Awareness and utilization of social welfare schemes among elderly villagers of Mahabubnagar rural region in Telangana State of India – An interventional study approach

ABSTRACT

Introduction:

Demographic transition enhanced the proportion of geriatric population in India. Senior citizens experience progressive economic dependency for their daily survival. The Government of India provides economic assistance through social welfare schemes. However, inadequate awareness of schemes is the key reason for its low utilization. The present study was implemented to evaluate knowledge and utilization of social welfare schemes and also to assess the effect of educational intervention on awareness of elderly persons about welfare schemes.

Materials and Methods:

A community-based interventional study carried out from July to December 2022. A structured ‘TIV intervention’ comprised of ‘Training module’, ‘Interactive sessions’ and ‘Village Health Meeting’ was administered on 839 elderly persons in one of the rural blocks of Mahabubnagar district of Telangana State of India. Community health workers were actively involved in sensitization sessions. Pre- and postintervention questionnaires were completed through face-to-face interview with participants by trained social workers. The statistical analysis was performed using SPSS Version 20 Software.

Results:

There was a statistically significant improvement in awareness levels and utilization of social welfare schemes due to TIV intervention (P < 0.001, SD = 3.01vs 1.21). The awareness of schemes was significantly greater among males, literates, socioeconomic scale of classes 1 and 2 and with age group of 60-70 years.

Conclusions:

Simple, cost-effective intervention can make significant gain in awareness and utilization levels of social welfare schemes among elderly population. ‘Traditional Village Meetings’ can be used as a potential opportunity to sensitize community members about social welfare schemes.

Introduction

India is an aging nation with around 8.6% of the population aged above 60 years according to national census 2011.[1] It is estimated that the percentage will upsurge to 19.4% by the end of 2050.[1] It is observed that almost 65% to 75% of old people are economically dependent for their daily maintenance activities either fully or partially.[2,3]

Policymakers endorse social security to citizens if they are old, sick, unemployed, and disabled within the limits of the state’s economic capability and development.[4] There are several programs and schemes which are runned by the different ministries of Government of India for welfare of elderly. National Social Assistance Programme (NSAP), Annapurna Scheme, Antyodaya Anna Yojana (AAY), etc., are few of the centrally sponsored schemes, which provide benefit to population with below poverty line.[5] Indigent old individuals who are eligible for Indira Gandhi National Old Age Pension Scheme (IGNOAPS) but remain uncovered by this scheme are given 10 kg of food grains per person per month free of Department of Food and Public Distribution.[6] However, the state has flexibility to amend the quantity of monetary benefit. As a part of its social safety net strategy, Telangana Government has introduced the ‘Aasara Pension Scheme’ (APS) to safeguard secured life with dignity for old people and other vulnerable segments of community.[7] From year 2020–21, under APS, the government is providing pension of Rs 2016 per month to senior citizens, widows, beedi workers, AIDS victims, etc., and Rs 3016 for disabled population.[7]

Lack of dependence in the economic circumstances of the old individuals not only enhances the health-seeking behaviour but also their health outcomes.[8] The sole presence of such schemes is not adequate; in fact, acquaintance as well as utilization of schemes by senior citizens are highly warranted to accomplish an acceptable level of social welfare. To the best of our knowledge, no study has been implemented so far where any specific educational intervention was used to improve awareness levels about social welfare schemes among geriatric population.

Primary health care is the most efficient, equitable as well as cost-effective approach to improve physical, mental and social well-being of individuals. Social welfare schemes assist people to achieve positive primary health. These schemes enable individuals to acquire through challenging periods in their lives by relieving them of a part of their financial problems. Such schemes foster labour and education, and provide an advanced standard of living. Primary care physicians are known as ‘quarterback’ in their patients’ care, connecting and coordinating with other parts of health system.[6,7] They not only diagnose and treat acute and chronic diseases but also avert disease and maintain health; work together with other health providers and boost knowledge through research in patient care and its delivery. In many situations, they act as first contact physicians and can educate patients about certain social determinants of health like social welfare schemes, which have an essential role in maintaining positive health and quality of life among patients.

The present study was undertaken to evaluate the awareness and utilization levels of social welfare schemes among elderly persons in rural regions of Mahabubnagar District of Telangana State of India. An attempt was also made to assess the effect of educational intervention on their knowledge and utilization of these schemes.

Materials and Methods

Study design and study settings

A community-based interventional study was conducted between July and December 2022. The Mahabubnagar district has 15 administrative blocks with an estimated population density of 222, 573.[9] The single rural block that was under field practice area of institute was randomly selected for the execution of study.

Study population, sample size estimation, and sampling procedures

The demographic data were retrieved from local Gram Panchayats (basic governing institutions of villages) in selected block. Individuals of both genders with age of 60 years and above and living in same area for at least 12 months were considered as eligible study participants. The required sample size was computed depending on four factors, namely, the population proportion of 50%, confidence level at 99%, allowable level of margin of error of 5% and predictable non response rate of 10%. The required sample size was 842. Through simple random sampling procedure, 842 out of 3789 eligible elderly population were enrolled as study participants.

Inclusion and exclusion criteria

Eligible study participants who were terminally ill or bed ridden and those who could not communicate or understand the questions were excluded. Those participants who were illiterate but showed willingness to participate in the study were included.

Ethics considerations

An ethics approval was obtained from Institutional Ethics Committee (IEC) of the respective institute (Reference Number: 009/GMCM/IEC/19). A voluntary participation was ascertained throughout the study. An informed consent was received from all study participants.

Study tools and procedures

Pre-intervention phase

A structured validated questionnaire was formulated in local (Telugu) language. Apart from sociodemographic attributes, the questionnaire also comprised of 20 close-ended questions on knowledge and utilization of existing social welfare schemes. Three trained social workers conducted house-to-house visits and collected the information about knowledge and utilization of schemes among participants. The responses were analysed, and based on learning needs of participants, the design and content of an intervention was planned.

Intervention phase

We decided to use ‘TIV’ intervention which encompassed of ‘Training module’, ‘Interactive sessions’ and ‘Village Health Meeting’. For module activity, 30 Community Health Workers [Anganwadi workers (AWWs)] were identified on voluntary basis and they were involved in preparing one low cost structured module in local (Telugu) language. The module was validated by research investigation team, social workers and representatives from local government system. The module consisted of detailed information about all available social welfare schemes for old people. Each scheme was described in detail emphasizing beneficiaries, eligibility, benefits and its application process. Over the period of 6 months, 30 education sessions of one hour duration each were conducted in local language by trained AWWs for all participants in subgroups of 25 to 30. The prepared module was used as a primary teaching tool to educate participants during all sessions. To make it interesting, sessions were supplemented with interactive activities like role play, street plays, puppetry, quizzes and video clips. In addition, two common sessions (45 minutes each) were implemented by social workers during traditional periodical ‘Gram Sabha/Village Meeting’. Both sessions focussed on detailed information of social welfare schemes for elderly individuals. In each of two village meetings, the name of scheme, its beneficiary and eligibility details were addressed in first session, and in subsequent session, the available benefits and application process of each scheme were covered by facilitators. The questions/queries raised by participants during meetings were effectively responded by facilitators. The entire intervention was supervised and guided by principal investigator and team members. If participant knew at least the name of mentioned scheme, he/she was considered ‘aware’ of that respective scheme. If the participant was registered/was receiving benefit from any of the mentioned schemes, it was categorized as ‘utilizing schemes’.

Postintervention phase

The similar questionnaire was used, and the responses were gathered from participants three weeks after an intervention. Pre- and postintervention questionnaires were completed through face-to-face interview with participants by trained social workers. The written as well as verbal feedback was also taken from participants and AWWs regarding educational intervention. After collection and editing of data, classification and tabulation was performed under appropriate heading to obtain the summary values for further statistical treatment. All descriptive statistics were presented in the form of Mean ± SD (Standard Deviation) and Percentages. Statistical analysis was performed with Statistical Package for the Social Sciences (SPSS) Version 20 software (IBM SPSS Statistics Inc., Chicago, Illinois, USA). The difference in pre- and postintervention knowledge was assessed using paired t test. Two-tailed P value less than 0.05 was considered statistically significant.

Results

Sociodemographic profile of study participants

In the current study, after applying necessary exclusions, the data analysis was performed for 839 participants. Table 1 depicts sociodemographic characteristics of participants.

Table 1.

Sociodemographic Distribution of Study Participants (n=839)

Parameter	Number (n)	Percentage
Gender
Male	472	56.25
Female	367	43.74
Age (in years)
60-64	256	30.51
65-69	398	47.43
70-74	177	21.09
>75	08	0.95
Literacy status
Illiterate	239	28.48
Literate ( till middle school)	578	68.89
Literate ( high school and above)	22	2.62
Marital status
Married	618	73.65
Single/divorced/widowed/separated	221	26.34
Previous occupation
Service	219	26.10
Labourer	427	50.89
Business	78	9.29
Homemaker	115	13.70

Awareness about schemes before application of an intervention

Table 2 indicates awareness levels of participants about social welfare schemes before application of an intervention. It also shows that the awareness of schemes was significantly greater among males, literates, socioeconomic scale of classes 1 and 2 and with age group of 60-70 years [Table 2].

Table 2.

Awareness of Participants as Per Sociodemographic Attributes (n=839)

Attribute	Aware	Not aware	P*
Age
60-70	288 (76.19%)	359 (77.87%)	0.0001
>70	90 (23.80%)	102 (22.12%)
Gender
Male	299 (79.10)	425 (92.19%)	0.005
Female	79 (20.63%)	36 (7.80%)
Educational status
Illiterate	57 (15.07%)	378 (81.99%)	0.0001
Literate	321 (84.92%)	83 (18%)
Socioeconomic class
I and II	272 (71.95%)	289 (62.68%)	0.003
III and IV	106 (28.04%)	172 (37.31%)
Total	378 (45.05%)	461 (54.94%)

*P<0.05=Statistically Significant

In the present study, among 378 (45.05%) participants who were aware of schemes,[10] 76.45%, 79.62%, 81.64%, 84.37% and 92.85% of participants had knowledge about Rashtriya Vayoshri Yojana (RVY), Indira Gandhi National Old Age Pension Scheme (IGNOPS), Indira Gandhi National Widow Pension Scheme (IGNWPS), Indira Gandhi National Disability Pension Scheme (IGNDPS) and Railway concession scheme (RCS), respectively [Figure 1]. However, all (100%) participants were familiar with Aasara Pension Scheme (APS).

Figure 1.

Awareness of participants about social welfare schemes

Regarding utilization rates, among those 378 (45.05%) knowledgeable participants, 298 (78.83%) were registered and availing benefits for any one or more than one of the mentioned schemes. Maximum registration was noted for Aasara Pension Scheme (94.70%) followed by Indira Gandhi National Old Age Pension Scheme (79.62%). However, there was less registration for remaining schemes. Males had higher utilization of schemes compared to females (P < 0.05). Literates showed significantly greater utilization rates than illiterate participants (P < 0.05) but utilization was found to be more among participants who had completed primary and middle school than who acquired high school and above qualifications (P < 0.05). Participants aged between 60 and 70 years had nearly three times higher utilization of schemes compared to those with above 70 years, and the difference was statistically significant (P < 0.001). Currently, married participants had significantly lower utilization of schemes than single/divorced/widowed/separated participants (P < 0.05).

Effect of an intervention

The current study reported statistically significant improvement in awareness levels as well as utilization rates as a result of TIV intervention (P < 0.001, SD = 3.01 vs 1.21) [Figure 2]. Teaching through module and interactive sessions not only helped participants to become aware of social welfare schemes but also to comprehend the detailed knowledge about each scheme including eligibility criteria, available benefits, and application procedure pertaining to individual scheme. An analysis of feedback received from participants revealed that the used intervention was simple, easy to understand and enhanced their knowledge about social welfare schemes and encouraged them to get registered for such schemes and avail benefit from it.

Figure 2.

Effect of an intervention on awareness of participants about schemes

Discussion

There are sparse studies on senior citizen’s awareness of social welfare schemes especially in India. The evidence indicates that, among those people who could not utilize such schemes, inadequate knowledge pertaining to scheme was the major reason followed by non-necessity of the scheme.[11-13] In spite of Government of India’s extensive efforts to increase awareness for various social security schemes, it was revealed that almost around 50% of the rural population in the current study was unaware of such schemes. However, significant improvement in knowledge and utilization of schemes was reported among participants due to use of simple, low-cost and feasible intervention. This reiterates the strong need to use such types of educational programmes to augment the public awareness of social welfare schemes particularly among rural regions in India where social protection coverage is usually lower than urban areas.

In rural community-based study conducted by Vidhate et al.,[14] it was documented that the level of awareness about schemes improved with increased age range between 18 and 60 years. However, contrast findings were reported in our study where knowledge as well as utilization of social welfare schemes was more among young participants (60-70 years) than old participants (>70 years). In this study, males were more aware of the schemes than females. This finding was corroborated with the study of Joseph et al.[15] However, Bartwal et al.[16] and Goswami AK et al.[6] showed comparative results in which female participants had less knowledge about schemes than males.

In India, the geriatric population is expanding at a rate of 3.5%, which is almost twofold the rate of the entire population.[17] It is projected that elderly population will dramatically rise in near future.[17] In context of this situation, all elements of care for old persons including health, financial, and social aspects require meticulous consideration. This situation becomes even dire among economically deprived old individuals who are unable to work due to ageing process and associated weakening health as well as inadequate financial sources. To counteract this condition, implementing social welfare schemes successfully and addressing barriers plaguing them is of paramount importance. Additionally, community/grassroot-level health workers can be actively involved to ensure that benefits of schemes must reach to every needy senior citizen in the community. Old individuals predominantly pose the risk of acquiring lifestyle diseases and several other health problems, which imposes higher costs to the socio-healthcare system.[18] Therefore, the system should be prepared for such change in the nature of diseases or infirmities distressing the population. Furthermore, economic empowerment may assist elderly population to fulfil their healthcare needs appropriately.

The current study indicated that the awareness was 100% for state social welfare schemes like ‘Aasara Pension Scheme’ than national-level schemes. Even though the majority of schemes available at country level also exist at the state level, however, individuals tend to remember state-level schemes more than national-level schemes.[19,20] The possible reasons for high awareness for state level schemes could be direct and frequent contacts of residents with local community health workers to gain information and comparatively easy access to welfare schemes compared to central level schemes.

The multiple strengths of this study were its community-based interventional study approach and positive perceptions of participants towards educational intervention. The data gathered by specifically trained interviewers amplified the reliability of information. An effective use of Gram Sabha (Periodical Village Meeting) as a platform to educate study participants with overwhelming cooperation from village political leaders and active involvement of community health workers (Anganwadi workers) in sensitizing participants about schemes were some of the potential strengths of the study. However, there were some limitations of the study. Single centred study may not be appropriate to generalize study inferences. Multicentric studies with large sample size are highly warranted for better generalization of results. The study could not include urban population as urban–rural comparison could have been helped to understand differences in knowledge and utilization levels of social welfare schemes and associated hurdles to access these schemes.

Primary care physicians understand how social determinants influence almost each aspect of an individual’s health and well-being. They work as a healthcare partner, educator, advocate and navigator in patient’s entire lifespan. In contemporary situation, the need for primary care physicians is greater than ever before.[21] Being first contact physicians, they can impart comprehensive education to community members about social security schemes, which can counteract the financial challenges perceived by poor people in accessing quality health care.

Several challenges have been encountered while imparting the social security to the poor and marginalized sections of society.[22] Focused delivery of social security/social welfare schemes is a significant challenge, which needs to be addressed as there are lot of beneficiaries waiting in line.[23] The simplified sensitization interventions like used in the current study may help community people to understand the importance of these schemes in holistic way and they can utilize it effectively to promote their optimum health.

Conclusions

Simple, cost-effective educational intervention can make significant gain in awareness and utilization levels of social welfare schemes among elderly population. Inclusion of community health workers like accredited social health activist (ASHAs)/AWWs in educational programmes can have a positive impact on utilization social welfare schemes by elderly persons. ‘Gram Sabha/Village Meetings’ can be used as a potential opportunity to sensitize community members about social welfare schemes.

Recommendations

1. TIV intervention (Training module, Interactive sessions and Village meetings) is highly replicable and can be implemented in other rural and urban areas to enhance the awareness of social welfare schemes.

2. Since CHWs like ASHAs/AWWs are one of the major sources of information for elderly people, they should be adequately trained regarding social welfare schemes particularly utilization aspects of schemes.

3. Involving CHWs, village stakeholders including political leaders and general community members altogether and ensuring their joint efforts can be a significant milestone in ensuring higher knowledge and full utilization of social welfare schemes especially in remote and marginalized regions of India.

4. Gram Sabha/Periodical Village Meetings must be used as a consistent platform to generate awareness about state and central social security schemes. The emphasis should be given on how to utilize schemes to the fullest.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.