 720-7., 39Borders TF. Rural community-dwelling elders’ reports of access to care: Are there Hispanic versus non-Hispanic white disparities? J Rural Health 2004; 20(3): 210-20.
[http://dx.doi.org/10.1111/j.1748-0361.2004.tb00031.x] [PMID: 15298095]
, 40Liu LJ, Sun X, Zhang CL, Guo Q. Health-care utilization among empty-nesters in the rural area of a mountainous county in China. Public Health Rep 2007; 122(3): 407-13.
[http://dx.doi.org/10.1177/003335490712200315] [PMID: 17518313]
]. No study found in both low income and high income countries that reported the the avarage waiting times in seeking care [23Nipun A, Prakash SV, Kumar SA, Danish I. Healthcare services utilization by geriatric population in rural area of District Bareilly, India. Int J Curr Microbiol Appl Sci 2015; 4(5): 720-7., 38Young AF, Dobson AJ, Byles JE. Access and equity in the provision of general practitioner services for women in Australia. Aust N Z J Public Health 2000; 24(5): 474-80.
[http://dx.doi.org/10.1111/j.1467-842X.2000.tb00496.x] [PMID: 11109683]
, 39Borders TF. Rural community-dwelling elders’ reports of access to care: Are there Hispanic versus non-Hispanic white disparities? J Rural Health 2004; 20(3): 210-20.
[http://dx.doi.org/10.1111/j.1748-0361.2004.tb00031.x] [PMID: 15298095]
, 41Hossen MA, Westhues A. Rural women’s access to health care in Bangladesh: Swimming against the tide? Soc Work Public Health 2011; 26(3): 278-93.
[http://dx.doi.org/10.1080/19371910903126747] [PMID: 21534125]
].

The attitude of healthcare professionals had a negative and statistically significant effect on MHS use [12Ameh S, Gómez-Olivé FX, Kahn K, Tollman SM, Klipstein-Grobusch K. Predictors of health care use by adults 50 years and over in a rural South African setting. Glob Health Action 2014; 24(7): 771., 40Liu LJ, Sun X, Zhang CL, Guo Q. Health-care utilization among empty-nesters in the rural area of a mountainous county in China. Public Health Rep 2007; 122(3): 407-13.
[http://dx.doi.org/10.1177/003335490712200315] [PMID: 17518313]
]. Ameh et al. (2014) highlighted that the attitudes of doctors and nurses at first visit [6.7% empty nesters reported as a barrier] were significantly associated with the use of healthcare services in subsequent visits in South Africa. Rural elderly women expressed their dissatisfaction with the way they were treated by doctors and nurses in a number of low income countries including South Africa, China and India [29Peltzer K. Health beliefs and prescription medication compliance among diagnosed hypertension clinic attenders in a rural South African Hospital. Curationis 2004; 27(3): 15-23.
[http://dx.doi.org/10.4102/curationis.v27i3.994] [PMID: 15777026]
, 30Sharma D, Mazta SR, Parashar A. Morbidity pattern and health-seeking behavior of aged population residing in Shimla hills of north India: A cross-sectional study. J Family Med Prim Care 2013; 2(2): 188-93.
[http://dx.doi.org/10.4103/2249-4863.117421] [PMID: 24479077]
, 40Liu LJ, Sun X, Zhang CL, Guo Q. Health-care utilization among empty-nesters in the rural area of a mountainous county in China. Public Health Rep 2007; 122(3): 407-13.
[http://dx.doi.org/10.1177/003335490712200315] [PMID: 17518313]
]. Experience of mistreatment included receiving no or little attention, as well as a perception of receiving incorrect medical treatment [30Sharma D, Mazta SR, Parashar A. Morbidity pattern and health-seeking behavior of aged population residing in Shimla hills of north India: A cross-sectional study. J Family Med Prim Care 2013; 2(2): 188-93.
[http://dx.doi.org/10.4103/2249-4863.117421] [PMID: 24479077]
, 40Liu LJ, Sun X, Zhang CL, Guo Q. Health-care utilization among empty-nesters in the rural area of a mountainous county in China. Public Health Rep 2007; 122(3): 407-13.
[http://dx.doi.org/10.1177/003335490712200315] [PMID: 17518313]
]. This experience of mistreatment by REW was a negative factor impacting on subsequent access to healthcare centres.

Lack of healthcare insurance coverage was another important barrier in the use of MHS. Rural elderly women who had healthcare insurance were more likely to use healthcare than non-policy holders in low income countries such as Brazil [(outpatient: 2.42 (2.11–2.77); (any hospitalization: 1.18 (1.03-1.36) and more than one hospitalization: 1.18 (0.91-1.52)] and Ghana [75% of health insurance policy holders said they utilize care facilities as against 56.2% of non-policy holders] [15Adu-Gyamfi AB, Abane AM. Utilization of health care facilities among residents of Lake Bosomtwe basin of Ghana. EIJST 2013; 2(4): 131-42., 17Blay SL, Fillenbaum GG, Andreoli SB, Gastal FL. Equity of access to outpatient care and hospitalization among older community residents in Brazil. Med Care 2008; 46(9): 930-7.
[http://dx.doi.org/10.1097/MLR.0b013e318179254c] [PMID: 18725847]
]. Healthcare insurance also had a positive affect on improving access for REW living in the USA [p < 0.05 (p = 0.0001)] [31Xu KT, Borders TF. Characteristics of rural elderly people who bypass local pharmacies. J Rural Health 2003; 19(2): 156-64.
[http://dx.doi.org/10.1111/j.1748-0361.2003.tb00557.x] [PMID: 12696852]
, 42Hong T, Oddone E, Weinfurt K, Friedman J, Schulman K, Bosworth H. The relationship between perceived barriers to healthcare and self-rated health. Psychol Health Med 2004; 9(4): 476-82.
[http://dx.doi.org/10.1080/13548500412331298966]
]. However, Ameh et al. (2014) identified that a small number of REW, who received free consultations and medications under government schemes in South Africa, better utilised MHS. Only three studies assessed the effect of health insurance on REW’s MHS use in low income countries [12Ameh S, Gómez-Olivé FX, Kahn K, Tollman SM, Klipstein-Grobusch K. Predictors of health care use by adults 50 years and over in a rural South African setting. Glob Health Action 2014; 24(7): 771., 15Adu-Gyamfi AB, Abane AM. Utilization of health care facilities among residents of Lake Bosomtwe basin of Ghana. EIJST 2013; 2(4): 131-42., 22Gopalan SS, Durairaj V. Addressing women’s non-maternal healthcare financing in developing countries: What can we learn from the experiences of rural Indian women? PLoS One 2012; 7(1): e29936.
[http://dx.doi.org/10.1371/journal.pone.0029936] [PMID: 22272262]
]. Those REW with healthcare insurance were more likely to access MHS and access was also influenced by free healthcare and the financial resources available to them.

3.4. Financial Constraints

Most studies indicated a statistically significant association between financial constraints and REW’s healthcare access. The economic factors identified included levels of poverty, the cost of treatments and a lack of finances whether personal, from the family or the government. The impact of each of these determinants negatively affected healthcare access for REW.

The association between poverty and access to MHS was identified as one of the most important SDoH in the non-use of MHS and included individual poverty and household poverty [14Abdulraheem IS. Health needs assessment and determinants of health-seeking behaviour among elderly Nigerians: A house-hold survey. Ann Afr Med 2007; 6(2): 58-63.
[http://dx.doi.org/10.4103/1596-3519.55715] [PMID: 18240704]
, 16Bell RA, Quandt SA, Arcury TA, et al. Primary and specialty medical care among ethnically diverse, older rural adults with type 2 diabetes: the ELDER Diabetes Study. J Rural Health 2005; 21(3): 198-205.
[http://dx.doi.org/10.1111/j.1748-0361.2005.tb00083.x] [PMID: 16092292]
, 17Blay SL, Fillenbaum GG, Andreoli SB, Gastal FL. Equity of access to outpatient care and hospitalization among older community residents in Brazil. Med Care 2008; 46(9): 930-7.
[http://dx.doi.org/10.1097/MLR.0b013e318179254c] [PMID: 18725847]
, 21Cheng G, Tolhurst R, Li RZ, Meng QY, Tang S. Factors affecting delays in tuberculosis diagnosis in rural China: A case study in four counties in Shandong Province. Trans R Soc Trop Med Hyg 2005; 99(5): 355-62.
[http://dx.doi.org/10.1016/j.trstmh.2004.07.005] [PMID: 15780342]
]. Elderly women who had no or low incomes and personal savings were less likely to use healthcare from MHS in rural Bangladesh [p < 0.05 (OR 0.75; CI 0.60 - 0.95)] and in India [p < 0.05 (OR 2.00, 95% CI 0.84-4.80)] [26Ahmed SM, Tomson G, Petzold M, Kabir ZN. Socioeconomic status overrides age and gender in determining health-seeking behaviour in rural Bangladesh. Bull World Health Organ 2005; 83(2): 109-17.
[PMID: 15744403]
]. There was no difference identified between low/middle and high income countries in relation to the impact of personal income on healthcare use, which was also determined by the household’s economic status [12Ameh S, Gómez-Olivé FX, Kahn K, Tollman SM, Klipstein-Grobusch K. Predictors of health care use by adults 50 years and over in a rural South African setting. Glob Health Action 2014; 24(7): 771., 16Bell RA, Quandt SA, Arcury TA, et al. Primary and specialty medical care among ethnically diverse, older rural adults with type 2 diabetes: the ELDER Diabetes Study. J Rural Health 2005; 21(3): 198-205.
[http://dx.doi.org/10.1111/j.1748-0361.2005.tb00083.x] [PMID: 16092292]
, 21Cheng G, Tolhurst R, Li RZ, Meng QY, Tang S. Factors affecting delays in tuberculosis diagnosis in rural China: A case study in four counties in Shandong Province. Trans R Soc Trop Med Hyg 2005; 99(5): 355-62.
[http://dx.doi.org/10.1016/j.trstmh.2004.07.005] [PMID: 15780342]
, 23Nipun A, Prakash SV, Kumar SA, Danish I. Healthcare services utilization by geriatric population in rural area of District Bareilly, India. Int J Curr Microbiol Appl Sci 2015; 4(5): 720-7.]. The higher the household economic status meant the more positive and statistically significant impact on the adequate use of MHS in Nigeria [OR: 0.46 (0.38 - 0.67)] and India [p < 0.05 (p = 0.0409)] [14Abdulraheem IS. Health needs assessment and determinants of health-seeking behaviour among elderly Nigerians: A house-hold survey. Ann Afr Med 2007; 6(2): 58-63.
[http://dx.doi.org/10.4103/1596-3519.55715] [PMID: 18240704]
, 23Nipun A, Prakash SV, Kumar SA, Danish I. Healthcare services utilization by geriatric population in rural area of District Bareilly, India. Int J Curr Microbiol Appl Sci 2015; 4(5): 720-7., 26Ahmed SM, Tomson G, Petzold M, Kabir ZN. Socioeconomic status overrides age and gender in determining health-seeking behaviour in rural Bangladesh. Bull World Health Organ 2005; 83(2): 109-17.
[PMID: 15744403]
]. Poverty was also statistically significant in meeting the costs of medical treatments and this led to less health seeking and a low use of MHS.

Some studies indicated an association of the costs of seeking treatments (i.e. transportation, fees for physicians, laboratory tests and medications) with MHS use. For example, REW who sought healthcare were restricted in using MHS regularly because of the high cost of treatments [24Onwubiko SN, Eze BI, Udeh NN, Arinze OC, Okoloagu MN, Chuka-Okosa CM. Mapping the pathways to eye care in a rural south-east Nigerian population: Any implications for practice, eye care programs and policy? Rural Remote Health 2014; 14(4): 2729.
[PMID: 25382094]
, 28Byles J, Powers J, Chojenta C, Warner-Smith P. Older women in Australia: Ageing in urban, rural and remote environments. Australas J Ageing 2006; 25(3): 151-7.
[http://dx.doi.org/10.1111/j.1741-6612.2006.00171.x]
, 43Yamasaki-Nakagawa M, Ozasa K, Yamada N, et al. Gender difference in delays to diagnosis and health care seeking behaviour in a rural area of Nepal. Int J Tuberc Lung Dis 2001; 5(1): 24-31.
[PMID: 11263512]
]. In contrast, free and/or subsidized healthcare support enhanced the utilization of MHS in Nepal, which more men received free care than women [(56% of men, 35% of women, P= 0.073)] [43Yamasaki-Nakagawa M, Ozasa K, Yamada N, et al. Gender difference in delays to diagnosis and health care seeking behaviour in a rural area of Nepal. Int J Tuberc Lung Dis 2001; 5(1): 24-31.
[PMID: 11263512]
]. This subsidized healthcare support was also evident in Australia that contributed to the increase of the rate of MHS utilization among REW [38Young AF, Dobson AJ, Byles JE. Access and equity in the provision of general practitioner services for women in Australia. Aust N Z J Public Health 2000; 24(5): 474-80.
[http://dx.doi.org/10.1111/j.1467-842X.2000.tb00496.x] [PMID: 11109683]
, 44Young AF, Dobson AJ, Byles JE. Determinants of general practitioner use among women in Australia. Soc Sci Med 2001; 53(12): 1641-51.
[http://dx.doi.org/10.1016/S0277-9536(00)00449-4] [PMID: 11762890]
]. A low economic capacity influenced REW seeking healthcare and was identified as due to a lack of financial support from family members and the governments.

Three studies found that REW who perceived they had adequate support from family members and the government were more likely to use MHS [22Gopalan SS, Durairaj V. Addressing women’s non-maternal healthcare financing in developing countries: What can we learn from the experiences of rural Indian women? PLoS One 2012; 7(1): e29936.
[http://dx.doi.org/10.1371/journal.pone.0029936] [PMID: 22272262]
, 30Sharma D, Mazta SR, Parashar A. Morbidity pattern and health-seeking behavior of aged population residing in Shimla hills of north India: A cross-sectional study. J Family Med Prim Care 2013; 2(2): 188-93.
[http://dx.doi.org/10.4103/2249-4863.117421] [PMID: 24479077]
, 32Chan EY, Griffiths S. Comparision of health needs of older people between affected rural and urban areas after the 2005 Kashmir, Pakistan earthquake. Prehosp Disaster Med 2009; 24(5): 365-71.
[http://dx.doi.org/10.1017/S1049023X00007159] [PMID: 20066635]
]. Disinterest of younger family members in spending money on elderly women in the family also resulted in REW reduced use of MHS in India [p < 0.05 (OR 2.04, 95% CI 1.09-3.83)] and Pakistan [p < 0.001] [22Gopalan SS, Durairaj V. Addressing women’s non-maternal healthcare financing in developing countries: What can we learn from the experiences of rural Indian women? PLoS One 2012; 7(1): e29936.
[http://dx.doi.org/10.1371/journal.pone.0029936] [PMID: 22272262]
, 32Chan EY, Griffiths S. Comparision of health needs of older people between affected rural and urban areas after the 2005 Kashmir, Pakistan earthquake. Prehosp Disaster Med 2009; 24(5): 365-71.
[http://dx.doi.org/10.1017/S1049023X00007159] [PMID: 20066635]
]. Furthermore, REW who did not receive financial support from the government in India were less likely to use MHS than elderly women who had such support [p < 0.05 (OR 2.13, 95% CI 1.11-4.07)] [22Gopalan SS, Durairaj V. Addressing women’s non-maternal healthcare financing in developing countries: What can we learn from the experiences of rural Indian women? PLoS One 2012; 7(1): e29936.
[http://dx.doi.org/10.1371/journal.pone.0029936] [PMID: 22272262]
]. Living in a low income country was statistically associated with a lack of financial support from both the family and the government, and this significantly impacted on their access.

3.5. Transportation Difficulties

Access to MHS was affected by geographical accessibility factors including distances, travelling and transportation [18Iecovich E, Carmel S. Differences in accessibility, affordability, and availability (AAA) of medical specialists among three age-groups of elderly people in Israel. J Aging Health 2009; 21(5): 776-97.
[http://dx.doi.org/10.1177/0898264309333322] [PMID: 19282268]
, 21Cheng G, Tolhurst R, Li RZ, Meng QY, Tang S. Factors affecting delays in tuberculosis diagnosis in rural China: A case study in four counties in Shandong Province. Trans R Soc Trop Med Hyg 2005; 99(5): 355-62.
[http://dx.doi.org/10.1016/j.trstmh.2004.07.005] [PMID: 15780342]
, 23Nipun A, Prakash SV, Kumar SA, Danish I. Healthcare services utilization by geriatric population in rural area of District Bareilly, India. Int J Curr Microbiol Appl Sci 2015; 4(5): 720-7., 32Chan EY, Griffiths S. Comparision of health needs of older people between affected rural and urban areas after the 2005 Kashmir, Pakistan earthquake. Prehosp Disaster Med 2009; 24(5): 365-71.
[http://dx.doi.org/10.1017/S1049023X00007159] [PMID: 20066635]
, 44Young AF, Dobson AJ, Byles JE. Determinants of general practitioner use among women in Australia. Soc Sci Med 2001; 53(12): 1641-51.
[http://dx.doi.org/10.1016/S0277-9536(00)00449-4] [PMID: 11762890]
, 45Mariolis A, Mihas C, Alevizos A, et al. Dissatisfaction with cardiovascular health and primary health care services: Southern Mani, isolated area in Europe. A case study. Hellenic J Cardiol 2008; 49(3): 139-44.
[PMID: 18543642]
]. A long distance to healthcare centers reduced the number of regular visits for REW in both low/middle and high income countries [14Abdulraheem IS. Health needs assessment and determinants of health-seeking behaviour among elderly Nigerians: A house-hold survey. Ann Afr Med 2007; 6(2): 58-63.
[http://dx.doi.org/10.4103/1596-3519.55715] [PMID: 18240704]
, 15Adu-Gyamfi AB, Abane AM. Utilization of health care facilities among residents of Lake Bosomtwe basin of Ghana. EIJST 2013; 2(4): 131-42., 44Young AF, Dobson AJ, Byles JE. Determinants of general practitioner use among women in Australia. Soc Sci Med 2001; 53(12): 1641-51.
[http://dx.doi.org/10.1016/S0277-9536(00)00449-4] [PMID: 11762890]
, 46Harrison WN, Wardle SA. Factors affecting the uptake of cardiac rehabilitation services in a rural locality. Public Health 2005; 119(11): 1016-22.
[http://dx.doi.org/10.1016/j.puhe.2005.01.016] [PMID: 16085152]
]. Long distances caused increased travel time and led REW to fewer visits to healthcare centers in Ghana [p < 0.05 (p = 0.021)], India [28.4% reported as a barrier] and Vietnam [p < 0.05] [15Adu-Gyamfi AB, Abane AM. Utilization of health care facilities among residents of Lake Bosomtwe basin of Ghana. EIJST 2013; 2(4): 131-42., 22Gopalan SS, Durairaj V. Addressing women’s non-maternal healthcare financing in developing countries: What can we learn from the experiences of rural Indian women? PLoS One 2012; 7(1): e29936.
[http://dx.doi.org/10.1371/journal.pone.0029936] [PMID: 22272262]
, 47Huong NT, Vree M, Duong BD, et al. Delays in the diagnosis and treatment of tuberculosis patients in Vietnam: A cross-sectional study. BMC Public Health 2007; 7: 110.
[http://dx.doi.org/10.1186/1471-2458-7-110] [PMID: 17567521]
]. Several studies reported an association of inconvenient transportation with the non-use of MHS and this inconvenience was related to the unavailability in low/middle income countries like South Africa [1.1% reported it as a barrier] and Ghana [p < 0.05 (p = 0.001)] and also discomfort in using transportation in USA [p < 0.05 (p = 0.02)] [12Ameh S, Gómez-Olivé FX, Kahn K, Tollman SM, Klipstein-Grobusch K. Predictors of health care use by adults 50 years and over in a rural South African setting. Glob Health Action 2014; 24(7): 771., 15Adu-Gyamfi AB, Abane AM. Utilization of health care facilities among residents of Lake Bosomtwe basin of Ghana. EIJST 2013; 2(4): 131-42., 42Hong T, Oddone E, Weinfurt K, Friedman J, Schulman K, Bosworth H. The relationship between perceived barriers to healthcare and self-rated health. Psychol Health Med 2004; 9(4): 476-82.
[http://dx.doi.org/10.1080/13548500412331298966]
]. Consequently, the distance and travel time in combination with an inadequate transportation system were significant barriers [32Chan EY, Griffiths S. Comparision of health needs of older people between affected rural and urban areas after the 2005 Kashmir, Pakistan earthquake. Prehosp Disaster Med 2009; 24(5): 365-71.
[http://dx.doi.org/10.1017/S1049023X00007159] [PMID: 20066635]
, 40Liu LJ, Sun X, Zhang CL, Guo Q. Health-care utilization among empty-nesters in the rural area of a mountainous county in China. Public Health Rep 2007; 122(3): 407-13.
[http://dx.doi.org/10.1177/003335490712200315] [PMID: 17518313]
]. Thus, living in rural areas was positively associated with the problems of transportation that impacted on visits to healthcare centers. Being reliant on family members for transportation and access to MHS made family relationships another important factor for REW accessing healthcare.

3.6. Relationship Matters

A reliance on social and family relationships had a statistically significant impact on REW’s access to MHS with poor quality relationships negatively influencing the access [30Sharma D, Mazta SR, Parashar A. Morbidity pattern and health-seeking behavior of aged population residing in Shimla hills of north India: A cross-sectional study. J Family Med Prim Care 2013; 2(2): 188-93.
[http://dx.doi.org/10.4103/2249-4863.117421] [PMID: 24479077]
, 33Ingold BB, Yersin B, Wietlisbach V, Burckhardt P, Bumand B, Büla CJ. Characteristics associated with inappropriate hospital use in elderly patients admitted to a general internal medicine service. Aging (Milano) 2000; 12(6): 430-8.
[PMID: 11211952]
, 48Melese M, Alemayehu W, Friedlander E, Courtright P. Indirect costs associated with accessing eye care services as a barrier to service use in Ethiopia. Trop Med Int Health 2004; 9(3): 426-31.
[http://dx.doi.org/10.1111/j.1365-3156.2004.01205.x] [PMID: 14996373]
]. Chan & Griffths (2009) and Onwubiko et al. (2014) found that REW who had a feeling of social loneliness were less likely to use MHS in Pakistan [p < 0.01] and Nigeria [p = 0.01 (OR 2.26; CI 1.41-3.63)]. Isolation from intimate relationships increased the chances of vulnerability and an unwillingness to utilize medical treatments as REW often needed someone to help them in travelling and seeking healthcare [24Onwubiko SN, Eze BI, Udeh NN, Arinze OC, Okoloagu MN, Chuka-Okosa CM. Mapping the pathways to eye care in a rural south-east Nigerian population: Any implications for practice, eye care programs and policy? Rural Remote Health 2014; 14(4): 2729.
[PMID: 25382094]
]. Three studies also indicated a relationship between healthcare access and social networks [30Sharma D, Mazta SR, Parashar A. Morbidity pattern and health-seeking behavior of aged population residing in Shimla hills of north India: A cross-sectional study. J Family Med Prim Care 2013; 2(2): 188-93.
[http://dx.doi.org/10.4103/2249-4863.117421] [PMID: 24479077]
, 32Chan EY, Griffiths S. Comparision of health needs of older people between affected rural and urban areas after the 2005 Kashmir, Pakistan earthquake. Prehosp Disaster Med 2009; 24(5): 365-71.
[http://dx.doi.org/10.1017/S1049023X00007159] [PMID: 20066635]
, 40Liu LJ, Sun X, Zhang CL, Guo Q. Health-care utilization among empty-nesters in the rural area of a mountainous county in China. Public Health Rep 2007; 122(3): 407-13.
[http://dx.doi.org/10.1177/003335490712200315] [PMID: 17518313]
]. Liu et al. (2007) reported that decreasing social networks also led REW to use medical treatments in an inappropriate way in China [p < .05]. Dependency of REW on their friends, family and neighbors in seeking healthcare was compounded when they were more likely to lose their friends as they aged that then resulted in less access.

3.7. Culture of Restriction

The cultural determinants included family restrictions on mobility and or a dependency on male family members. Being an aged woman, resulted in limited autonomy to travel alone to healthcare centers in both Switzerland [p < 0.05 (p = 0.003)] and Vietnam [p < 0.005 ] [33Ingold BB, Yersin B, Wietlisbach V, Burckhardt P, Bumand B, Büla CJ. Characteristics associated with inappropriate hospital use in elderly patients admitted to a general internal medicine service. Aging (Milano) 2000; 12(6): 430-8.
[PMID: 11211952]
, 47Huong NT, Vree M, Duong BD, et al. Delays in the diagnosis and treatment of tuberculosis patients in Vietnam: A cross-sectional study. BMC Public Health 2007; 7: 110.
[http://dx.doi.org/10.1186/1471-2458-7-110] [PMID: 17567521]
]. Though the causes were not clear, this restriction in movement impacted on the use of MHS, and in some countries was also influenced by being dependent on male family members. Three studies indicated that REW were dependent on family members, male family members in particular, in relation to receiving in-home help, accompaniment in travelling to the healthcare centers and in managing healthcare [33Ingold BB, Yersin B, Wietlisbach V, Burckhardt P, Bumand B, Büla CJ. Characteristics associated with inappropriate hospital use in elderly patients admitted to a general internal medicine service. Aging (Milano) 2000; 12(6): 430-8.
[PMID: 11211952]
, 37Heinrich S, Luppa M, Matschinger H, Angermeyer MC, Riedel-Heller SG, König HH. Service utilization and health-care costs in the advanced elderly. Value Health 2008; 11(4): 611-20.
[http://dx.doi.org/10.1111/j.1524-4733.2007.00285.x] [PMID: 18179660]
, 49Odaman OM, Ibiezugbe M. Health seeking behavior among the elderly in Edo Central Nigeria. IRSSH 2014; 7(1): 201-10.]. Rural elderly women who were mostly dependent on family members were less likely to use MHS in Switzerland [p < 0.05 (p = 0.031)] and in Germany [p < 0.05 (p = 0.008)] [33Ingold BB, Yersin B, Wietlisbach V, Burckhardt P, Bumand B, Büla CJ. Characteristics associated with inappropriate hospital use in elderly patients admitted to a general internal medicine service. Aging (Milano) 2000; 12(6): 430-8.
[PMID: 11211952]
, 37Heinrich S, Luppa M, Matschinger H, Angermeyer MC, Riedel-Heller SG, König HH. Service utilization and health-care costs in the advanced elderly. Value Health 2008; 11(4): 611-20.
[http://dx.doi.org/10.1111/j.1524-4733.2007.00285.x] [PMID: 18179660]
]. Additionally, refusal from family members to help the REW was an important factor for the non-utilization [49Odaman OM, Ibiezugbe M. Health seeking behavior among the elderly in Edo Central Nigeria. IRSSH 2014; 7(1): 201-10.]. Such dependent circumstances for REW did not improve their healthcare access in these communities both in developing and developed countries.

In summarizing the findings, the review suggested a number of determinants in relation to REW’s access to MHS. It was evident that REW were disadvantaged by individual, institutional, economic, social and cultural determinants under seven categories described above. This review confirmed that not only did healthcare systems impact on outcomes, but also individual, socioeconomic and cultural barriers influenced REW’s access. These constraints in healthcare and social environments shaped REW’s personal healthcare seeking behaviors. Thus, individual circumstances in combination with healthcare, cultural and social environments and reliance on others were significant determinants in the utilization of MHS for REW.

4. DISCUSSION

This review identified a number of statistically significant SDoH of REW’s access to MHS. Although these determinants were country and context specific, they can be seen in an integrated manner with common factors impacting on healthcare access. The use of MHS is mainly mediated by personal, socioeconomic, cultural and health systems that shape the way REW perceive their health and healthcare access. Personal healthcare seeking behaviors and cultural issues in low/middle income countries may or may not be similar in high income countries, however, they are significant in understanding the overall status of REW’s access to MHS globally. The authenticity and consistency across the findings in the reviewed studies have led to conclusions on the SDoH including downstream and upstream SDoH that impact on REW’s access.

Downstream SDoH spatially and provisionally influence REW’s access to MHS [50Braveman P, Gottlieb L. The social determinants of health: It’s time to consider the causes of the causes. Public Health Reports 2014; 129-41.
[http://dx.doi.org/10.1177/00333549141291S206] [PMID: 24385661]
]. As such, this review found a number of downstream determinants that are grouped into three categories: health literacy and education, care seeking behavior and lack healthcare support. Regardless the country difference, health illiteracy and educational levels emerged as the most dominant determinant in MHS use. Because of higher education rate in high income countries, REW are more likely to have better healthcare knowledge leading to an increased realization of the benefits of MHS use [51Kabir ZN, Tishelman C, Agüero-Torres H, Chowdhury AM, Winblad B, Höjer B. Gender and rural-urban differences in reported health status by older people in Bangladesh. Arch Gerontol Geriatr 2003; 37(1): 77-91.
[http://dx.doi.org/10.1016/S0167-4943(03)00019-0] [PMID: 12849075]
-53Terraneo M. Inequities in health care utilization by people aged 50+: Evidence from 12 European countries. Soc Sci Med 2015; 126: 154-63.
[http://dx.doi.org/10.1016/j.socscimed.2014.12.028] [PMID: 25562311]
]. In contrast, REW living in low/middle income countries experience more drop out from the school in their early life than male children [26Ahmed SM, Tomson G, Petzold M, Kabir ZN. Socioeconomic status overrides age and gender in determining health-seeking behaviour in rural Bangladesh. Bull World Health Organ 2005; 83(2): 109-17.
[PMID: 15744403]
, 53Terraneo M. Inequities in health care utilization by people aged 50+: Evidence from 12 European countries. Soc Sci Med 2015; 126: 154-63.
[http://dx.doi.org/10.1016/j.socscimed.2014.12.028] [PMID: 25562311]
]. This lack of education is the result of social positioning of women in the rural society, and this could be a reason of the REW’s increased dependency and lack of confidence in making decisions regarding healthcare access [41Hossen MA, Westhues A. Rural women’s access to health care in Bangladesh: Swimming against the tide? Soc Work Public Health 2011; 26(3): 278-93.
[http://dx.doi.org/10.1080/19371910903126747] [PMID: 21534125]
, 53Terraneo M. Inequities in health care utilization by people aged 50+: Evidence from 12 European countries. Soc Sci Med 2015; 126: 154-63.
[http://dx.doi.org/10.1016/j.socscimed.2014.12.028] [PMID: 25562311]
, 54Adler NE, Glymour MM, Fielding J. Addressing social determinants of health and health inequalities. JAMA 2016; 316(16): 1641-2.
[http://dx.doi.org/10.1001/jama.2016.14058] [PMID: 27669456]
]. Interventions aimed at maximizing health literacy of REW may increase their hospital visits, and also improve their health seeking behaviors in accessing MHS.

Passive behaviors were identified as important determinants in this review, especially for REW living in low/middle income countries. The passive behaviors included self-care tendencies, their mistrust of MHS and staff, whether depression was present and any perceived stigma. While the seriousness in seeking healthcare, mistrust to MHS, stigma and self-care tendencies were common in the REW living low/middle income countries, REW who live in high income countries presented their depression. Studies examining the passive behaviors reported on the coping strategies employed by REW, rather than on the REW’s autonomy and recognition within healthcare system, especially in low income countries [41Hossen MA, Westhues A. Rural women’s access to health care in Bangladesh: Swimming against the tide? Soc Work Public Health 2011; 26(3): 278-93.
[http://dx.doi.org/10.1080/19371910903126747] [PMID: 21534125]
, 55Women, Ageing and health: A framework for action 2007., 56Fitzpatrick AL, Powe NR, Cooper LS, Ives DG, Robbins JA. Barriers to health care access among the elderly and who perceives them. Am J Public Health 2004; 94(10): 1788-94.
[http://dx.doi.org/10.2105/AJPH.94.10.1788] [PMID: 15451751]
]. Taking universal healthcare seriously did not confirm the consideration of individual determinants such as self-care tendencies and trust on MHS at policy and research levels in low income countries [56Fitzpatrick AL, Powe NR, Cooper LS, Ives DG, Robbins JA. Barriers to health care access among the elderly and who perceives them. Am J Public Health 2004; 94(10): 1788-94.
[http://dx.doi.org/10.2105/AJPH.94.10.1788] [PMID: 15451751]
-58Rahman SA, Kielmann T, McPake B, Normand C. Healthcare-seeking behaviour among the tribal people of Bangladesh: Can the current health system really meet their needs? J Health Popul Nutr 2012; 30(3): 353-65.
[http://dx.doi.org/10.3329/jhpn.v30i3.12299] [PMID: 23082637]
]. Such determinants could be demotivating factors in the cultures where dominance and disempowerment are prevalent [59Ukwaja KN, Alobu I, Nweke CO, Onyenwe EC. Healthcare-seeking behavior, treatment delays and its determinants among pulmonary tuberculosis patients in rural Nigeria: A cross-sectional study. BMC Health Serv Res 2013; 13(1): 25.
[http://dx.doi.org/10.1186/1472-6963-13-25] [PMID: 23327613]
]. The impact of these determinants in using MHS is furthered when considering the life-long depression and perceived stigma among REW [60Wang C, Li J, Wan X, Wang X, Kane RL, Wang K. Effects of stigma on Chinese women’s attitudes towards seeking treatment for urinary incontinence. J Clin Nurs 2015; 24(7-8): 1112-21.
[http://dx.doi.org/10.1111/jocn.12729] [PMID: 25422008]
, 61Whitehead J, Shaver J, Stephenson R. Outness, stigma, and primary health care utilization among rural LGBT populations. PLoS One 2016; 11(1): e0146139.
[http://dx.doi.org/10.1371/journal.pone.0146139] [PMID: 26731405]
]. Thus, the individual circumstances in using MHS require attention, together with the systemic, economic and social circumstances.

Healthcare support was a key downstream determinant in MHS utilization. This review identified a range of scarcities including lack of services, healthcare professionals and medical equipment and medications. Lack of services and shortage of healthcare professionals were important even in high income countries as REW live away from mainstream populations [16Bell RA, Quandt SA, Arcury TA, et al. Primary and specialty medical care among ethnically diverse, older rural adults with type 2 diabetes: the ELDER Diabetes Study. J Rural Health 2005; 21(3): 198-205.
[http://dx.doi.org/10.1111/j.1748-0361.2005.tb00083.x] [PMID: 16092292]
, 62Wurie HR, Samai M, Witter S. Retention of health workers in rural Sierra Leone: Findings from life histories. Hum Resour Health 2016; 14(1): 3.
[http://dx.doi.org/10.1186/s12960-016-0099-6] [PMID: 26833070]
]. Rural elderly women with comorbidities and/or chronic conditions may find it difficult to use MHS especially when resources are limited, and lengthy waiting periods in healthcare centers can make this situation worse [56Fitzpatrick AL, Powe NR, Cooper LS, Ives DG, Robbins JA. Barriers to health care access among the elderly and who perceives them. Am J Public Health 2004; 94(10): 1788-94.
[http://dx.doi.org/10.2105/AJPH.94.10.1788] [PMID: 15451751]
]. Though there was no evidence between low/middle and high income countries relating to the difference in average waiting time, this lengthy waiting period demotivated REW in low income countries because of their chronic health condition, dependency in managing healthcare and limited healthcare professionals [5WHO. Women and health: Today's evidence tomorrow's agenda. World Health Organization: Geneva 2009.]. The attitude of healthcare professionals towards REW was cited as a significant determinant in low/middle income countries and it was clear that the relationships between REW and healthcare professionals impacted on MHS use [41Hossen MA, Westhues A. Rural women’s access to health care in Bangladesh: Swimming against the tide? Soc Work Public Health 2011; 26(3): 278-93.
[http://dx.doi.org/10.1080/19371910903126747] [PMID: 21534125]
, 58Rahman SA, Kielmann T, McPake B, Normand C. Healthcare-seeking behaviour among the tribal people of Bangladesh: Can the current health system really meet their needs? J Health Popul Nutr 2012; 30(3): 353-65.
[http://dx.doi.org/10.3329/jhpn.v30i3.12299] [PMID: 23082637]
]. The cultural competent approach of the healthcare professionals may contribute to the increase of the number of visits of REW at hospitals. Even though health insurance coverage had a positive effect on MHS use, there was a lack of focus on this issue in low/middle income countries [41Hossen MA, Westhues A. Rural women’s access to health care in Bangladesh: Swimming against the tide? Soc Work Public Health 2011; 26(3): 278-93.
[http://dx.doi.org/10.1080/19371910903126747] [PMID: 21534125]
, 55Women, Ageing and health: A framework for action 2007.]. Accordingly, the role played by staff in MHS in REW’s healthcare access was of particular interest. These downstream determinants were further shaped by a number of upstream determinants.

The fundamental factors impacting on access can be defined as upstream determinants [50Braveman P, Gottlieb L. The social determinants of health: It’s time to consider the causes of the causes. Public Health Reports 2014; 129-41.
[http://dx.doi.org/10.1177/00333549141291S206] [PMID: 24385661]
]. This review identified a number of fundamental determinants grouped into four themes including financial constraints, transportation difficulties, relationship matters and cultural restrictions. Financial constraint was a result of poverty, the cost of services and a lack of support from family members and the state and this has been supported by other reports [54Adler NE, Glymour MM, Fielding J. Addressing social determinants of health and health inequalities. JAMA 2016; 316(16): 1641-2.
[http://dx.doi.org/10.1001/jama.2016.14058] [PMID: 27669456]
]. Poverty and the cost of services were important for REW seeking healthcare or not, especially where there was no or limited support from family members or the government in low/middle income countries [63Wandera SO, Kwagala B, Ntozi J. Determinants of access to healthcare by older persons in Uganda: A cross-sectional study. Int J Equity Health 2015; 14(1): 26.
[http://dx.doi.org/10.1186/s12939-015-0157-z] [PMID: 25889558]
]. Possessing savings from employment and having support from the governments in high income countries encouraged the people including REW to access healthcare [64Leach-Kemon K, Chou DP, Schneider MT, et al. The global financial crisis has led to a slowdown in growth of funding to improve health in many developing countries. Health Aff (Millwood) 2012; 31(1): 228-35.
[http://dx.doi.org/10.1377/hlthaff.2011.1154] [PMID: 22174301]
]. However, the financial constraints of REW were reinforced in low income countries where local cultural values and customs denied employment for REW and make independent decisions in seeking MHS [64Leach-Kemon K, Chou DP, Schneider MT, et al. The global financial crisis has led to a slowdown in growth of funding to improve health in many developing countries. Health Aff (Millwood) 2012; 31(1): 228-35.
[http://dx.doi.org/10.1377/hlthaff.2011.1154] [PMID: 22174301]
-66Mills A. Health care systems in low- and middle-income countries. N Engl J Med 2014; 370(6): 552-7.
[http://dx.doi.org/10.1056/NEJMra1110897] [PMID: 24499213]
]. Other studies have also found rural households with low financial security had less access

to social resources such as education and healthcare, and this was especially true for REW in low income countries because of their low income and savings and an economic dependency on family members.

Transportation difficulties were also central concerns in MHS use in the forms of distance, travel time and convenience. Living at a distance from healthcare centers demotivated REW to access MHS as it involved time, money, transportation and accompaniment [67McLaren Z, Ardington C, Leibbrandt M. Distance as a barrier to health care access in South Africa 2013; 97, 68Syed ST, Gerber BS, Sharp LK. Traveling towards disease: Transportation barriers to health care access. J Community Health 2013; 38(5): 976-93.
[http://dx.doi.org/10.1007/s10900-013-9681-1] [PMID: 23543372]
]. While high income countries like USA, UK, Canada and Australia progressed in ensuring universal healthcare access for rural people including REW, the main focus of low/middle income countries was on urban infrastructures including education, employment, healthcare and transportation [68Syed ST, Gerber BS, Sharp LK. Traveling towards disease: Transportation barriers to health care access. J Community Health 2013; 38(5): 976-93.
[http://dx.doi.org/10.1007/s10900-013-9681-1] [PMID: 23543372]
]. As a result, transportation emerged as an important determinant in low/middle income countries in accessing socioeconomic and healthcare resources. Apart from the debate about the location and the use of MHS, most studies found REW have less access due to transportation difficulties [68Syed ST, Gerber BS, Sharp LK. Traveling towards disease: Transportation barriers to health care access. J Community Health 2013; 38(5): 976-93.
[http://dx.doi.org/10.1007/s10900-013-9681-1] [PMID: 23543372]
, 69Strout EH, Fox L, Castro A, et al. Access to transportation for Chittenden County Vermont older adults. Aging Clin Exp Res 2016; 28(4): 769-74.
[http://dx.doi.org/10.1007/s40520-015-0476-3] [PMID: 26542413]
]. Living far away has been associated with REW’s low level of education and a poor access to MHS resulting in mistrust to MHS and a dependency on home-remedies and traditional healers [63Wandera SO, Kwagala B, Ntozi J. Determinants of access to healthcare by older persons in Uganda: A cross-sectional study. Int J Equity Health 2015; 14(1): 26.
[http://dx.doi.org/10.1186/s12939-015-0157-z] [PMID: 25889558]
, 68Syed ST, Gerber BS, Sharp LK. Traveling towards disease: Transportation barriers to health care access. J Community Health 2013; 38(5): 976-93.
[http://dx.doi.org/10.1007/s10900-013-9681-1] [PMID: 23543372]
]. Rural elderly women living in poor households in low income countries where family members failed to recognize and meet the needs of the women in relation to manage time and accompany them to MHS use [41Hossen MA, Westhues A. Rural women’s access to health care in Bangladesh: Swimming against the tide? Soc Work Public Health 2011; 26(3): 278-93.
[http://dx.doi.org/10.1080/19371910903126747] [PMID: 21534125]
]. Especially, REW with a disability may find it difficult to travel to healthcare services especially when the transportation was not available and no accompany [52Strasser R, Kam SM, Regalado SM. Rural health care access and policy in developing countries. Annu Rev Public Health 2016; 37: 395-412.
[http://dx.doi.org/10.1146/annurev-publhealth-032315-021507] [PMID: 26735432]
]. In general, the issue of distance and transportation along with social exclusion was vital determinant in using MHS, especially in low/middle income countries.

Social relationship was another major upstream determinant in the utilization of MHS. Though social exclusion of REW was common in developed and developing countries, the causes were different. In high income countries, poor social networks decreased the number of visits to MHS and also reduced the chance of getting information from others [70Copeland VC. African Americans: Disparities in health care access and utilization. Health Soc Work 2005; 30(3): 265-70.
[http://dx.doi.org/10.1093/hsw/30.3.265] [PMID: 16190303]
, 71Wedgeworth M, LaRocca MA, Chaplin WF, Scogin F. The role of interpersonal sensitivity, social support, and quality of life in rural older adults. Geriatr Nurs (Minneap) 2017; 38(1): 22-6.
[http://dx.doi.org/10.1016/j.gerinurse.2016.07.001] [PMID: 27480313]
]. In low/middle income countries, most REW were living with family members and their low status in the patriarchal family structure caused isolation in the family leading to diminished use of MHS [71Wedgeworth M, LaRocca MA, Chaplin WF, Scogin F. The role of interpersonal sensitivity, social support, and quality of life in rural older adults. Geriatr Nurs (Minneap) 2017; 38(1): 22-6.
[http://dx.doi.org/10.1016/j.gerinurse.2016.07.001] [PMID: 27480313]
]. This social isolation as a result of patriarchy plays a role in shaping the healthcare beliefs and behaviors such as superstitions, understanding of the importance of using MHS, self-care, feeling of loneliness and home-centeredness [8Hamiduzzaman M, De Bellis A, Kalaitzidis E, Abigail W. Factors impacting on elderly women’s access to healthcare in rural Bangladesh. Indian J Gerontol 2016; 30(2): 235-60.].

Cultural value was significant upstream determinant in MHS use. Though there was a lack of focus in quantitative studies conducted in low/middle and high income countries about the cultural obstacles, underutilization of MHS as a result of REW’s lack autonomy in moving out alone and travelling to healthcare centers was evident. Male dominance in the cultures of low income countries may have influenced a woman’s decision to use MHS [8Hamiduzzaman M, De Bellis A, Kalaitzidis E, Abigail W. Factors impacting on elderly women’s access to healthcare in rural Bangladesh. Indian J Gerontol 2016; 30(2): 235-60., 72Shaikh BT, Hatcher J. Health seeking behaviour and health service utilization in Pakistan: challenging the policy makers. J Public Health (Oxf) 2005; 27(1): 49-54.
[http://dx.doi.org/10.1093/pubmed/fdh207] [PMID: 15590705]
]. Rural elderly women living in a patriarchal context were less likely to use MHS because of a restriction in movement [73Sen G, Grown C. Development crises and alternative visions: Third world women’s perspectives 2013 ]. Moreover, the control of monetary issues by men can make it difficult for REW to independently pay for transportation [73Sen G, Grown C. Development crises and alternative visions: Third world women’s perspectives 2013 ]. Thus, experience of inequality by REW compared to men in low income societies has direct effects on their MHS use and this should be explored further [74Di Cesare M, Bhatti Z, Soofi SB, Fortunato L, Ezzati M, Bhutta ZA. Geographical and socioeconomic inequalities in women and children’s nutritional status in Pakistan in 2011: An analysis of data from a nationally representative survey. Lancet Glob Health 2015; 3(4): e229-39.
[http://dx.doi.org/10.1016/S2214-109X(15)70001-X] [PMID: 25794676]
, 75Lindio-McGovern L, Wallimann I. Eds. Globalization and third world women: Exploitation, coping and resistance 2016].

Overall, this study highlighted the complex downstream and upstream ways in which REW’s healthcare access affect. The downstream SDoH including health literacy and education, passive health seeking behavior and a lack of healthcare support had direct influence on the REW’s access to MHS. And the upstream SDoH such as financial constraints, transportation difficulties, relationship matters and cultural restrictions shaped the healthcare behaviors of the REW and an inequality in their access to education and resources. Because of the interrelationships, there is requirement for a holistic policy and practice for healthcare system based on the understanding of the SDoH. Construction of the determinants suggests the healthcare practice to be more inclusionary and comprehensive that can able to provide institutionalized, complete and sustainable care rather than disease centered care. Interventions at policy level should focus on different determinants at once to ensure the women’s recognition and their adequate and equal access to MHS. Low/middle income countries can follow the high income country’s policies and practices in developing healthcare and social policies and practice guidelines considering the local socioeconomic and cultural vulnerability of the REW in accessing MHS.

The review has several limitations as it was limited to peer-reviewed quantitative articles. A review of qualitative studies would add to the body of knowledge regarding REW access to healthcare. The decision to reject book chapters, grey literature and non-English language studies was made because of practical reasons including the complexity of synthesis and analysis and time constraints. There is a need to consider that research conducted in low income countries may not be published in peer-reviewed journals which may have impacted in identifying the determinants across the quantitative studies reviewed.

CONCLUSION

This review raised a number of practical and research issues in relation to MHS access and use by REW. Low utilization of MHS by REW was often caused by several downstream and upstream determinants. Adequate and quality access to MHS for REW that is respectful of the woman is not assured, particularly in low and middle income countries. The common and different issues identified across low/middle and high income countries suggest that access to MHS by REW was a global health priority. This review on the SDoH of REW’s healthcare access has substantial importance in the development of relevant policies and practices. At the policy level, increasing the REW’s participation in health education and ensuring adequate financial assistance and transportation will improve access, and sustainable healthcare and social support could bring a positive change in using MHS. At practice level, consideration of the SDoH may be helpful for developing an institutionalized and sustainable care management for the REW. Further research is recommended into REW’s experiences and perceptions in relation to the impact of cultural determinants on MHS use.

CONSENT FOR PUBLICATION

Not applicable.

CONFLICT OF INTEREST

The authors declare no conflict of interest, financial or otherwise.

ACKNOWLEDGEMENTS

Declared none.

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