Introduction
Many countries [
1], including Taiwan, have aging populations [
2]. Following an increase in the older adult population in Taiwan, the percentage of older adults using National Health Insurance resources has increased continually [
3], with chronic diseases being the primary factor contributing to said usage [
4]. According to a national health survey, 86.3% of older adults have been diagnosed with at least one chronic disease [
2]. Preventing chronic diseases, promoting older adults’ health, and maintaining older adults’ physical function are key goals in society [
5].
The purposes of primary health centers (PHCs) are to promote older adults’ health, prevent and monitor their diseases, and reduce their physical disabilities [
6]. PHCs provide older adults with health education, risk assessments, health screening, and primary care; when further medical care is required for older adults, they are referred to receive appropriate medical services [
7]. Additionally, PHCs integrate community resources to promote older adults’ social participation and help them live independently [
7]. This includes shuttle services and access to facilities, including those used for community service projects [
8].
The urban–rural gap, which has long been a prominent problem worldwide, is caused by the lower socioeconomic status and poorer health behaviors of rural populations compared with urban populations [
9]. It is also a consequence of the unequal distribution of medical resources; rural areas have fewer medical personnel, lower medical coverage, and a longer distance to medical centers than urban areas [
9]. Taiwan has many mountainous areas with uneven distribution of population and healthcare resources. In 1995, Taiwan started promoting its National Health Insurance program to remove financial barriers to medical care, but an urban–rural gap remains [
9]. Chronic disease management is required in rural PHCs because it can reduce the number of hospitalizations and mitigate problems in the community associated with chronic diseases [
10]. With the increase of aging population, PHCs in Taiwan have to take responsibility to provide primary care for older adults in different areas.
Older adults in urban areas have more medical resources than those in rural areas do [
11]; they are also more willing to participate in social activities [
12] and visit PHCs more frequently [
13]. Community environment is closely associated with older adults’ health behaviors, the comfort, safety, and accessibility of related facilities affect older adults’ intentions to participate in community activities. Therefore, community building must be planned in consideration of older adults’ needs to promote their physical, psychological, and social health [
13]. The present study explored the differences in the PHC experiences and usage needs between older adults in urban and in rural areas in Taiwan. The results can be used to establish primary health-care policies that meet the requirements of older adults in both types of areas.
Discussion
This qualitative study explored the differences in older adults’ use of PHC services related to medical resources, the environment and transportation, and active aging. Older adults in rural areas have a greater need for diverse medical facilities, interdisciplinary diagnostic and treatment options, and mobile and home medical care being offered by PHCs than those in urban areas do. By contrast, older adults in urban areas have a greater need for educational courses on physical and psychological health and having opportunities to volunteer, which can fulfill their social participation needs.
An urban–rural gap exists in Taiwan in terms of medical services [
9]. Rural areas lack sufficient medical resources, and PHCs may be the only available places for older adults in these areas to access medical services. Similar to Greece [
17] and Indonesia [
18], older adults in rural areas have disadvantage in using PHCs service. Therefore, interdisciplinary medical care is particularly important in rural PHCs [
19], and individualized health management is necessary for effective chronic disease control and health promotion [
20]. Moreover, rural areas are geographically disadvantaged and older adults have difficulty moving, and rural PHCs must provide mobile and home medical care to improve medical service accessibility [
21]. Older adults with chronic diseases receive case management in rural PHCs and in outpatient clinics through screening, care programs, condition evaluation, and disease monitoring [
22]. Although rural PHCs currently provide older adults with various services, difficulty in retaining doctors continues to encumber these PHCs. In response, the central government strengthens rural medical personnel training and provides retention bonuses to mitigate medical workforce shortages in rural areas [
23].
Older adults in urban areas are not reliant on PHCs for medical access. Older adults in such areas generally wish that PHCs would provide mobile health examinations in their communities and provide individualized notifications related to health-care activities. In response, the central government promotes community disease screening; specifically, PHCs across Taiwan are tasked with providing mobile health examinations at specific locations in each community, offering older adults easy access to health examinations [
24]. Because the nurse–patient ratio in urban areas is low [
25], urban PHCs tend to focus on group-based medical care and provide resources and referral services to groups of people with similar medical needs, thereby improving group health [
26].
The geographic conditions of rural areas lead older adults in such areas to have specific needs related to medical facilities and transportation. Older adults in rural areas have a greater need for public transportation, medical shuttle services, and telemedicine than those in urban areas do [
27]. This study revealed that older adults in rural areas expect their PHCs to provide diverse medical facilities, shuttle buses, and accessible facilities, whereas those in urban areas expect favorable recreational facilities. Therefore, the central government has established medical facilities and 5G online clinics in rural PHCs. Additionally, medical imaging services such as x-ray, ultrasounds, and electrocardiograms have been implemented or upgraded. Older adults in rural areas are offered shuttle services. An integrated delivery system is promoted to facilitate collaboration between hospitals and rural PHCs in providing local clinics and emergency care through medical vehicles and first-aid stations [
28]. Age-friendly environments are renovated; specifically, accessible and recreational facilities are refurbished according to the needs of the attendees of urban or rural PHCs [
29]. Rural PHCs have provided alternative measures to enhance older adults’ access to medical treatment, such as support for those with limited mobility.
Taiwan government promotes the policy of age-friendly PHCs and addresses not only disease prevention but also health promotion in PHCs. PHCs are responsible for the promotion of healthy and active aging, which involves older adults optimizing their physical health, psychological cognition, emotional regulation, and social function [
30]. Urban and rural PHCs employ different approaches to promoting active aging. This study indicated that rural PHCs have less diverse and frequent active aging courses than urban PHCs. The learning resources and formal classrooms for older adults in rural areas have been scarcer than have those in urban areas; when older adults in rural areas encounter problems, they usually ask for the opinions of their families and friends. Because the close bonds in rural communities are conducive to building trust and positive environments for discussion, autonomous learning has been the most preferred learning model by older adults in many countries [
31]. The central government plans to design a remote technology platform for experts to provide online learning services to older adults, which could mitigate the geographic restrictions to learning resource access [
32].
PHCs in rural areas take medical services as the priority and may not have enough resources to provide various kinds of courses. On the other hand, urban areas have abundant medical resources. PHCs in urban areas have less demands on medical services and have more resources to provide health promotion courses. Therefore, such PHCs can focus on promoting active aging through educational courses in which older adults can form interpersonal connections. Consequently, older adults in urban areas more frequently participate in social activities [
12]. Older adults in urban areas exhibit strong intentions to participate in the courses and volunteer services provide by PHCs. Urban PHCs offer many types of courses to older adults as well as a learning environment conducive to strengthening interpersonal relationships, enabling older adults to support each other in their exchanges, discuss their opinions in a safe environment, and enrich their own learning experience [
33]. Older adults’ psychological health can also be improved through social connections in courses, thereby promoting active aging [
19]. Autonomous participation in volunteer services satisfies older adults’ psychological needs and improves their life satisfaction [
34]. Accordingly, urban PHCs have substantially contributed greatly to the active aging of older adults in urban areas.
The present study focused on the subjective experiences of older adults who had used PHCs. Because of geographical differences and the unequal distribution of medical resources, older adults in urban and rural areas have different needs for PHCs. Urban PHCs focus on health screening and the courses of active aging, while as rural PHCs take medical care and disease prevention as priority, as well as the needs of transportation for accessing services. Medical care is one of the most important needs of older adults, and those in rural areas may have unmet needs. Therefore, Taiwan government uses some strategies, including budget for medical staff, shuttle buses, and telecommunication, to solve the problems.
Some limitations of this study should be acknowledged. First, only qualitative data were collected, with these data being collected from subjective interviews. In future studies, other forms of data, such as nonparticipatory observations, medical case analyses, National Health Insurance data, and health examination records can be employed to strengthen data credibility and integrity. Second, the participants were recruited through purposive sampling and, therefore, may be inadequately representative. Quantitative studies with random sampling should be conducted to compare older adults in urban areas with those in rural areas based on their requirements when using PHCs, increasing the generalizability of relevant research results.
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