Aging, health, and health care access for older adults in Paraguay and Latin America and the Caribbean
Background: Rapid growth in aging populations in Latin America and the Caribbean (LAC) in recent years has not been accompanied by the same increase in research about the implications of this process - an extensive gap in knowledge that poses a significant barrier to evidence-based policy development. With significant inequalities in health and social indicators, particularly among older adults, governments and organizations must be prepared to meet the needs of this growing population. To inform the development of health and social policies for older adults throughout the region, we must better understand perspectives of older individuals on themselves and their lives, and the implications of these perspectives. Objectives: This dissertation aimed to understand knowledge and perceptions of health care, health, and old age among older adults in Paraguay. Additionally, the dissertation systematically mapped the existing evidence on self-perceived health (SPH) among adults aged 60 and older in LAC and described the use of the single-item measure of SPH with this population. Methods: This dissertation employs a three-paper approach. In paper 1, a scoping review of literature explored studies published between 2009-2019; written in English, Spanish, or Portuguese; with original or secondary data; involving adults over 60 years old in LAC; and reporting the use of a single-item measure of SPH with an ordinal scale of descriptive response categories. Papers 2 and 3 examined semi-structured, in-depth interviews conducted with Paraguayans aged 60 years and older in Paraguay in 2018 and 2019. Participants were asked a series of open-ended questions about their perceptions of their health and age, and perceptions and experiences of health care access and utilization. Interviews were conducted in Spanish and Guarani, transcribed, and translated from Guarani to Spanish where applicable. Interviews were inductively and deductively coded in Spanish via NVivo software. In paper 2, the data were then thematically analyzed in an iterative process with co-authors and synthesized into summary tables. In Paper 3, a portion of interview transcripts were dual coded until consistency was reached between coders, and thematic findings were then mapped onto domains of Andersen’s Behavioral Model of Health Services Use (ABM). Findings were further categorized into facilitators, barriers, and neutral factors impacting health care access for older Paraguayans. Results: In Paper 1, the database and secondary searches identified 516 articles. After removing duplicates and assessing titles and abstracts for inclusion, reviewers assessed 263 full-text articles for eligibility using the inclusion criteria and excluded an additional 89 articles. Ultimately, 174 articles were included in the scoping review. Studies included participants from 17 countries in LAC, led in frequency by Brazil with 120 articles. The SPH question most often included a five-category response scale (146) and response options were predominantly divided into two (95) or three (52) categories for analysis. In Papers 2 and 3, a total of 58 older adults were interviewed, 26 in Guairá and 32 in Asunción. The average age was 73.4 years, ranging from 61 to 99 years, and 42 (72%) were women. The highest level of education achieved by most participants in Guairá was less than seventh grade (85%), while most in Asunción had some university education (63%). Most participants were either married (43%) or widowed (33%). In Paper 2, participants focused responses on the physical aspects of health and old age, particularly decline and limitations in old age. They described good health as being able to be active and mobile, free of pain and illness, independent and well-rested. To achieve good health in old age, participants discussed positive personal health behaviors, such as eating well and exercising, as well as the importance of institutional support for older adults including health care, economic support, and preparation for old age. In Paper 3, participants described important barriers to access health care including associated costs, availability of services and medications, wait times, and lack of social support. This population has adapted their health behavior to these barriers by utilizing multiple health care systems, paying out-of-pocket for services and medications, and delaying or forgoing care altogether. Conclusion: Information on the health and social needs of people aged 60 and older in Paraguay and across LAC, particularly their perceptions of health and aging, is limited. This dissertation highlights current gaps in the literature and serves to contribute to the development of services and policies aimed at improving health and wellbeing of older adults.