{"paper_id":"38ebabcf-9f07-4f3e-bed2-7bd05bf26898","body_text":"Role of pension and insurance schemes in healthcare utilisation and catastrophic health expenditure among rural elderly in Bengaluru | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Role of pension and insurance schemes in healthcare utilisation and catastrophic health expenditure among rural elderly in Bengaluru Kimberley Maria D'Souza, Pretesh Rohan Kiran This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8878988/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Background : Financial vulnerability is a major barrier to healthcare access among the rural elderly in India. Pension and government insurance schemes aim to improve financial risk protection, yet their influence on healthcare utilisation and catastrophic health expenditure remains uncertain. Objectives : To estimate the coverage of pension and insurance schemes among the rural elderly, assess their association with healthcare utilisation and catastrophic health expenditure, and explore stakeholder perspectives on accessibility and effectiveness. Methodology : This study adopted a convergent parallel mixed-methods design, in which quantitative and qualitative data were collected concurrently, analysed separately and integrated during interpretation to enable triangulation of findings. It was conducted from December 2024 to February 2025 in six rural villages of Bengaluru. One hundred elderly individuals aged ≥60 years attending geriatric outreach clinics were recruited using convenience sampling. In-depth interviews with local stakeholders were analysed thematically to explore contextual barriers to scheme utilisation. Associations were assessed using Fisher’s exact test and logistic regression to estimate adjusted odds ratios. Results : Fifty-six percent of participants received old age pensions and 31% had health insurance coverage. Twenty-five percent experienced catastrophic health expenditure. Pension receipt was associated with higher regular healthcare utilisation (OR 3.0, p = 0.089). In adjusted analysis, pension receipt was associated with lower odds of catastrophic expenditure (AOR 0.42, 95% CI 0.16–1.06), whereas insurance coverage showed higher odds (AOR 2.19, 95% CI 0.84–5.73); neither was statistically significant. Qualitative interviews highlighted irregular pension disbursement, documentation barriers and limited awareness of scheme entitlements. Conclusion : Pension receipt showed a trend towards improved healthcare utilisation and reduced financial hardship, while insurance coverage did not demonstrate significant protection against catastrophic expenditure. Strengthening benefit coverage and implementation mechanisms may enhance financial risk protection for rural elderly populations. Aged Health Expenditures Insurance Health Pensions Rural Population Introduction India is undergoing a demographic transition marked by a steady rise in the elderly population. According to the United Nations World Population Prospects 2022, the proportion of individuals aged 60 years and above continues to increase and is projected to rise substantially in the coming decades [ 1 ]. The Longitudinal Ageing Study in India (LASI) Wave 1 reported that nearly 10% of India’s population is aged 60 years and above, with a significant rural concentration [ 2 ]. Ageing is accompanied by an increased burden of chronic non-communicable diseases and rising healthcare utilisation [ 9 , 12 , 13 ]. Older adults in rural settings frequently depend on family support and social assistance schemes for financial security [ 10 , 11 ]. Out-of-pocket expenditure remains a major component of healthcare financing in India. National Health Accounts estimates indicate that households continue to bear a substantial share of health expenditure [ 3 ]. Catastrophic health expenditure is defined as health spending exceeding 40% of a household’s capacity to pay and represents a key indicator of financial risk protection [ 4 ]. The Government of India has introduced multiple initiatives to address elderly health and financial vulnerability. The National Programme for Health Care of the Elderly aims to improve access to dedicated geriatric services [ 6 ]. Publicly financed insurance schemes, particularly Ayushman Bharat Pradhan Mantri Jan Arogya Yojana, seek to reduce financial hardship by providing secondary and tertiary care coverage [ 7 ]. However, recent evaluations suggest that insurance enrolment does not consistently eliminate out-of-pocket spending [ 5 , 8 ]. Old age pension schemes provide predictable income support and may positively influence healthcare-seeking behaviour. Evidence examining the combined role of pension and insurance coverage among rural elderly populations remains limited. This study aimed to assess the association between pension and insurance coverage, healthcare utilisation and catastrophic health expenditure among the rural elderly in Bengaluru, alongside qualitative exploration of implementation challenges. While quantitative analyses can identify associations between financial benefit schemes and healthcare utilisation or expenditure, they are limited in explaining contextual and implementation-related factors influencing scheme access. Therefore, a qualitative component was incorporated to explore stakeholder perspectives on accessibility, awareness and administrative challenges, providing complementary insights and justifying the mixed-methods approach. Methodology Study Design and Setting A mixed-methods study was conducted in six rural villages under the field practice area of a tertiary care medical college in Bengaluru between December 2024 and February 2025. This study employed a convergent parallel mixed-methods design (QUAN + QUAL), wherein quantitative and qualitative data were collected during the same study period, analysed independently, and subsequently integrated during interpretation. The quantitative component was dominant and assessed associations between pension and insurance coverage, healthcare utilisation and catastrophic health expenditure, while the qualitative component provided contextual explanations for observed patterns. Quantitative Component Elderly individuals aged 60 years and above attending monthly geriatric outreach clinics were recruited using convenience sampling. Sample size was calculated using the formula n= Zα 2 p (1- p) / e 2 where, n = sample size Zα =1.96 at 95% confidence interval P = 50% e = allowable error If e = 10%, n = 97 ≈ 100 A total of 100 participants were included in the study. Data collection took place from December 2024 to February 2025. The study population included patients aged 60 years and above attending the monthly geriatric clinics held in six different villages by our department. A convenience sampling technique was used to recruit participants. A pretested face validated structured interview schedule was administered. Our study tool included the socio-demographic details, household economics, pension and health-insurance coverage, patterns of healthcare use and spending, and participants’ awareness and perceptions of related government schemes and access challenges. The inclusion criteria were elderly patients (above 60 years old) who are attending the Geriatric Clinics run by the Department of Community Health of our institution. The exclusion criteria were Patients with any moribund or terminal illness or intellectual disability. Qualitative Component For the qualitative component, in-depth interviews were conducted with members of the panchayat from the same six villages. Participants were purposively selected based on their involvement in local governance and familiarity with welfare scheme implementation. A topic guide was used. Interviews were conducted either in English or local language and then translated ad verbatim into English. Interviews were conducted until thematic saturation was achieved, at which point no new themes emerged from subsequent interviews. For the qualitative part of our study, convenience sampling was used. Transcripts were coded inductively and themes and sub-themes were generated through iterative reading and discussion to enhance analytical rigour. Ethical approval for the study was obtained from the Authors’ Institutional Ethics Review Board (IERB), prior to its commencement. Informed consent was taken from all the patients. Statistical Analysis Data were collected using Epicollect5 and exported to Microsoft Excel for cleaning and coding. Statistical analysis was performed using Jamovi version 2.4.11. Sociodemographic characteristics were summarised using frequencies and proportions for categorical variables and mean with standard deviation or median with interquartile range for continuous variables, as appropriate. Catastrophic health expenditure was defined as out-of-pocket expenditure ≥40% of household capacity to pay, calculated as total household income minus subsistence expenditure, in accordance with WHO methodology. Income lower bounds were used for participants reporting income in strata to derive conservative estimates. Associations between financial benefit schemes and healthcare utilisation were assessed using Fisher’s exact test. Associations between pension and insurance coverage and catastrophic health expenditure were examined using unadjusted odds ratios with 95% confidence intervals. Multivariable logistic regression analysis was performed to estimate adjusted odds ratios, including pension and insurance status as independent variables. A p-value of <0.05 was considered statistically significant. For qualitative analysis, interview transcripts were coded inductively. Themes and sub-themes were generated through iterative review and consensus. Triangulation was achieved by comparing and integrating quantitative results with qualitative themes during interpretation, thereby enabling a more comprehensive understanding of scheme utilisation and financial protection. Results Qualitative component- Sociodemographic Characteristics Table 1 presents the sociodemographic characteristics of the 100 elderly participants from rural Bengaluru. The mean age of participants was 67.5 years (±7.6), with a predominance of female participants (74%). Most were homemakers (56%), followed by daily wage workers (30%) and those engaged in agriculture (20%). A smaller proportion were unemployed (11%). In terms of family structure, 61% lived in nuclear families, 29% in joint families, and 10% in extended family settings. Regarding marital status, a large majority (86%) were currently married, while 11% were widows and 3% were widowers. Table 1: Sociodemographic details of the participants Sociodemographic variable Rural (n=100) Mean age of patients (in years) 67.5 ± 7.6 Gender of patients Female 74% Male 26% Occupation Homemaker 56% Agriculture 20% Daily wage worker 30% Unemployed 11% Type of Family Nuclear 61% Joint 29% Extended 10% Marital Status Married 86% Widow 11% Widower 3% Healthcare Utilisation Table 2 shows that more than half of the participants (56%) reported receiving old age pension benefits, while 31% had health insurance coverage. We see that the receipt of old age pension was associated with higher regular healthcare utilisation, although the association did not reach statistical significance. Health insurance coverage was not significantly associated with utilisation. Table 2: Association between financial benefit schemes and regular healthcare utilisation (n = 100) Variable Irregular Visits Regular Visits Unadjusted OR p-value Old Age Pension – No (n = 44) 10 34 Reference – Old Age Pension – Yes (n = 56) 5 51 3.00 0.089 Health Insurance – No (n = 69) 9 60 Reference – Health Insurance – Yes (n = 31) 6 25 0.63 0.545 p-value <0.05 was considered statistically significant Catastrophic Health Expenditure Twenty-five participants (25%) experienced catastrophic health expenditure. Table 3: Association of pension and insurance with catastrophic health expenditure (n = 100) Variable No CHE CHE Unadjusted OR p-value Adjusted OR (95% CI) p-value Old Age Pension – No 29 15 Reference – Reference – Old Age Pension – Yes 46 10 0.42 0.102 0.42 (0.16–1.06) 0.067 Health Insurance – No 55 14 Reference – Reference – Health Insurance – Yes 20 11 2.16 0.135 2.19 (0.84–5.73) 0.109 p-value <0.05 was considered statistically significant Table 3 shows that receipt of old age pension was associated with lower odds of catastrophic health expenditure in both unadjusted and adjusted analyses, although the association did not reach statistical significance. Health insurance coverage was associated with higher odds of catastrophic expenditure, but this association was not statistically significant after adjustment. These quantitative findings were further explored through qualitative interviews to understand contextual barriers influencing scheme utilisation and financial protection. Qualitative Component- Themes and sub-themes Irregular Pension Disbursement Participants frequently highlighted delays and inconsistencies in the disbursement of pension funds. These irregularities caused financial instability among elderly individuals, affecting their ability to access timely healthcare. “ Many elderly find it difficult to manage without regular pensions. When they receive pensions, they are more likely to visit clinics for check-ups .” (IDI 2) Administrative Barriers Key informants reported challenges in accessing government schemes due to bureaucratic hurdles. Common issues included errors in income and caste certificates, and technical difficulties related to Aadhaar-PAN linking. These obstacles delayed or prevented eligible individuals from availing of their entitled benefits. “ There are so many problems with Aadhaar linking and income proof—by the time it gets sorted, the elderly person has already lost interest or hope .” (IDI 3) Accessibility Challenges and Limited Awareness about Schemes Stakeholders observed that elderly individuals faced significant challenges in managing banking transactions, especially due to lack of digital literacy and physical access to financial institutions. Moreover, confusion about scheme eligibility and documentation requirements further hindered participation. “ Old people struggle to withdraw money from banks. Earlier, the post office system was better for them.” (IDI 5) Discussion This study examined the relationship between pension and insurance schemes, healthcare utilisation and catastrophic health expenditure among the rural elderly. The integration of quantitative and qualitative findings enabled triangulation of results. While quantitative analysis demonstrated non-significant associations between financial benefit schemes and catastrophic health expenditure, qualitative insights revealed contextual barriers such as irregular pension disbursement, documentation challenges and limited awareness, which may explain the lack of measurable financial protection. Receipt of old age pension demonstrated a positive association with regular healthcare utilisation, although the association did not reach statistical significance. Income support may reduce financial hesitation in seeking care, particularly for chronic disease management. Similar associations between financial stability and healthcare utilisation have been observed in national ageing datasets [ 14 ]. One-quarter of participants experienced catastrophic health expenditure. Pension receipt was associated with lower odds of catastrophic expenditure in both unadjusted and adjusted analyses, although statistical significance was not achieved. This trend suggests a possible protective effect of predictable income support, which has been highlighted in prior studies evaluating social assistance mechanisms for older adults [ 10 , 15 ]. Health insurance coverage was associated with higher odds of catastrophic expenditure, though this finding was not statistically significant after adjustment. Similar observations have been reported in evaluations of publicly financed insurance schemes in India, where enrolment did not uniformly translate into effective financial risk protection [ 5 , 8 ]. Persistent out-of-pocket payments despite insurance coverage may reflect partial benefit coverage, exclusions, indirect costs or supply-side constraints. The qualitative findings complemented the quantitative results by highlighting implementation-level challenges that potentially dilute the intended financial protection benefits of pension and insurance schemes. National Health Accounts continue to report substantial household out-of-pocket expenditure despite expansion of financial protection initiatives [ 3 ]. These findings reinforce concerns that insurance enrolment alone may be insufficient to eliminate financial vulnerability among elderly populations. Qualitative findings in this study further highlighted irregular pension disbursement, documentation barriers and limited awareness of entitlements as systemic challenges. Prior studies examining elderly welfare schemes have reported similar operational bottlenecks and awareness gaps [ 14 , 15 ]. Overall, the findings suggest that while pension schemes may facilitate healthcare utilisation and potentially reduce financial stress, current insurance mechanisms may not fully achieve their intended financial protection objectives. We acknowledge limitations such as small sample size and use of convenience sampling and hence larger community-based studies may be required to better quantify these relationships. Although the qualitative component provided contextual insights, the limited number of interviews may restrict the depth of thematic exploration. Nevertheless, the mixed-methods design enabled a comprehensive assessment of both measurable financial outcomes and contextual implementation barriers, thereby contributing to the growing evidence base on elderly healthcare utilisation and financial vulnerability in rural India. Conclusion Old age pension receipt showed a positive association with healthcare utilisation and a trend towards reduced catastrophic health expenditure among the rural elderly, although statistical significance was not achieved. Health insurance coverage did not demonstrate measurable financial protection in this population. Strengthening benefit design, reimbursement mechanisms and implementation efficiency may be necessary to enhance financial risk protection among vulnerable elderly groups. Declarations There is no conflict of interest. This research received no specific grant from any funding agency. Acknowledgement : None Data Availability Statement : The datasets generated and analysed during the current study are not publicly available due to confidentiality of participant information but are available from the corresponding author on reasonable request. Ethical Approval : The study was approved by the Institutional Ethics Committee of St John’s Medical College, Bengaluru, India. Accordance : The study was conducted in accordance with the ethical standards of the Institutional Ethics Committee of St John’s Medical College and in line with the principles of the Declaration of Helsinki. Consent to Participate : Written informed consent was obtained from all participants prior to their inclusion in the study. Consent to Publish: Not applicable, as the manuscript does not contain any individual person’s identifiable data. Author Contributions: K.M.D. contributed to the conception of the study, protocol development, data collection, statistical analysis, interpretation of findings and manuscript drafting. P.R.K. contributed to the conception, protocol development and critical review of the manuscript. Both authors read and approved the final manuscript. References United Nations Department of Economic and Social Affairs. World Population Prospects 2022. New York: United Nations; 2022. International Institute for Population Sciences. Longitudinal Ageing Study in India (LASI) Wave 1 Report. Mumbai: IIPS; 2020. National Health Accounts Technical Secretariat. National Health Accounts Estimates for India 2019–20. New Delhi: Ministry of Health and Family Welfare; 2023. Xu K, Evans DB, Kawabata K, Zeramdini R, Klavus J, Murray CJL. Household catastrophic health expenditure: a multicountry analysis. Lancet. 2003;362:111–117. doi:10.1016/S0140-6736(03)13861-5. Prinja S, Bahuguna P, Gupta I, Chowdhury S, Trivedi M. Role of insurance in determining utilisation of healthcare and financial risk protection in India. PLoS One. 2019;14:e0211793. doi:10.1371/journal.pone.0211793. Government of India. National Programme for Health Care of the Elderly: Operational Guidelines. New Delhi: Ministry of Health and Family Welfare; 2011. National Health Authority. Ayushman Bharat PM-JAY Annual Report 2023–24. New Delhi: Government of India; 2024. Joe W, Kumar A, Rajpal S, Mishra US. Universal health coverage in India: Progress achieved and the way forward. Indian J Med Res. 2022;155:123–133. Lena A, Ashok K, Padma M, Kamath V, Kamath A. Health and social problems of the elderly: A cross-sectional study in Udupi Taluk, Karnataka. Indian J Community Med. 2009;34:131–134. Rajan SI. Social assistance for poor elderly: How effective? Econ Polit Wkly. 2001;36:613–617. Rajan SI, Kumar S. Living arrangements among Indian elderly: New evidence from National Family Health Survey. Econ Polit Wkly. 2003;38:75–80. Gupta PC, Maulik PK, Pednekar PK, Saxena S. Concurrent alcohol and tobacco use among middle-aged and elderly population in Mumbai. Natl Med J India. 2005;18:88–91. Vaz M, Bharathi AV. Perceptions of intensity of specific physical activities in Bangalore, South India. J Assoc Physicians India. 2004;52:541–544. Goswami AK, Ramadass S, Kalaivani M, Nongkynrih B, Kant S, Gupta SK. Awareness and utilisation of social welfare schemes among elderly persons. J Family Med Prim Care. 2019;8:960–965. Rajan SI, Mishra US, Sarma PS. Ageing in Kerala: State Level and District Level Trends. UNFPA Report. 2019. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 06 May, 2026 Reviews received at journal 31 Mar, 2026 Reviewers agreed at journal 31 Mar, 2026 Reviews received at journal 30 Mar, 2026 Reviewers agreed at journal 30 Mar, 2026 Reviews received at journal 19 Mar, 2026 Reviewers agreed at journal 13 Mar, 2026 Reviewers invited by journal 11 Mar, 2026 Editor assigned by journal 01 Mar, 2026 Submission checks completed at journal 27 Feb, 2026 First submitted to journal 27 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-8878988\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":false,\"archivedVersions\":[],\"articleType\":\"Research Article\",\"associatedPublications\":[],\"authors\":[{\"id\":604330417,\"identity\":\"4cfbbf15-fe9d-45d6-9534-4a41b21617af\",\"order_by\":0,\"name\":\"Kimberley Maria D'Souza\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"St.John's Medical College Hospital\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Kimberley\",\"middleName\":\"Maria\",\"lastName\":\"D'Souza\",\"suffix\":\"\"},{\"id\":604330425,\"identity\":\"b4963382-b52e-455f-b969-d542d2cdfd07\",\"order_by\":1,\"name\":\"Pretesh Rohan Kiran\",\"email\":\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+0lEQVRIie3OsWrDMBCA4TMCeVHjVUbQZzgjkBsIeZaUgKcEOnV2MXiKMydQ6Ft0LmjoUjp3yBAoeFaXkkFDLUOXEqtkC0T/IAlxHxxAKHS+vSB1lwEgwN0LveNR+UuiDeAJxL0Ic6P8n41yoV/3xu7kSOj2c2JtnIhGG7jbDZLxurh92NatoqMil8saSfr4XnDAdpDgG8uqq1JPKAMlliUS/Fio7l97SPJVWetI/C1ubE+k8RMWVUC1oowpAbQnyH1kvKLZtqm17Mh92tSSpJuF4jMPyRnZm4PV2dMqfuYHez1PeLeYsZ7F/n7M+3M2CI6QqWc4FAqFLrQfOFROs6JMLUEAAAAASUVORK5CYII=\",\"orcid\":\"\",\"institution\":\"St.John's Medical College Hospital\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"Pretesh\",\"middleName\":\"Rohan\",\"lastName\":\"Kiran\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2026-02-14 09:54:33\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-8878988/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-8878988/v1\",\"draftVersion\":[],\"editorialEvents\":[],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":104781418,\"identity\":\"32a1d6dd-ed0a-4aad-8104-18d365edef7d\",\"added_by\":\"auto\",\"created_at\":\"2026-03-17 07:55:38\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":768079,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8878988/v1/3d8b9644-71b3-4ba5-965b-2dfe10246200.pdf\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"Role of pension and insurance schemes in healthcare utilisation and catastrophic health expenditure among rural elderly in Bengaluru\",\"fulltext\":[{\"header\":\"Introduction\",\"content\":\"\\u003cp\\u003eIndia is undergoing a demographic transition marked by a steady rise in the elderly population. According to the United Nations World Population Prospects 2022, the proportion of individuals aged 60 years and above continues to increase and is projected to rise substantially in the coming decades [\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e]. The Longitudinal Ageing Study in India (LASI) Wave 1 reported that nearly 10% of India\\u0026rsquo;s population is aged 60 years and above, with a significant rural concentration [\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eAgeing is accompanied by an increased burden of chronic non-communicable diseases and rising healthcare utilisation [\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e]. Older adults in rural settings frequently depend on family support and social assistance schemes for financial security [\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eOut-of-pocket expenditure remains a major component of healthcare financing in India. National Health Accounts estimates indicate that households continue to bear a substantial share of health expenditure [\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e]. Catastrophic health expenditure is defined as health spending exceeding 40% of a household\\u0026rsquo;s capacity to pay and represents a key indicator of financial risk protection [\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eThe Government of India has introduced multiple initiatives to address elderly health and financial vulnerability. The National Programme for Health Care of the Elderly aims to improve access to dedicated geriatric services [\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e]. Publicly financed insurance schemes, particularly Ayushman Bharat Pradhan Mantri Jan Arogya Yojana, seek to reduce financial hardship by providing secondary and tertiary care coverage [\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e]. However, recent evaluations suggest that insurance enrolment does not consistently eliminate out-of-pocket spending [\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eOld age pension schemes provide predictable income support and may positively influence healthcare-seeking behaviour. Evidence examining the combined role of pension and insurance coverage among rural elderly populations remains limited.\\u003c/p\\u003e \\u003cp\\u003eThis study aimed to assess the association between pension and insurance coverage, healthcare utilisation and catastrophic health expenditure among the rural elderly in Bengaluru, alongside qualitative exploration of implementation challenges. While quantitative analyses can identify associations between financial benefit schemes and healthcare utilisation or expenditure, they are limited in explaining contextual and implementation-related factors influencing scheme access. Therefore, a qualitative component was incorporated to explore stakeholder perspectives on accessibility, awareness and administrative challenges, providing complementary insights and justifying the mixed-methods approach.\\u003c/p\\u003e\"},{\"header\":\"Methodology\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eStudy Design and Setting\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eA mixed-methods study was conducted in six rural villages under the field practice area of a tertiary care medical college in Bengaluru between December 2024 and February 2025. This study employed a convergent parallel mixed-methods design (QUAN + QUAL), wherein quantitative and qualitative data were collected during the same study period, analysed independently, and subsequently integrated during interpretation. The quantitative component was dominant and assessed associations between pension and insurance coverage, healthcare utilisation and catastrophic health expenditure, while the qualitative component provided contextual explanations for observed patterns.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eQuantitative Component\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eElderly individuals aged 60 years and above attending monthly geriatric outreach clinics were recruited using convenience sampling. Sample size was calculated using the formula\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003en= Z\\u0026alpha;\\u003csup\\u003e2\\u003c/sup\\u003e p (1- p) / e\\u003csup\\u003e2\\u003c/sup\\u003e\\u003c/em\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003ewhere,\\u003c/p\\u003e\\n\\u003cp\\u003en = sample size\\u003c/p\\u003e\\n\\u003cp\\u003eZ\\u0026alpha; =1.96 at 95% confidence interval\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eP\\u003c/em\\u003e = 50%\\u003c/p\\u003e\\n\\u003cp\\u003ee = allowable error\\u003c/p\\u003e\\n\\u003cp\\u003eIf e = 10%, n = 97\\u0026nbsp;\\u0026asymp; 100\\u003c/p\\u003e\\n\\u003cp\\u003eA total of 100 participants were included in the study. Data collection took place from December 2024 to February 2025. The study population included patients aged 60 years and above attending the monthly geriatric clinics held in six different villages by our department. A convenience sampling technique was used to recruit participants. A pretested face validated structured interview schedule was administered.\\u0026nbsp;Our study\\u003cstrong\\u003e\\u0026nbsp;\\u003c/strong\\u003etool included the\\u003cstrong\\u003e\\u0026nbsp;\\u003c/strong\\u003esocio-demographic details, household economics, pension and health-insurance coverage, patterns of healthcare use and spending, and participants\\u0026rsquo; awareness and perceptions of related government schemes and access challenges. The inclusion criteria\\u0026nbsp;were\\u0026nbsp;elderly patients (above 60 years old) who are attending the Geriatric Clinics run by the Department of Community Health of our institution. The exclusion criteria were Patients with any moribund or terminal illness or intellectual disability.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eQualitative Component\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eFor the qualitative component, in-depth interviews were conducted with members of the panchayat from the same six villages. Participants were purposively selected based on their involvement in local governance and familiarity with welfare scheme implementation. A topic guide was used. Interviews were conducted either in English or local language and then translated ad verbatim into English. Interviews were conducted until thematic saturation was achieved, at which point no new themes emerged from subsequent interviews. For the qualitative part of our study, convenience sampling was used. Transcripts were coded inductively and themes and sub-themes were generated through iterative reading and discussion to enhance analytical rigour.\\u003c/p\\u003e\\n\\u003cp\\u003eEthical approval for the study was obtained from the Authors\\u0026rsquo; Institutional Ethics Review Board (IERB), prior to its commencement. Informed consent was taken from all the patients.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eStatistical Analysis\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eData were collected using Epicollect5 and exported to Microsoft Excel for cleaning and coding. Statistical analysis was performed using Jamovi version 2.4.11.\\u003c/p\\u003e\\n\\u003cp\\u003eSociodemographic characteristics were summarised using frequencies and proportions for categorical variables and mean with standard deviation or median with interquartile range for continuous variables, as appropriate.\\u003c/p\\u003e\\n\\u003cp\\u003eCatastrophic health expenditure was defined as out-of-pocket expenditure \\u0026ge;40% of household capacity to pay, calculated as total household income minus subsistence expenditure, in accordance with WHO methodology. Income lower bounds were used for participants reporting income in strata to derive conservative estimates.\\u003c/p\\u003e\\n\\u003cp\\u003eAssociations between financial benefit schemes and healthcare utilisation were assessed using Fisher\\u0026rsquo;s exact test. Associations between pension and insurance coverage and catastrophic health expenditure were examined using unadjusted odds ratios with 95% confidence intervals. Multivariable logistic regression analysis was performed to estimate adjusted odds ratios, including pension and insurance status as independent variables. A p-value of \\u0026lt;0.05 was considered statistically significant.\\u003c/p\\u003e\\n\\u003cp\\u003eFor qualitative analysis, interview transcripts were coded inductively. Themes and sub-themes were generated through iterative review and consensus. Triangulation was achieved by comparing and integrating quantitative results with qualitative themes during interpretation, thereby enabling a more comprehensive understanding of scheme utilisation and financial protection.\\u003c/p\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eQualitative component- Sociodemographic Characteristics\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eTable 1\\u003c/strong\\u003e presents the sociodemographic characteristics of the 100 elderly participants from rural Bengaluru. The mean age of participants was 67.5 years (\\u0026plusmn;7.6), with a predominance of female participants (74%). Most were homemakers (56%), followed by daily wage workers (30%) and those engaged in agriculture (20%). A smaller proportion were unemployed (11%). In terms of family structure, 61% lived in nuclear families, 29% in joint families, and 10% in extended family settings. Regarding marital status, a large majority (86%) were currently married, while 11% were widows and 3% were widowers.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eTable 1: Sociodemographic details of the participants\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003ctable border=\\\"1\\\" cellspacing=\\\"0\\\" cellpadding=\\\"0\\\" align=\\\"\\\"\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 282px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eSociodemographic variable\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 134px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eRural (n=100)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 282px;\\\"\\u003e\\n \\u003cp\\u003eMean age of patients (in years)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 134px;\\\"\\u003e\\n \\u003cp\\u003e67.5 \\u0026plusmn; 7.6\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 282px;\\\"\\u003e\\n \\u003cp\\u003eGender of patients\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 134px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 282px;\\\"\\u003e\\n \\u003cp\\u003eFemale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 134px;\\\"\\u003e\\n \\u003cp\\u003e74%\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 282px;\\\"\\u003e\\n \\u003cp\\u003eMale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 134px;\\\"\\u003e\\n \\u003cp\\u003e26%\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 282px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eOccupation\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 134px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 282px;\\\"\\u003e\\n \\u003cp\\u003eHomemaker\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 134px;\\\"\\u003e\\n \\u003cp\\u003e56%\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 282px;\\\"\\u003e\\n \\u003cp\\u003eAgriculture\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 134px;\\\"\\u003e\\n \\u003cp\\u003e20%\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 282px;\\\"\\u003e\\n \\u003cp\\u003eDaily wage worker\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 134px;\\\"\\u003e\\n \\u003cp\\u003e30%\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 282px;\\\"\\u003e\\n \\u003cp\\u003eUnemployed\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 134px;\\\"\\u003e\\n \\u003cp\\u003e11%\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 282px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eType of Family\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 134px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 282px;\\\"\\u003e\\n \\u003cp\\u003eNuclear\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 134px;\\\"\\u003e\\n \\u003cp\\u003e61%\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 282px;\\\"\\u003e\\n \\u003cp\\u003eJoint\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 134px;\\\"\\u003e\\n \\u003cp\\u003e29%\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 282px;\\\"\\u003e\\n \\u003cp\\u003eExtended\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 134px;\\\"\\u003e\\n \\u003cp\\u003e10%\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 282px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eMarital Status\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 134px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 282px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;Married\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 134px;\\\"\\u003e\\n \\u003cp\\u003e86%\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 282px;\\\"\\u003e\\n \\u003cp\\u003eWidow\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 134px;\\\"\\u003e\\n \\u003cp\\u003e11%\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 282px;\\\"\\u003e\\n \\u003cp\\u003eWidower\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 134px;\\\"\\u003e\\n \\u003cp\\u003e3%\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eHealthcare Utilisation\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eTable 2 shows that more than half of the participants (56%) reported receiving old age pension benefits, while 31% had health insurance coverage. We see that the receipt of old age pension was associated with higher regular healthcare utilisation, although the association did not reach statistical significance. Health insurance coverage was not significantly associated with utilisation.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eTable 2: Association between financial benefit schemes and regular healthcare utilisation (n = 100)\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003ctable border=\\\"1\\\" cellpadding=\\\"0\\\"\\u003e\\n \\u003cthead\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eVariable\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eIrregular Visits\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eRegular Visits\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eUnadjusted OR\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003ep-value\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/thead\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eOld Age Pension \\u0026ndash; No (n = 44)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e10\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e34\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eReference\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u0026ndash;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eOld Age Pension \\u0026ndash; Yes (n = 56)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e5\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e51\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e3.00\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e0.089\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eHealth Insurance \\u0026ndash; No (n = 69)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e9\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e60\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eReference\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u0026ndash;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eHealth Insurance \\u0026ndash; Yes (n = 31)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e6\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e25\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e0.63\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e0.545\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003e\\u003cem\\u003ep-value \\u0026lt;0.05 was considered statistically significant\\u003c/em\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eCatastrophic Health Expenditure\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eTwenty-five participants (25%) experienced catastrophic health expenditure.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eTable 3: Association of pension and insurance with catastrophic health expenditure (n = 100)\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003ctable border=\\\"1\\\" cellpadding=\\\"0\\\"\\u003e\\n \\u003cthead\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eVariable\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eNo CHE\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eCHE\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eUnadjusted OR\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003ep-value\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eAdjusted OR (95% CI)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003ep-value\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/thead\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eOld Age Pension \\u0026ndash; No\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e29\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e15\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eReference\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u0026ndash;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eReference\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u0026ndash;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eOld Age Pension \\u0026ndash; Yes\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e46\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e10\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e0.42\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e0.102\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e0.42 (0.16\\u0026ndash;1.06)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e0.067\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eHealth Insurance \\u0026ndash; No\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e55\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e14\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eReference\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u0026ndash;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eReference\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u0026ndash;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eHealth Insurance \\u0026ndash; Yes\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e20\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e11\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e2.16\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e0.135\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e2.19 (0.84\\u0026ndash;5.73)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e0.109\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003e\\u003cem\\u003ep-value \\u0026lt;0.05 was considered statistically significant\\u003c/em\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eTable 3 shows that receipt of old age pension was associated with lower odds of catastrophic health expenditure in both unadjusted and adjusted analyses, although the association did not reach statistical significance. Health insurance coverage was associated with higher odds of catastrophic expenditure, but this association was not statistically significant after adjustment.\\u003c/p\\u003e\\n\\u003cp\\u003eThese quantitative findings were further explored through qualitative interviews to understand contextual barriers influencing scheme utilisation and financial protection.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eQualitative Component- Themes and sub-themes\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003col\\u003e\\n \\u003cli\\u003e\\u003cstrong\\u003eIrregular Pension Disbursement\\u003c/strong\\u003e\\u003c/li\\u003e\\n\\u003c/ol\\u003e\\n\\u003cp\\u003eParticipants frequently highlighted delays and inconsistencies in the disbursement of pension funds. These irregularities caused financial instability among elderly individuals, affecting their ability to access timely healthcare.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u0026ldquo;\\u003cem\\u003eMany elderly find it difficult to manage without regular pensions. When they receive pensions, they are more likely to visit clinics for check-ups\\u003c/em\\u003e.\\u0026rdquo; (IDI 2)\\u003c/p\\u003e\\n\\u003col start=\\\"2\\\"\\u003e\\n \\u003cli\\u003e\\u003cstrong\\u003eAdministrative Barriers\\u003c/strong\\u003e\\u003c/li\\u003e\\n\\u003c/ol\\u003e\\n\\u003cp\\u003eKey informants reported challenges in accessing government schemes due to bureaucratic hurdles. Common issues included errors in income and caste certificates, and technical difficulties related to Aadhaar-PAN linking. These obstacles delayed or prevented eligible individuals from availing of their entitled benefits.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u0026ldquo;\\u003cem\\u003eThere are so many problems with Aadhaar linking and income proof\\u0026mdash;by the time it gets sorted, the elderly person has already lost interest or hope\\u003c/em\\u003e.\\u0026rdquo; (IDI 3)\\u003c/p\\u003e\\n\\u003col start=\\\"3\\\"\\u003e\\n \\u003cli\\u003e\\u003cstrong\\u003eAccessibility Challenges and Limited Awareness about Schemes\\u003c/strong\\u003e\\u003c/li\\u003e\\n\\u003c/ol\\u003e\\n\\u003cp\\u003eStakeholders observed that elderly individuals faced significant challenges in managing banking transactions, especially due to lack of digital literacy and physical access to financial institutions. Moreover, confusion about scheme eligibility and documentation requirements further hindered participation.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u0026ldquo;\\u003cem\\u003eOld people struggle to withdraw money from banks. Earlier, the post office system was better for them.\\u0026rdquo;\\u003c/em\\u003e (IDI 5)\\u003c/p\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eThis study examined the relationship between pension and insurance schemes, healthcare utilisation and catastrophic health expenditure among the rural elderly. The integration of quantitative and qualitative findings enabled triangulation of results. While quantitative analysis demonstrated non-significant associations between financial benefit schemes and catastrophic health expenditure, qualitative insights revealed contextual barriers such as irregular pension disbursement, documentation challenges and limited awareness, which may explain the lack of measurable financial protection.\\u003c/p\\u003e \\u003cp\\u003eReceipt of old age pension demonstrated a positive association with regular healthcare utilisation, although the association did not reach statistical significance. Income support may reduce financial hesitation in seeking care, particularly for chronic disease management. Similar associations between financial stability and healthcare utilisation have been observed in national ageing datasets [\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eOne-quarter of participants experienced catastrophic health expenditure. Pension receipt was associated with lower odds of catastrophic expenditure in both unadjusted and adjusted analyses, although statistical significance was not achieved. This trend suggests a possible protective effect of predictable income support, which has been highlighted in prior studies evaluating social assistance mechanisms for older adults [\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eHealth insurance coverage was associated with higher odds of catastrophic expenditure, though this finding was not statistically significant after adjustment. Similar observations have been reported in evaluations of publicly financed insurance schemes in India, where enrolment did not uniformly translate into effective financial risk protection [\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e]. Persistent out-of-pocket payments despite insurance coverage may reflect partial benefit coverage, exclusions, indirect costs or supply-side constraints. The qualitative findings complemented the quantitative results by highlighting implementation-level challenges that potentially dilute the intended financial protection benefits of pension and insurance schemes.\\u003c/p\\u003e \\u003cp\\u003eNational Health Accounts continue to report substantial household out-of-pocket expenditure despite expansion of financial protection initiatives [\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e]. These findings reinforce concerns that insurance enrolment alone may be insufficient to eliminate financial vulnerability among elderly populations.\\u003c/p\\u003e \\u003cp\\u003eQualitative findings in this study further highlighted irregular pension disbursement, documentation barriers and limited awareness of entitlements as systemic challenges. Prior studies examining elderly welfare schemes have reported similar operational bottlenecks and awareness gaps [\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eOverall, the findings suggest that while pension schemes may facilitate healthcare utilisation and potentially reduce financial stress, current insurance mechanisms may not fully achieve their intended financial protection objectives. We acknowledge limitations such as small sample size and use of convenience sampling and hence larger community-based studies may be required to better quantify these relationships. Although the qualitative component provided contextual insights, the limited number of interviews may restrict the depth of thematic exploration. Nevertheless, the mixed-methods design enabled a comprehensive assessment of both measurable financial outcomes and contextual implementation barriers, thereby contributing to the growing evidence base on elderly healthcare utilisation and financial vulnerability in rural India.\\u003c/p\\u003e\"},{\"header\":\"Conclusion\",\"content\":\"\\u003cp\\u003eOld age pension receipt showed a positive association with healthcare utilisation and a trend towards reduced catastrophic health expenditure among the rural elderly, although statistical significance was not achieved. Health insurance coverage did not demonstrate measurable financial protection in this population. Strengthening benefit design, reimbursement mechanisms and implementation efficiency may be necessary to enhance financial risk protection among vulnerable elderly groups.\\u003c/p\\u003e \"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003eThere is no conflict of interest. This research received no specific grant from any funding agency.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAcknowledgement\\u003c/strong\\u003e: None\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eData Availability Statement\\u003c/strong\\u003e: The datasets generated and analysed during the current study are not publicly available due to confidentiality of participant information but are available from the corresponding author on reasonable request.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eEthical Approval\\u003c/strong\\u003e: The study was approved by the Institutional Ethics Committee of St John\\u0026rsquo;s Medical College, Bengaluru, India.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAccordance\\u003c/strong\\u003e: The study was conducted in accordance with the ethical standards of the Institutional Ethics Committee of St John\\u0026rsquo;s Medical College and in line with the principles of the Declaration of Helsinki.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e\\u0026nbsp;Consent to Participate\\u003c/strong\\u003e: Written informed consent was obtained from all participants prior to their inclusion in the study.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConsent to Publish:\\u003c/strong\\u003e Not applicable, as the manuscript does not contain any individual person\\u0026rsquo;s identifiable data.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAuthor Contributions:\\u0026nbsp;\\u003c/strong\\u003eK.M.D. contributed to the conception of the study, protocol development, data collection, statistical analysis, interpretation of findings and manuscript drafting. P.R.K. contributed to the conception, protocol development and critical review of the manuscript. Both authors read and approved the final manuscript.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\n \\u003cli\\u003eUnited Nations Department of Economic and Social Affairs. World Population Prospects 2022. New York: United Nations; 2022.\\u003c/li\\u003e\\n \\u003cli\\u003eInternational Institute for Population Sciences. Longitudinal Ageing Study in India (LASI) Wave 1 Report. Mumbai: IIPS; 2020.\\u003c/li\\u003e\\n \\u003cli\\u003eNational Health Accounts Technical Secretariat. National Health Accounts Estimates for India 2019\\u0026ndash;20. New Delhi: Ministry of Health and Family Welfare; 2023.\\u003c/li\\u003e\\n \\u003cli\\u003eXu K, Evans DB, Kawabata K, Zeramdini R, Klavus J, Murray CJL. Household catastrophic health expenditure: a multicountry analysis. Lancet. 2003;362:111\\u0026ndash;117. doi:10.1016/S0140-6736(03)13861-5.\\u003c/li\\u003e\\n \\u003cli\\u003ePrinja S, Bahuguna P, Gupta I, Chowdhury S, Trivedi M. Role of insurance in determining utilisation of healthcare and financial risk protection in India. PLoS One. 2019;14:e0211793. doi:10.1371/journal.pone.0211793.\\u003c/li\\u003e\\n \\u003cli\\u003eGovernment of India. National Programme for Health Care of the Elderly: Operational Guidelines. New Delhi: Ministry of Health and Family Welfare; 2011.\\u003c/li\\u003e\\n \\u003cli\\u003eNational Health Authority. Ayushman Bharat PM-JAY Annual Report 2023\\u0026ndash;24. New Delhi: Government of India; 2024.\\u003c/li\\u003e\\n \\u003cli\\u003eJoe W, Kumar A, Rajpal S, Mishra US. Universal health coverage in India: Progress achieved and the way forward. Indian J Med Res. 2022;155:123\\u0026ndash;133.\\u003c/li\\u003e\\n \\u003cli\\u003eLena A, Ashok K, Padma M, Kamath V, Kamath A. Health and social problems of the elderly: A cross-sectional study in Udupi Taluk, Karnataka. Indian J Community Med. 2009;34:131\\u0026ndash;134.\\u003c/li\\u003e\\n \\u003cli\\u003eRajan SI. Social assistance for poor elderly: How effective? Econ Polit Wkly. 2001;36:613\\u0026ndash;617.\\u003c/li\\u003e\\n \\u003cli\\u003eRajan SI, Kumar S. Living arrangements among Indian elderly: New evidence from National Family Health Survey. Econ Polit Wkly. 2003;38:75\\u0026ndash;80.\\u003c/li\\u003e\\n \\u003cli\\u003eGupta PC, Maulik PK, Pednekar PK, Saxena S. Concurrent alcohol and tobacco use among middle-aged and elderly population in Mumbai. Natl Med J India. 2005;18:88\\u0026ndash;91.\\u003c/li\\u003e\\n \\u003cli\\u003eVaz M, Bharathi AV. Perceptions of intensity of specific physical activities in Bangalore, South India. J Assoc Physicians India. 2004;52:541\\u0026ndash;544.\\u003c/li\\u003e\\n \\u003cli\\u003eGoswami AK, Ramadass S, Kalaivani M, Nongkynrih B, Kant S, Gupta SK. Awareness and utilisation of social welfare schemes among elderly persons. J Family Med Prim Care. 2019;8:960\\u0026ndash;965.\\u003c/li\\u003e\\n \\u003cli\\u003eRajan SI, Mishra US, Sarma PS. Ageing in Kerala: State Level and District Level Trends. UNFPA Report. 2019.\\u003c/li\\u003e\\n\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"discover-public-health\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"\",\"sideBox\":\"Learn more about [Discover Public Health](https://link.springer.com/journal/12982)\",\"snPcode\":\"12982\",\"submissionUrl\":\"https://submission.springernature.com/new-submission/12982/3\",\"title\":\"Discover Public Health\",\"twitterHandle\":\"\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"stoa\",\"reportingPortfolio\":\"Discover Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true},\"keywords\":\"Aged, Health Expenditures, Insurance Health, Pensions, Rural Population\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-8878988/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-8878988/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003e\\u003cstrong\\u003eBackground\\u003c/strong\\u003e: Financial vulnerability is a major barrier to healthcare access among the rural elderly in India. Pension and government insurance schemes aim to improve financial risk protection, yet their influence on healthcare utilisation and catastrophic health expenditure remains uncertain.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eObjectives\\u003c/strong\\u003e: To estimate the coverage of pension and insurance schemes among the rural elderly, assess their association with healthcare utilisation and catastrophic health expenditure, and explore stakeholder perspectives on accessibility and effectiveness.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eMethodology\\u003c/strong\\u003e: This study adopted a convergent parallel mixed-methods design, in which quantitative and qualitative data were collected concurrently, analysed separately and integrated during interpretation to enable triangulation of findings. It was conducted from December 2024 to February 2025 in six rural villages of Bengaluru. One hundred elderly individuals aged ≥60 years attending geriatric outreach clinics were recruited using convenience sampling. In-depth interviews with local stakeholders were analysed thematically to explore contextual barriers to scheme utilisation. Associations were assessed using Fisher’s exact test and logistic regression to estimate adjusted odds ratios.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eResults\\u003c/strong\\u003e: Fifty-six percent of participants received old age pensions and 31% had health insurance coverage. Twenty-five percent experienced catastrophic health expenditure. Pension receipt was associated with higher regular healthcare utilisation (OR 3.0, p = 0.089). In adjusted analysis, pension receipt was associated with lower odds of catastrophic expenditure (AOR 0.42, 95% CI 0.16–1.06), whereas insurance coverage showed higher odds (AOR 2.19, 95% CI 0.84–5.73); neither was statistically significant. Qualitative interviews highlighted irregular pension disbursement, documentation barriers and limited awareness of scheme entitlements.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConclusion\\u003c/strong\\u003e: Pension receipt showed a trend towards improved healthcare utilisation and reduced financial hardship, while insurance coverage did not demonstrate significant protection against catastrophic expenditure. Strengthening benefit coverage and implementation mechanisms may enhance financial risk protection for rural elderly populations.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Role of pension and insurance schemes in healthcare utilisation and catastrophic health expenditure among rural elderly in Bengaluru\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2026-03-13 14:13:19\",\"doi\":\"10.21203/rs.3.rs-8878988/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"decision\",\"content\":\"Revision requested\",\"date\":\"2026-05-06T05:14:52+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2026-03-31T20:30:56+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"213447212256304947409791995191218031949\",\"date\":\"2026-03-31T20:29:20+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2026-03-30T14:19:56+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"219858310785103837920219102813606699803\",\"date\":\"2026-03-30T14:06:14+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2026-03-19T14:19:47+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"227969715509096609065945145143231939293\",\"date\":\"2026-03-13T08:02:05+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewersInvited\",\"content\":\"\",\"date\":\"2026-03-11T06:10:46+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2026-03-01T15:59:24+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"checksComplete\",\"content\":\"\",\"date\":\"2026-02-27T12:05:53+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"submitted\",\"content\":\"Discover Public Health\",\"date\":\"2026-02-27T08:15:45+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"discover-public-health\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"\",\"sideBox\":\"Learn more about [Discover Public Health](https://link.springer.com/journal/12982)\",\"snPcode\":\"12982\",\"submissionUrl\":\"https://submission.springernature.com/new-submission/12982/3\",\"title\":\"Discover Public Health\",\"twitterHandle\":\"\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"stoa\",\"reportingPortfolio\":\"Discover Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"861274fb-fea5-4099-af28-46bf39ca1495\",\"owner\":[],\"postedDate\":\"March 13th, 2026\",\"published\":true,\"recentEditorialEvents\":[{\"type\":\"decision\",\"content\":\"Revision requested\",\"date\":\"2026-05-06T05:14:52+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"under-review\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2026-05-08T03:08:36+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2026-03-13 14:13:19\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-8878988\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-8878988\",\"identity\":\"rs-8878988\",\"version\":[\"v1\"]},\"buildId\":\"XKTyCvWXoU3ODBz1xrDgd\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}