Enablers and Barriers of Accessing Health Care Services among Older Adults in South-East Asia: A Scoping Review

South-East Asia (SEA) is the home of the largest number of the world’s older population. In this scoping review, we aimed to map the existing enablers and barriers of accessing healthcare services among older adults in SEA countries. Articles that were published from January 2001 until November 2021 were searched in four data sources (PubMed, Web of Science, EBSCO Host and The Cochrane Library). Studies pertaining to the factors which assist or obstruct older Southeast Asian adults from assessing healthcare services were chosen for this scoping review. First, two reviewers screened the titles and abstracts of articles in the data sources. After identifying appropriate articles, the reviewers read them. Data extracted by one reviewer were verified by the other reviewer. The findings were then classified according to Penchansky and Thomas’s five domains of access. A total of 19 studies were included in the final scoping review. Accessibility and acceptability were the two factors most often identified as enablers or barriers to older adults from accessing healthcare. Other often mentioned factors were finances, transportation and social/family support. Older adults living in rural areas were especially impacted by these factors. To promote healthy ageing, optimum healthcare and wellbeing among older adults in Southeast Asia, it is extremely important to consider accessibility and acceptability when planning healthcare services.


Introduction
In 2050, there will an estimated 1.5 billion persons aged 65 and over globally. In the Southeast Asian (SEA) countries, the proportion of people aged 60 years and above has been predicted to account for 13.7% and 20.3% of the population in 2030 and 2050, respectively [1]. East and Southeast Asia are home to 260 million of the world's older population. The high proportion of older individuals in SEA means that the cost of providing them with healthcare services will be high [2]. This is significant as only two of the eleven (11) southeast Asian countries (Brunei and Singapore) have high income status. The other nine (Cambodia, Indonesia, Laos, Malaysia, Myanmar, Philippines, Vietnam, Timor-Leste and Thailand) have varied income statuses [3].
Ageing is commonly associated with progressive loss of skeletal muscle mass and decrease in metabolism function and functional capacity [4]. The other challenges include chronic illnesses, sensory impairments (vision and hearing), risk of falls and mobility and cognitive decline [5]. The disability burden among older adults globally is primarily driven by functional decline, vision and hearing loss, and pain [6]. Despite the physiological changes that lead to limitations, evidence have revealed that older adults can indeed age successfully [7]. However, it may be a challenge for any healthcare system to maintain the health and wellbeing of this vulnerable group. It is particularly challenging for most 1. Older population OR Elderly OR Ageing population OR Geriatric 2.
Enabler* OR Enabling OR Factor* OR Facilitator OR Motivator* 3.
Barrier* OR Limitation* OR Restriction OR Challenges OR Difficulty 4.
Health Service* OR Health care OR Healthcare 5.
South-East Asia OR Brunei OR Burma OR Myanmar OR Cambodia OR Timor-Leste OR Indonesia OR Laos OR Malaysia OR Philippines OR Singapore OR Thailand OR Vietnam 6.
1 AND 2 AND 3 AND 4 AND 5

Selection Criteria
All studies that reported issues with older adults accessing health services, regardless of study design (except for letters to the editor and conference proceedings with abstract only), were eligible for this review. This scoping review included only studies conducted among adults (aged 50 years and above). All types of health care services were included.

Selection of Included Publications
The search outcomes from each database were first screened for eligibility by reviewing the studies' titles and abstracts. The studies were then read completely to further screen for suitability based on the review questions and inclusion criteria. Figure 1 outlines the selection process. Experts were not consulted for this scoping review.

Data Extraction and Analysis
NS and AF sorted the included papers according to Penchansky and Thomas's [19] five dimensions of access: availability, accessibility, accommodation, affordability and acceptability, which are defined as follows: • Availability compares the volume and type of available healthcare services with the demand for said services. Availability refers to whether healthcare providers and facilities (including clinics and hospitals), including providers of specialized services such as mental health and emergency care, can adequately supply the said services. • Accessibility refers to the location of healthcare services and the location of the demand for said services, considering distance, travel cost, and time to travel to these services. • Accommodation pertains to how healthcare services meet the demand for their services (for example, appointment systems, operation hours, walk-in facilities, telephone services). • Affordability describes the cost of healthcare services and the availability of insurance and/or other means to pay for said services. • Acceptability refers to whether the parties demanding healthcare services accept the personal and other characteristics of the healthcare providers (including age, sex, location, type of facility, religious affiliation) and trust the healthcare providers.
removed. After screening the titles and abstracts of the articles, it was determined that the majority (n=2109) of these articles did not meet the inclusion criteria. 40 papers were identified as potentially relevant, but 21 papers did not pertain to the issue of accessibility to healthcare services in SEA countries and were discarded. A total of 19 articles were included in this review. Data regarding study design, age, country, type of healthcare service, main findings and the five dimensions of access were then combined into   Figure 1 shows a PRISMA flowchart for the selection of papers for this scoping review. Searches of the four databases yielded 2149 articles after duplicates were removed. After screening the titles and abstracts of the articles, it was determined that the majority (n = 2109) of these articles did not meet the inclusion criteria. Forty papers were identified as potentially relevant, but 21 papers did not pertain to the issue of accessibility to healthcare services in SEA countries and were discarded. A total of 19 articles were included in this review. Data regarding study design, age, country, type of healthcare service, main findings and the five dimensions of access were then combined into Table 1.

Characteristics of the Included Studies
All the publications (n = 19) used in the final data extraction were published between 2001 and 2021. The included studies were from Cambodia (n = 2), Indonesia (n = 3), Malaysia (n = 2), Philippines (n = 1), Singapore (n = 2), Thailand (n = 6), Timor-Leste (n = 1) and Vietnam (n = 2). Of the 11 South-East Asia countries, studies regarding enablers and barriers in accessing healthcare services for older adults were found in eight countries. Brunei and Burma were the exceptions.
Study design, age, country, type of healthcare service, and main findings of the studies that met the inclusion criteria are summarized in Table 1. Thirteen studies used quantitative methods, while four studies used qualitative methods of data collection. Only two studies used a mixed-methods approach involving interviews and focus group discussions, with data relevant to issues of accessibility to healthcare services presented quantitatively and qualitatively.
The results from the included papers were then categorized according to Penchansky and Thomas's [19] five dimensions of access, as shown in Table 2. Of the 19 papers included in this review, 11 identified accessibility issues, ten identified acceptability issues, eight identified affordability issues and two identified availability and accommodation issues. Papers that had the respective dimensions of access discussion are marked 'X'

Availability
The issue of availability was discussed in two studies [20,36]. The studies indicated that availability of healthcare services in rural areas is still a significant issue. The disparity in the availability of mental health services in the rural areas of Vietnam was reported as a barrier [36]. The availability issue was further discussed in terms of the limited number of health care professionals in rural areas. An under-supply leading to the unavailability of doctors was also highlighted by older adults in the Philippines as one of the reasons for their health care needs not being met [20]. This may be due to the high numbers of skilled health professionals moving from rural to urban areas [31].

Accessibility
Accessibility issues were reported in more than half the studies (58%) included in this review [20][21][22]25,26,29,30,33,35,36,38] The review determined that the accessibility issues faced by older adults in SEA countries primarily concerned geographic, financial and social/family support factors. In a Thai population, urban dwellers were more likely than dwellers in rural areas to use health care services [25]. The distance an older adult had to travel to access health care services was also an important determinant, as a major reason for unmet health care needs was that the health care services were too far away to access [20,24,32].
Rittirong [33] found that the likelihood of an older adult not using a health care service increased by about 30% with an increase of every kilometer they had to travel to said health care service. In contrast, Kullanit & Taneepanichskul [26] found that older adults who lived far away from healthcare services were more likely to use them. In addition, a strong correlation between transportation costs and the use of healthcare services was highlighted [26]. The higher the transportation costs, the less likely older people were to use healthcare services. This indicates that travel cost and travel distance are important factors older adults consider when deciding whether or not they should access healthcare services.
Several studies included in this review highlighted that, in terms of family and social support, older adults who are married and/or have children are more likely to use healthcare services [25,26]. One of the reasons for unmet health needs was "there is nobody to take me to hospital," which is cited often by older adults living alone and older adults living with only one family member [29].

Accommodation
Accommodation issues were reported in two studies [22,24]. The operating hours of government-run healthcare services were noted as a barrier to older adults accessing healthcare services. Older adults in Cambodia found the hours to access government-run dental services inconvenient [22].

Affordability
The issue of affordability appeared in eight of the included studies [21,22,28,29,32,[36][37][38]. Older adults whose incomes are below national poverty levels are more likely to have unmet healthcare needs, compared to those whose incomes are above national poverty levels [29]. The older adults' inability to pay for healthcare services is a highly significant issue. In a recent Indonesian study that examined the association between economic barrier (insurance ownership) and access to health services revealed that 15% of very poor older persons have major access barriers to health services [38].

Acceptability
Acceptability was discussed in majority of the included studies [23,24,[26][27][28][29][30][31]34,35]. Older adults' perceptions on their health condition and healthcare services may motivate or hinder them from accessing services. The older adults' perceptions of their health condition and healthcare services motivate or hinder them from accessing healthcare services. This review found that the older adults' perceptions, age, sex, type of facility and the healthcare providers' attitudes played important roles in determining whether they accessed healthcare services.
Two studies found that trust in healthcare professionals is an important factor [24,27]. Older Cambodians expressed distrust in their local dentists as one of their reasons for not seeking dental care. The studies found no strong association between perceptions and satisfaction in hospital visits among older adults [26]. This may indicate that older adults perceive the maintenance of their general health as more crucial compared to the maintenance of their mental and dental care.
Based on the qualitative studies that were included in this review, the main themes that emerged as factors that may act as enablers or barriers to access health services were: (1) transportation, (2) financial, (3) family/social support, and (4) perceived need for care. Similar to the quantitative findings included is this review, the themes transportation, financial and family/social support factors can be explained in the accessibility domain of Penchansky and Thomas [19]. In terms of perceived needs for care, older adults' perception towards dental and eye health were lower compared to general health. Fear, anxiety and past negative experience with dentistry care were the main factors appearing as barriers to access dental clinic. For instance, an older adult shared "I am always worried because I am very scared of tooth polishing which I had the last time." [30]. In addition, a low perceived need to visit dental clinic due to the absence of teeth, which is prevalent among older adults, was stated as "Now I have no teeth, so no need to visit a dentist." [30]. The theme 'perceived need for care' that emerged in the qualitative studies [30,31] could be explained based on the acceptability domain.

Discussion
This scoping review aimed to map the literature concerning factors which enable and obstruct older adults in SEA countries from accessing health care services. To the best of our knowledge, this is the first such review concerning access to healthcare among older adults in SEA countries. In the past ten years there has been increasing interest in healthcare access for older adults as countries prepare for aging populations. Our findings will assist policymakers and stakeholders as they develop plans to cater to the needs of older adults, which would include improving their access to healthcare.
The present review presented the issues of access to healthcare according to Penchansky and Thomas [19]. This scoping review suggests that access to healthcare services for older people is a construct between individuals and services. Service accessibility, availability and individual acceptability play important roles in facilitating or hindering older people's access to healthcare services. The availability and accessibility of healthcare services may not be sufficient to encourage older people to access them. Moreover, older people should not be treated as a homogeneous group [39], as factors that act as enablers or barriers for a particular individual may not apply to other older persons.
The studies included in the scoping review indicate that accessibility and acceptability are the two accessibility domains most often discussed. Financial, geographical and social/family support are viewed as interactive factors that determine older adults' accessibility to healthcare services. Older people with no formal employment tend to have only limited pension or no pension at all. Throughout SEA, there are numerous innovative, pro-poor financing schemes to increase coverage of basic health services for the vulnerable and disadvantaged groups. For instance, Thailand has its Health Card and 30-baht Schemes, Vietnam has the Health Fund for the Poor, Cambodia and Laos have their Health Equity Funds, and Singapore has its Medifund [40]. In Malaysia, older adults can assess public health services with little cost. Moreover, the nominal fee is subsidized for government pensioners and employees [41]. However, older adults with lower socioeconomic status may still be unable to afford these services [42]. Older adults in Indonesia are covered by the National Health Insurance and, in 2015, approximately 54.58% of Indonesian older adults were covered by this insurance scheme [43].
This review identified that, despite these health financing schemes, older adults in SEA countries still face financial barriers when accessing healthcare services. In Indonesia, older adults not covered by insurance have decreased access to healthcare services, leading to unmet healthcare needs and negative health outcomes [28]. The "wealth-health" gradient, which highlights the positive relationship between health and wealth, becomes more pronounced as people age [44]. Since financial resources are directly proportional to healthcare access and thus health status, more efforts are required to support older adults and over-burdened healthcare systems.
Societal and family support also play important roles in enabling older people to access healthcare. Several of the included studies that reported older persons' unmet health needs focused on older persons living alone or living with only one family member. In Asia, there is a long-standing custom of parent-grandparent co-parenting [45]. A few studies reported the positive effects on older people's psychological and well-being when they are cared for by their children [46]. However, as the older people would be taking care of their grandchildren in exchange, they may be hindered from going for health checks [36].
This review identified older persons' perceptions, age, sex, type of facility, as well as the healthcare provider's attitude as important factors in increasing access to healthcare services. Older people's perceptions are important in determining acceptability. This is especially evident in mental health services, which relate to stigma and other emotional concerns. In Vietnam, mental illness is defined as severe psychiatric abnormality or mad-ness that can also afflict others [36]. Negative perceptions of mental health services increase the difficulties for older people to access mental health services. Figure 2 illustrates the framework of factors that may act as enablers or barriers for older adults' access to healthcare adapted from the Aday and Andersen (1974) model [47]. The framework describes the interaction among five domains: (1) health policy, (2) characteristics of the health delivery system, (3) characteristics of the individual, (4) health services utilization, and (5) consumer satisfaction. This review found that health policy, such as financing, manpower and organization, are the key drivers in ensuring access to healthcare among older adults. Health policy has a unidirectional effect on health delivery system and individual characteristics. The health delivery system characteristics, which are levels of healthcare (preventive or acute/rehabilitation) and types of healthcare (medical, dental, and mental health), have an influence on the utilization or access health services. Utilization or access to health services was the main interest of this review. Within the Aday and Andersen (1974) [47] model, we found that individual characteristics and consumer satisfaction towards services are the main factors that may act as enablers or barriers to access among older adults in this review. This finding is similar to an international report, where the access and utilization to health services were greatly influenced by health delivery system features, consumer satisfaction and individual characteristics [48].
The findings from this review have important implications for both healthcare service providers and healthcare policymakers. SEA is a region with more than half a billion people, diverse cultures and a rapidly ageing population. In order to tackle future challenges related to an ageing population, knowledge of older adults' accessibility to health care services should be addressed to better provide healthcare for this vulnerable group. For instance, identifying specific issues older persons encounter when accessing healthcare services can facilitate planning and allocating the right resources, for example, identifying locations for the provision of future healthcare services, revising operating hours, and making health insurance more affordable.
With the recent COVID-19 outbreak, older adults' access to healthcare was highly jeopardized. Limited contact with friends, family and caregivers disrupted the older adults' daily routines and access to healthcare [49]. As a result, telerehabilitation became an alternative platform to deliver health education and care [50]. Despite the majority of older adults being digitally illiterate, a recent review study found that older adults found telerehabilitation acceptable, thus improving access to healthcare [51,52]. However, the older adults' acceptability and barriers in implementing telerehabilitation should be addressed first to improve the achievement of targeted outcomes. Providing preventive healthcare services closer to home or basing them in the community would make them more accessible for older adults [52]. Such services could be used to empower and engage older persons for self or home care [26,50].
This review maps out the issues faced by older adults in SEA countries when accessing healthcare services. Although the search was comprehensive, there are some limitations. Only 19 studies that were relevant to this review objectives were included. While this may be insufficient to conclude a reliable conclusion, it is an indicator that more research is needed in this area for evidence to strategize and meet the health needs of older adults. In addition, grey literature, which may provide additional insights, was not searched. This review was also limited to citizens of SEA countries. Migrants/refugees were excluded from this review. Thus, given the inadequate health care access by migrants or refugees in SEA countries, it is recommended that further studies investigate healthcare accessibility of migrants/refugees groups.

Conclusions
This review summarized the issues that act as enablers or barriers for older adults to access healthcare services in SEA countries. Numerous issues were identified as enablers or barriers to access health services, according to the individuals' socioeconomic, living status and geographical area. Understanding the current healthcare access for older persons is crucial for policy makers and providers to formulate and implement policies and services that are applicable to Asian cultures, life experiences and social circumstances.