1. Introduction
emographic changes, along with changes in the epidemiological pattern of diseases in old age, as well as limited human and financial resources, especially in developing countries, have made the provision of health facilities and services to the elderly face serious problems [18]. Rising care needs for the elderly are a concern of health care systems in countries with an aging population [16, 17]. Given the challenges of aging population and the relatively high cost of health services for them, identifying the factors affecting the use of health services by the elderly is of particular importance for health decision-makers to determine potential problems and develop appropriate interventions for increasing access and remove barriers to health services [16, 27]. Therefore, the aim of this review study is to investigate the determinants, barriers, and facilitators of using outpatient health services for older people.
2. Methods & Materials 
In this systematic review, the search was conducted in Web of Science, PubMed, and Scopus databases among the studies in English from 1996 to 2019 according to PRISMA checklist and using following keywords: Health service Utilities, aging, older people, older adult, elderly, aged, factor, determinant, predictor, health care Utilities, health service use, health care use. Quantitative, observational, and cross-sectional studies using secondary and longitudinal analysis of factors affecting the use of outpatient health services by the elderly aged ≥60 years were included in the study. Studies on the use of unofficial health services (e.g. from friends/ family, or religious support), studies with the immigrant, incarcerated, hospitalized elderly population, residents of nursing homes, and the elderly with certain illnesses including oral disease, mental illness, and cancers or disability were excluded. Studies that used data from health centers, as well as dissertations, review studies, and letters to the editors were also excluded. The search in databases yielded 300 articles. In addition, 3 new articles were found through search in the reference lists of articles. After removing duplicate and irrelevant articles, 47 articles remained and entered the qualitative evaluation phase. The quality of the articles was evaluated independently by two raters based on the STROBE checklist. After quality assessment, finally 44 articles entered into the review. In order to combine the data of these 44 articles, the narrative synthesis method was used.
3. Results
In this study, the quality of 44 articles was confirmed. Andersen’s behavioral model of health service utilization was used as a theoretical framework to classify the Results of this study into three categories: predisposing factors (Age, gender, marital status, ethnicity), enabling factors (Education level, employment status, income level, insurance coverage, social network, social support, place of residence) and need factors (Having a chronic disease, self-assessed health status, need for health care services, severity of the disease, number of diseases, comorbid diseases, type and duration of disease, having disability or functional limitation, unhealthy lifestyle). Findings of the reviewed articles showed that with the increase of age, the need to use health services increases [3, 15, 25, 33, 37, 39, 40, 43, 50, 53, 54, 56, 59], but in some studies, with increasing age and exceeding 85 years, the use of health services decreased [55, 58, 61]. Gender was associated with access to health services such that women were significantly more likely to seek health services [5, 9, 15, 17, 25, 30, 39, 43, 45, 49, 50, 52, 53, 54, 58, 59, 61, 64]. Married people used more health services than divorced, single, and never married people [25, 30, 43, 52, 57, 60].
 Ethnic minorities had less access to health services than the dominant ethnic group [63]. As income increased, the use of health services increased and vice versa. This relationship was also true based on satisfaction with economic status, household assets, individual wealth, household expenses, monthly and annual household income [5, 17, 25, 30, 31, 37, 39, 43, 47, 52, 53, 58, 59, 61]. Regarding employment status, retired and unemployed elderly people used less health services than employed elderly people [3, 12, 64]. Several studies have linked higher education to health service use [1, 3, 25, 35, 43, 47, 52], although some studies showed that this linear relationship is not always established and higher education was related to using less outpatient health services in the elderly [5, 16, 17, 37, 58, 61]. Having health insurance, including commercial and private insurance, and the amount of costs covered by insurance was associated with greater access to health services in the elderly [25, 41, 43, 47, 59, 63, 64]. Wider social network [61], family social support [46], having a caregiver or a companion during disease, and having a child [46] were associated with more access to health services, and in various studies living alone was one of the causes of lack of use [33, 49]. 
Studies showed that rural life is not only associated with low health service use [5, 25, 31, 35, 43, 47, 54]; in studies by Park (2018) and Pletzer (2014), elderly people living in rural areas used outpatient health services more than the elderly living in urban areas [54, 61]. Shorter duration or distance in access to health care centers increased the likelihood of using health services in the elderly [3, 46]. Having chronic diseases [1, 5, 9, 12, 16, 17, 25, 40, 42, 43, 47, 49, 52, 53, 54, 55, 57, 59], low mental health, depression [38, 46, 49, 50, 57, 61], cognitive impairment [61], physical disability [25], low self-assessed health status [3, 5, 9, 12, 15, 31, 50, 52, 53, 59], correct perception of the problem [46], need for health care services [15,، 58], comorbid diseases [55], feeling pain [25, 46] and unhealthy lifestyle (smoking and alcohol consumption) [25] were associated with using more outpatient health services (Table 1). 



4. Conclusion
A set of factors are consistently associated with the use of health services by the elderly. The present study identified the factors affecting the use of outpatient health services by the elderly according to Andersen’s behavioral model of health service use. It seems that interventions to increase the use of health services in the elderly should be based on three categories of predisposing, enabling and need-related factors. Given that most of the reviewed studies indicated to the variables of income, insurance coverage, age >80 years, and having chronic diseases, these factors are then the most important factors affecting the use of health services in the elderly which should be considered as the policy makers’ health policy priorities for the elderly so as not to increase the burden of services caused by diseases.
Ethical Considerations
Compliance with ethical guidelines
The present study obtained its ethical approval from the University of Social Welfare and Rehabilitation Sciences (code: IR.USWR.REC.1397.029).
Funding
The project was funded by the Deputy of Social and Cultural Affairs of Tehran Municipality (Grant number: 990.473667). Also, This review study was part of a PhD. dissertation of second author at Department of Social Welfare Management, School of Education Sciences and Social Welfare, University of Social Welfare and Rehabilitation Sciences.
Authors' contributions
All authors had equal contribution in preparing this article.
Conflicts of interest
The authors declare no conflict of interest
Acknowledgements
We thank Professor Hossein Malek Afzali for his guidance and scientific support.


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