---
title: "Barriers to Primary Healthcare for the Rural Bangladeshi Elderly: A Social Ecological Model Review"
id: "plos-one-19-using-the-social-ecological-model-to-identify-barriers-to-accessing-and-using"
canonical_url: "https://medichelpline.com/clinical-feed/plos-one-19-using-the-social-ecological-model-to-identify-barriers-to-accessing-and-using"
content_type: "clinical_feed_article"
specialty: "General"
source_name: "PLOS ONE (Medicine)"
source_url: "https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0358477"
published_at: "2026-09-18T14:00:00.000Z"
evidence_level: "Journal Feed"
license: "CC-BY-NC-4.0 / Informational Use"
---
# Barriers to Primary Healthcare for the Rural Bangladeshi Elderly: A Social Ecological Model Review
## Provenance & Clinical Metadata
- **Canonical URL:** https://medichelpline.com/clinical-feed/plos-one-19-using-the-social-ecological-model-to-identify-barriers-to-accessing-and-using
- **Specialty:** [General](https://medichelpline.com/clinical-feed/general.md)
- **Primary Source:** PLOS ONE (Medicine)
- **Source URL:** [Original Journal Publication](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0358477)
- **Published At:** 2026-09-18T14:00:00.000Z
- **Evidence Rating:** Journal Feed
## Executive GIST (TL;DR)
- This systematic review used the **Social Ecological Model (SEM)** to synthesize multilevel barriers that limit access to and use of **primary healthcare (PHC)** among the rural elderly in Bangladesh. - The authors registered the review in PROSPERO and searched Scopus, PubMed, ProQuest Sociological Abstracts, Google Scholar and Google in March 2026, identifying 2,099 records and including 19 articles after applying inclusion/exclusion criteria. - Quality appraisal employed the Critical Appraisal Skills Programme (CASP) and the Mixed Methods Appraisal Tool (MMAT). - Thematic synthesis guided by SEM organized barriers into five domains: **individual**, **family**, **organizational**, **social and community**, and **policy** levels. - Key individual barriers: reduced physical capability, financial insolvency, and insufficient knowledge of PHC services. - Family-level barriers: limited contact with family/relatives, family influence over healthcare decisions, and intra-household gender disparities affecting care-seeking. - Organizational barriers: inadequate infrastructure at PHC facilities, unsatisfactory attitudes of healthcare providers, preference for gender-concordant providers, and direct treatment costs. - Social and community barriers: reliance on traditional healers and limited mobility within communities. - Policy-level barrier noted: gaps in rural elderly health insurance and lack of targeted elderly health programs within Government of Bangladesh frameworks. - The review highlights the absence of comprehensive, well-funded implementation for the National Policy on Elder Persons (2013) and notes limited research focused specifically on rural elderly healthcare access in Bangladesh. - Recommendations from the review include PHC awareness campaigns, strengthening family support mechanisms, simplifying service-related processes, providing social assistance, and developing health coverage programs for the rural elderly.
## Clinical Analysis & Structured Key Points
Using the Social Ecological Model to identify barriers to accessing and using primary healthcare services by the rural Bangladeshi elderly: A systematic review | PLOS One Browse Subject Areas ? Click through the PLOS taxonomy to find articles in your field. For more information about PLOS Subject Areas, click here . Article Authors Metrics Comments Media Coverage Peer Review Reader Comments Figures Figures Abstract Background Bangladesh's government is focusing on the United Nations Sustainable Development Goal 3 to improve primary healthcare (PHC) services, although rural elderly populations still lack access. The systematic review aimed at exploring and synthesizing the multilevel barriers to accessing and using PHC services by the rural Bangladeshi elderly based on the Social Ecological Model (SEM). Method After completing registration in PROSPERO, electronic searches were conducted in March 2026 for a systematic literature search in the Scopus, PubMed, and ProQuest Sociological Abstracts databases, as well as in Google and Google Scholar. After a rigorous search, this review included 19 of 2099 articles, following the inclusion and exclusion criteria of the review. The quality of the articles was assessed using the Critical Appraisal Skills Programme and Mixed Methods Appraisal Tools. Barriers were identified using the thematic synthesis approach guided by the SEM. Results The 19 included articles were synthesized into five themes: individual, family, organizational, social and community, and policy barriers. The review findings revealed that the key individual-level barriers included less physical capability, financial insolvency, and lack of PHC service knowledge. The family-level barriers included less connectivity with family and relatives, family influence over healthcare decisions, and gender disparity in families. The organizational-level barriers incorporated limited infrastructural facilities, unsatisfactory attitudes of healthcare providers (HPs), preference for gender-specific HPs, and treatment expenses. Dependence on traditional healers and lack of mobility were the social and community-level barriers. Finally, the policy-level barriers included rural elderly health insurance gaps. Conclusion The review recommends PHC awareness campaigns, family support, simplification of PHC service-related facilities, social assistance, and health coverage programs to help rural Bangladeshi elderly access PHC services. Citation: Chandra D, Chanda SK, Shohel TA, Banik BK, Yulian V (2026) Using the Social Ecological Model to identify barriers to accessing and using primary healthcare services by the rural Bangladeshi elderly: A systematic review. PLoS One 21(9): e0358477. https://doi.org/10.1371/journal.pone.0358477 Editor: Tadashi Kobayashi, Hirosaki University School of Medicine & Hospital, JAPAN Received: March 18, 2026; Accepted: September 1, 2026; Published: September 18, 2026 Copyright: © 2026 Chandra et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability: All relevant data are included within the paper and were obtained from articles publicly available in Scopus, PubMed, the ProQuest Sociological Abstract, Google Scholar, and Google using “healthcare”, “access to primary healthcare services”, “aging and barriers to healthcare facilities”, “limitations of primary healthcare services for the elderly”, and “healthcare impediments for older persons in rural Bangladesh” as keywords. Funding: The author(s) received no specific funding for this work. Competing interests: The authors have declared that no competing interests exist. Abbreviations: CCs, Community Clinics; CASP, Critical Appraisal Skills Programme; FGs, Focus Groups; GoB, Government of Bangladesh; HBM, Health Belief Model; HPs, Healthcare Providers; IDIs, In-depth Interviews; KIIs, Key Informant Interviews; LMICs, Low- and Middle-Income Countries; MOHFW, Ministry of Health and Family Welfare; MoSW, Ministry of Social Welfare; MMAT, Mixed Methods Appraisal Tool; MMs, Mixed Methods; PHC, Primary Healthcare; PEO, Population, Exposure and Outcome; PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses; RSC, Rural Sub-centers; SDG3, Sustainable Development Goal 3; SDGs, Sustainable Development Goals; SEM, Social Ecological Model; UHC, Upazila Health Complex; UN, United Nations; USCs, Union sub-centres; WHO, World Health Organization Introduction Although the United Nations (UN) Sustainable Development Goal 3 (SDG3) has a call to ensure health and well-being for all, the growing number of the elderly has been reported as a challenge to meet the healthcare requirements worldwide at present [ 1 , 2 ]. In Bangladesh, the emerging aging issue is associated with several challenges, such as lack of financial security, feelings of loneliness and exclusion, frequent sufferings of illness, and inadequate health facilities [ 3 , 4 ]. The health vulnerability of the elderly is more acute than that of adolescents and young people [ 5 ]. As a result, the elderly suffer from a wide range of chronic diseases, such as diabetes, cancer, and heart attacks [ 2 , 6 ]. In Bangladesh, healthcare services are provided through three levels, including primary, secondary, and tertiary [ 7 ]. The primary healthcare (PHC) service denotes the first stage of interaction between individuals and the organizational healthcare systems, which provides accessible, integrated, continuous, and individual-focused basic healthcare facilities [ 8 ]. The elderly generally prefer to seek easily available and accessible PHC services for illness treatment [ 9 ]. In rural Bangladesh, seeking healthcare services by the rural elderly is highly influenced by their socioeconomic condition, familial decisions, cultural issues, and the provision of institutional services [ 10 , 11 ]. In the last few decades, although progress in many health indicators has been noticed, people, particularly the elderly, from the Low- and Middle-Income Countries (LMICs), still face substantial challenges such as lack of essential medicine facilities in healthcare centers [ 12 , 13 ]. Additionally, studies showed that many of the rural elderly were unable to access and use PHC services due to insufficient legal frameworks, such as health allowances and insurance driven for elderly care and healthcare support [ 14 ]. On the contrary, several studies found that elderly people were reluctant to seek institutional healthcare services due to a lack of professionalism, knowledge, and skills of healthcare providers (HPs) [ 10 , 15 ]. It is noteworthy that Bangladesh has set a target to achieve the SDG3 targets to promote healthy lives by 2030 [ 5 , 16 ]. The Government of Bangladesh (GoB) has its health policy, which aims to deliver quality healthcare facilities to all its citizens, alongside special attention to children, adolescents, women, and disadvantaged rural people [ 17 ]. However, similar to other developing countries, the GoB lacks a comprehensive health policy and program for the rural elderly [ 5 , 16 ]. Though the previous studies have shown that the health vulnerability of rural elderly remains a significant concern across the country [ 14 , 18 ], the healthcare system of Bangladesh is inadequately prepared to address the growing healthcare needs of the elderly [ 19 ]. Research on the barriers to PHC services faced by the rural elderly in Bangladesh is scarce. However, the prior studies were limited to the rural elderly women, and very few studies were undertaken solely on socioeconomic and cultural impediments to avail PHC services of the elderly living in rural Bangladesh [ 14 , 19 – 21 ]. Furthermore, under the healthcare framework of GoB, there are many health programs, such as maternal healthcare, child healthcare, and adolescent healthcare, but there is no specific program for elderly healthcare [ 22 ]. Although the Ministry of Social Welfare (MoSW) formulated the National Policy on Elder Persons 2013 to ensure social security for the elderly [ 23 ], no policy direction about the implementations of the policy was found due to the lack of substantial funding, investment, and human resources [ 24 ]. This systematic review provides evidence on the barriers to accessing PHC services among the elderly, highlights the necessity of improving healthcare services for the elderly to achieve SDG3, and informs evidence-based policies to improve accessibility of PHC services for the elderly, particularly in rural areas of Bangladesh. Consequently, this systematic review aimed at exploring and synthesizing the multilevel barriers to accessing and using PHC services by the rural Bangladeshi elderly. Guiding framework: The Social Ecological Model (SEM) Several models, such as the Health Belief Model (HBM), Andersen’s Behavioral Model, and the SEM, are used in health research [ 25 – 28 ]. HBM gives more emphasis on an individual’s desired actions towards health and illness [ 29 ], and Andersen’s revised Behavioral Model predominantly focuses only on health outcomes of an individual but provides less understanding of psychological, social, and cultural mechanisms to utilize healthcare services [ 30 , 31 ]. However, this paper used the SEM over other models, as this model provides multilevel understanding of barriers faced by the elderly in accessing PHC services, a feature that is absent in the other two models. Adopting the ideas from Bronfenbrenner’s Ecological Systems Theory (1977), McLeroy et al. (1988) first systematically applied SEM as a comprehensive framework to health promotion for understanding data from multiple perspectives (see Fig 1 ) [ 27 , 32 , 33 ]. This model conceptualizes the multidimensional determinants at the intrapersonal-level (e.g., age, sex, occupation, income, savings, etc.), the interpersonal-level (e.g., relationship with spouse, family members, and PHC service providers), the institutional-level (e.g., access and facilities in healthcare service centers), the social and community-level (e.g., sociocultural beliefs and community practices), and the policy-level (e.g., scarcity in health benefits coverage, healthcare policies and regulations, etc.) [ 27 , 34 ]. This review adopted the SEM to provide a holistic understanding of barriers faced by the elderly in accessing and using PHC services and organize the findings identified from the studies included in this review. Download: PNG larger image TIFF original image Fig 1. The Social Ecological Model. Adopted from Ma et al. (2017). https://doi.org/10.1371/journal.pone.0358477.g001 Materials and methods Study design This systematic review was registered in the PROSPERO database (the International Prospective Register of Systematic Reviews; with the identification number CRD420251164335), the website of the National Institute for Health and Care Research (NIHR) [ 35 ] (see S1 File ), and conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines as a systematic framework for reporting reviews [ 36 ] (see S2 File ). A systematic review was deemed the most suitable approach to comprehensively understand the barriers faced by the rural elderly in accessing PHC services, given the diverse nature of the literature, rather than merely summarizing findings in relation to a specific research question, as would be done in a narrative review [ 37 ]. Eligibility criteria This review included full-text, peer-reviewed studies that addressed barriers to accessing and using PHC services by the rural elderly (60 years and above) in Bangladesh. The timeline chosen for the selected studies was set from January 2000 to 2026 to identify the barriers to accessing healthcare facilities for the rural elderly in the 21st century and to avoid redundancy and overlapping of prior data. Additionally, the year 2000 signified the commencement of national and global actions for promoting PHC services, and studies limited to 2026 permitted this review to include the latest evidence regarding healthcare access for the elderly. Moreover, only scholarly studies were included in this review, as grey literature contained an absence of peer review, lacked standardized quality assessment, had incomplete or inconsistent research methods and results, increased the risk of bias, and limited accessibility to literature sources. Table 1 includes more detailed information about the eligibility criteria. Download: PNG larger image TIFF original image Table 1. Eligibility criteria for selection of studies. https://doi.org/10.1371/journal.pone.0358477.t001 Search strategies Systematic and manual search strategies were applied to find out the studies included in this review. A Systematic search was undertaken with three electronic databases, including Scopus, PubMed, and ProQuest Sociological Abstracts, and a manual search with Google Scholar and Google on March 3, 2026 (see Table 2 ). The Population, Exposure, Outcome (PEO) Model was used to find out the relationship between exposure and health outcomes [ 38 ], and to develop search terms from the research question: What are the barriers elderly people face in accessing and using PHC services in rural areas of Bangladesh? Keeping in mind the research question, the PEO components identified in the study were: P: elderly (60 years and above); E: barriers; O: outcome (PHC access and utilization) The key search terms included in electronic databases, Google Scholar, and Google were: “healthcare”, “access to primary healthcare services”, “aging and barriers to healthcare facilities”, “limitations of primary healthcare services for the elderly”, and “healthcare impediments for older persons in rural Bangladesh”. The eligibility criteria for screening studies from Google Scholar and Google search were similar to the electronic search (see Table 1 ). Table 2 presents the details of the search terms in the electronic databases and the number of items included in each database. Download: PNG larger image TIFF original image Table 2. Applied search strategy and number of items found in the electronic database. https://doi.org/10.1371/journal.pone.0358477.t002 Selection of the studies A total of 2099 studies were initially identified through database searching, of which 1272 were removed because of duplication. The process of removing duplication was completed using EndNote software (v 21) and an intensive manual process by checking every study, while the rest (827 studies) were taken for screening. The first and second authors of this study (DC and SC) independently screened the titles, abstracts, and objectives of the retrieved publications based on the eligibility criteria outlined above. Additionally, the studies found similar to the eligibility criteria of this study, were moved at full-text review screening step. Among 827 studies, 555 were excluded as those studies did not match the current research topic. Finally, the full text of 272 studies was gone into detail and based on the exclusion criteria (see Table 1 ), the remaining 262 studies were again excluded. The full text of the eligible studies was available from the open-access journals, and if any study was not available, the lead author of that study was requested through email for access. Furthermore, from additional searches with Google and Google Scholar, 9 studies were included from 28 assessed studies. Finally, a total of 19 studies were considered eligible for review based on the inclusion criteria. There was no disagreement between the two investigators about the final decision to select 19 studies. The PRISMA flowchart was adopted to outline the details of the literature search and selection procedure [ 36 ] (see Fig 2 ). Download: PNG larger image TIFF original image Fig 2. PRISMA flowchart for searches of the database and records. Adopted from Page et al. (2020). https://doi.org/10.1371/journal.pone.0358477.g002 Data extraction Data were extracted independently by DC and SC using a standardized Excel checklist form agreed upon by the researchers of this study. Inter-rater reliability was assessed using Cohen’s kappa (κ = 0.75, 95% CI 0.71–0.82), indicating substantial agreement [ 39 ]. Each eligible study was checked by this standardized checklist, including (i) authors name, publication year, and country; (ii) age and sex of the participants; (iii) total sample size; (iv) study design; (v) study timeframe; and (vi) findings of the study (morbidity pattern of the participants, healthcare seeking behavior of the participants, and barriers related to accessing healthcare services or PHC services by the participants) for extracting data and the discrepancies were resolved with consensus by TAS. Assessing the quality of the included studies The quality of the selected studies was assessed before including them in this review study. The quality of quantitative cross-sectional studies was assessed by the checklist of Critical Appraisal Skills Programme (CASP), adopted from Crombie [ 40 ]. The CASP included 12 questions with three possible answers: ‘Yes’, ‘Can’t tell’, and ‘No’ to assess research design, participants, data collection tool, satisfaction of response, measurement of reliability, and statistical significance (see Table 3 ). Download: PNG larger image TIFF original image Table 3. Appraisal tools for studies included in this literature review. https://doi.org/10.1371/journal.pone.0358477.t003 The checklist of CASP for qualitative studies (see Table 3 ) was also adopted to address the quality of the selected qualitative studies [ 41 , 42 ]. The checklist contained 10 questions with possible answers: ‘Yes’, ‘Can’t tell’, and ‘No’ to examine the aim, method, participants, rigor and findings of the qualitative research. For Mixed Methods studies (MMs), 17 questions of the MMs Appraisal Tool (MMAT), version 2018 [ 43 ], were used for critical appraisal of the studies (see Table 3 ). Among the seventeen items, the first two were screening questions, and the rest 15 were related to qualitative, quantitative, and MMs studies with possible answers: ‘Yes’, ‘Can’t tell’, and ‘No’. To assess the quality of the studies included in the systematic review, the three Cochrane risk‑of‑bias levels—low, some concerns, and high—were adopted [ 44 ]. The studies were evaluated based on (1) signaling questions with possible responses: Yes, Can’t tell, and No; and (2) descriptive responses for open‑ended questions. A low risk of bias was assigned when all responses were met; some concerns when one or two responses were unmet; and high risk of bias when three or more responses were unmet. DC and SC independently assessed the quality of the included studies, and discrepancies were resolved through consensus meetings, during which DC and SC justified their ratings outlined in the appraisal tools. Inter-rater reliability was assessed using Cohen’s kappa (κ = 0.75, 95% CI 0.71–0.82), indicating substantial agreement [ 39 ].In case of disagreement, other co-authors were consulted to negotiate the rankings and make the final decision. Data synthesis In recent years, several methods, such as meta-analysis, meta-synthesis, and thematic synthesis, have emerged to synthesize data from existing literature related to health research [ 45 , 46 ]. Meta-analysis focuses on objective idealism (quantitative data synthesis), meta-synthesis deals with individual studies under review (qualitative data synthesis), and thematic synthesis accounts for constant comparison methods (multiple approaches to the study) [ 46 , 47 ]. However, the thematic synthesis approach is widely preferred to arrange the free codes of findings into descriptive themes and later interpreted to analytical themes [ 46 , 47 ]. Therefore, as the review included multiple natures of st
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