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BMC Public Health
BMC Public Health
BMC Public Health
1471-2458
BioMed Central London

39300405
19910
10.1186/s12889-024-19910-y
Research
Barriers and facilitators for accepting health education of Chinese rural older adults in Henan Province: a qualitative study
Zhang Huizhong
Zhang Yan zhangyanmy@126.com

Yan Yuwen
Li Xizheng
Tian Yutong
https://ror.org/04ypx8c21 grid.207374.5 0000 0001 2189 3846 School of Nursing and Health, Zhengzhou University, Zhengzhou, 450001 China
19 9 2024
19 9 2024
2024
24 256428 10 2023
27 8 2024
© The Author(s) 2024
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.
Background

As global aging continues to intensify, the health status of the older people requires urgent attention, and health education provides a pathway for active aging. However, the current outlook on health education for older people in rural areas of China is not optimistic. This study used Social Ecosystems Theory and explored the deep-rooted influencing factors on the acceptance of health education from the perspective of the rural older people.

Methods

In this study, a purposive sampling method was adopted, and eligible rural older individuals were selected from Hebi city, Henan Province, China, from March to May 2023 as the research participants. A semistructured interview method was used to explore the factors affecting the acceptance of health education by older people. The interview data were analyzed using the qualitative content analysis method to obtain relevant themes and subthemes.

Results

A total of 14 participants were recruited for the interviews; 8 were male, 6 were female, most had an elementary school education, and most were farmers. The results of the thematic analysis revealed a total of nine facilitators and nine barriers in micro, meso and macro levels. Among the findings, our important and unique finding is that inadequate intergenerational support somewhat hinders older adults’ exposure to health education.

Conclusion

There are numerous and complex facilitators of and barriers to accessing health education for rural older adults; of these, a lack of intergenerational support is particularly important. In the future, health education needs to be centered on the families of older people with the assistance of village committees so that older people and their children can learn and communicate together.

Henan Provincial Social Science Circles FederationSKL-2023-569 SKL-2023-569 SKL-2023-569 SKL-2023-569 SKL-2023-569 issue-copyright-statement© BioMed Central Ltd., part of Springer Nature 2024
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pmcIntroduction

The international aging process is accelerating, and it is estimated that by 2030 there will be more than 1 billion people over 65 years of age [1]. With the rapid aging of the population, the health burden of the older population has increased, posing a great challenge to countries around the world. China’s older population accounts for one fifth of the global older population, and ranks first in the world [2]. According to the latest demographic data released by the National Statistical Office [3], the total number of urban and rural older people in China has exceeded 260 million, accounting for 18.7% of China’s total population, and it is expected that by the end of the twenty-first century, China’s older people will be maintained at approximately one-third of the total population. With the increase in age, the number of older people in China has increased dramatically, and there has been an “urban‒rural inversion” situation [4]. The level of aging in rural areas is greater than that in towns and cities, and the number of older people in rural areas exceeds 200 million [5], and in 2021, these people accounted for 23.99% of the total rural population, and are expected to exceed 30% in 2033 [6].

Older adults are at a relatively high risk of disease owing to the decline in physical functioning as they age, and poor health leads to increased costs of medical and nursing care [7]; this is a continuing caregiving burden on society and families. Several studies have shown that [8], the self-assessed health status of older people in rural China is worse than that of older people in urban areas. In rural areas, 83.69% of older people suffer from at least one chronic disease [9], and they are generally in a state of multimorbidity. The health status of older people is closely related to health behaviors, and older people can adopt health behaviors to improve their health status [10]. Health education is the main option and an effective method for promoting healthy behaviors among older persons [11]. In recent years, several studies at home and abroad have explored and practiced health education for older people. The Chinese government issued the “14th Five-Year Plan for the Development of the National Aging Career and Pension Service System” in 2022 [12], which puts forward new requirements for gerontological education in both urban and rural areas, advocating for measures to promote greater participation in society for the older people in both urban and rural areas.

At present, health education for older people is being carried out one after another, but there is still a lack of correct knowledge of health education among rural older people [13], low overall health literacy [14], insufficient levels of active aging, etc. [15]. At present, the main target of health education for older people is the older people in the community, while the health education research conducted in rural areas has a wide range of target audiences. Therefore, systematic and integrated health education for rural older adults is lacking. Second, there is a gap between health education research and translation into practice, and health education activities are seldom implemented in rural areas as needed [13]. In addition, the rural older people are different from individuals in other age groups. The overall literacy level of rural older adults is low [16], they are more forgetful, and there is a gap between them and modern technology [17]. Therefore, there are many unique influences on the learning of health education in this group that need to be explored.

In past studies, our focus has been on health education providers, and health education recipients have not been explored in depth. As technology advances and times change, health education should also shift the perspectives of both supply and demand. Therefore, under the new trend of health education, rural older people’s attitudes toward, perceptions of and objective factors related to health education need to be explored. No quantitative assessment tool was found at this stage; therefore, this study used a qualitative approach to preliminarily explore the factors influencing the acceptance of health education among rural older adults from their own perspective.

Henan Province is the most populous province in China, and the aging level of the rural population in Henan Province is higher than that in urban areas, which can represent the basic situation in China. The economic level of Hebi City is in the middle of the province, and at the same time, it is promoting the construction of a healthy city in the Healthy Central Plains Initiative. Therefore, the team has conducted a series of health-related studies on the rural older people in Hebi City in the previous period in cooperation with relevant people, and this study is an in-depth exploration based on the results of the previous studies. Based on the social-ecological system model, we conducted interviews with older people in Hebi city, Henan Province, and analyzed the facilitating and hindering factors for the acceptance of health education in this population.

Methods

Study setting and participants

This study adopted the constructivism research paradigm, and the method of descriptive qualitative research was used to analyze the influencing factors for accepting health education of rural older adults. This study referred to the Consolidated Criteria for Reporting Qualitative Research (COREQ), a 32-item checklist [18]. During the in-depth interviews, we strictly followed the principles of informed consent, and no harm or confidentiality. The research was approved by the Life Sciences Ethics Review Committee of Zhengzhou University (Ethics Review No. ZZUIRB 2021 − 105), and each participant signed an informed consent form.

The researcher used the purposive sampling method and followed the strategy of maximum variation sampling, focused on age, sex, education level, physical condition and other factors. We recruited rural older people in Hebi city, Henan Province, China, from March to May 2023. We recruited participants through the local township health center, a health institution in rural China that provides free physical examination services for rural older adults every year. The researchers built trust by helping medical staff at township health centers to provide volunteer services to rural older adults, and helped older adults interpret medical reports. Considering that the elderly were hungry after their check-ups, the researchers prepared some bread. The researchers recruited eligible older people who met the criteria to enter the study and recorded the contact information at the same time. The participants were recruited through the following criteria:

Inclusion criteria:

Over 60 years old [19];

Having had a rural household registration and living in a rural area at least year [20];

A clear consciousness can correctly understand the content of the interview, and there is no obvious obstacle to communication;

Informed consent

(4) and voluntary participation in this study.

Exclusion criteria:

Cognitive impairment, unclear thinking and mental illness;

Hearing and visual impairment.

The study allowed the participants to refuse or withdraw halfway through the interview, allowing participants to withdraw from the interview is not allowed at any time, but to reconfirm whether the participants agree to the interview before starting, and if irresistible factors arise during the interview, the researcher respects the participants’ choice. For example, two older adults refused at the beginning because they had been busy, and one participant withdrew halfway through due to additional household chores. The sample size of this study was based on the principle of reaching saturation; that is, the researchers continued to interview one or two participants, but no new interview themes emerged [21]. Fourteen rural older adults were eventually included in this study.

Conceptual framework

Social ecosystems theory involves the close integration of systems theory, sociology, and ecology, emphasizing that individual development interacts with the surrounding environment to form a complete ecosystem, including microsystems, mesosystems, and macrosystems [22].The microsystem includes influences on individuals; the mesosystem includes families, occupational groups, and other social groups; and the macrosystem mainly includes organizations, communities, and culture, as shown in Fig. 1. Based on this theory, this study aimed to explore the factors related to the acceptance of health education among older people from three perspectives, microsystems, mesosystems, and macrosystems, to provide practical and guiding significance for health education for rural older people.

Fig. 1 Social ecosystems theory

Procedure

The interviewers for this study included two nursing students, both of whom were engaged in geriatric nursing research. All the researchers systematically studied qualitative methods and interview techniques. We invited experts from geriatric nursing, health education, community care and other fields to discuss the outline, they have worked in the nursing field for more than 10 years, with the title of professor or chief nurse, and have rich clinical and research experience. The experts gave some opinions before the formal interview, such as using open-ended questions and language that is friendly to rural older adults. The researchers combined experts’ advice to formulate questions that were not isolated from the lives of rural older people and were relevant to the study topic. We selected two rural older adults for preinterviewing, and we found that rural older people did not know much about health education and that their attitude toward health education was not active enough; therefore, the interview questions were adjusted according to the circumstances of the interview and the mood of the participants. Moreover, information extraction was relatively limited during the process of analysis, and the structure of the outline was readjusted. According to the feedback, the researchers further discussed and determined the final version of the interview guide, which is shown in Table 1. Demographic information, including information on gender, age, and educational attainment, was collected at the beginning of the formal interview.

Table 1 Interview guide

Final edition	
Question1: Do you know what health education is? (Explain if you do not.) What do you think about health education?	
Question2: Have you ever received health education? If yes, what prompted you to receive health education? If not, what were the reasons for your refusal?	
Question3: What do you think are the current difficulties and challenges in accessing health education for rural older adults?	
Question4: What are your suggestions and expectations for health education?	

Data collection

In this study, a face-to-face semistructured interview method was used to conduct the interviews. Before the interviews, the researchers negotiated with participants on the time and place of the interviews by phone. We chose a scene that the participants were familiar with and ensured that the time was sufficient; thus, interviews were conducted in a quiet room at their home. At the same time, the researchers fully informed participants of the purpose and significance of the study. After providing informed consent, the researcher explained the concepts of health education and conducted a face-to-face interview via the interview guide. During the interview, the interviewer recorded the content of the interview by audio and text; if the participant appeared to be out of control, the interviewer paused the interview and comforted the participant. The interviewers promised the participants that the interview data would be used only for academic research and that personal privacy would be kept strictly confidential. The interviews lasted 30 to 40 min. After each interview, the interviewers thanked the participants by giving them gifts (in the form of a medicine box and salt-control spoon) and health education manuals.

Data analysis

Notably, the data analysis was carried out in parallel with the data collection. The interviewers continued to interview two participants, but no new interview themes emerged; thus, they conducted 17 interviews in total. After each interview, the interviewers transcribed the recordings within 24 h. A study team member collated each participant’s interview transcripts, and all team members checked the transcripts with recordings and notes for accuracy. Finally, the researchers returned the data to the participants to check for authenticity. The researchers created a unique file for each participant and used the codes from A1 to A14 instead of their real names. The themes were summarized and extracted using the qualitative content analysis method [23], a summative content approach [24]. First, the investigators read the transcripts to familiarize themselves with the data and marked the meaningful statements. Two team members were responsible for coding and categorizing the data independently. There was consensus among them, but when there was a disagreement that could not be resolved, a third researcher participated in the decision. The researchers subsequently sorted these initial codes into themes and subthemes and evaluated associations between themes. All the members discussed and confirmed the themes, and the above steps were repeated until the theme was met. Our data analysis steps were performed with the help of NVivo V.11.

To ensure the principles of credibility, dependability, and transferability. Two interviewers were trained in qualitative methods and transcribed the interviews within 24 h. Two members coded the data and reflected on themselves back to back. The results were discussed by all members of the research team, and they had no significant disagreements on themes or subthemes. In addition, the researchers met every week and discussed new findings to ensure the trustworthiness of the data. In the end, the researchers returned the themes to the participants and asked them if the themes accurately represented what they were talking about, and the participants agreed with the results.

Results

Participants

Eventually, 14 participants were included in this study; 8 were male, and 6 were female; 7 were in the 60–69 years age group, 5 were in the 70–79 years age group, and 2 were in the 80 years and older; 6 had education levels of elementary school and above, 4, 3, and 1 were in junior high school, senior high school, and college, respectively; 8 were farmers by occupation, 2 were veterans, 1 was retired teacher, 2 were freelancers, and 1 was migrant worker. The details of the study subjects are shown in Table 2.

Table 2 Characteristics of the participants

Number	Age	Gender	Education level	Career	Marital status	Health condition	
A1	69	male	elementary school	farmer	widowed	herpes zoster	
A2	76	male	elementary school	farmer	married	esophageal cancer	
A3	66	male	junior high school	freelancer	married	hypertension, diabetes	
A4	87	male	elementary school	veteran	married	healthy	
A5	63	male	senior high school	veteran	married	aortic aneurysm	
A6	72	female	senior high school	farmer	married	dermatology	
A7	68	male	junior high school	migrant worker	married	diabetes, coronary heart disease	
A8	69	female	college	teacher	married	hypertension, gastritis	
A9	71	male	elementary school	farmer	married	osteoarthritis	
A10	67	female	junior high school	farmer	married	hypertension	
A11	76	female	elementary school	farmer	widowed	esophageal cancer	
A12	75	female	elementary school	farmer	married	hyperlipemia	
A13	81	male	junior high school	farmer	widowed	diabetes	
A14	64	female	senior high school	freelancer	married	bronchitis	

The interviews produced three dimensions, microlevel, meso-level, and macrolevel, which were each categorized into facilitators and barriers; these themes and subthemes are presented in Table 3.

Table 3 Themes and sub-themes of research

	Facilitators	Barriers	
Microsystem level	Holding correct health concepts

Wish to enjoy a good later life

Enthusiasm for learning

Do not want to add trouble to others

	Inadequate awareness of health education

Limited personal learning ability

Negative attitudes toward health

	
Mesosystem level	Having a sense of family responsibility

Ethical benefits to family members

Reducing the financial burden of family

Villagers help each other

	Limitations on life’s chores

Insufficient intergenerational support

Social group interference

	
Macrosystem level	Help from the State and Society	Lack of learning opportunities and resources

Shortcomings in health education

Complexity of the health communication environment

	

Microsystem level

Facilitators

Influences at the microsystem level are mainly individual factors and comprise four main subthemes explaining the facilitators of accepting health education. These included:

Holding correct health concepts

In the interviews, most of the participants affirmed that health is the most important thing, and some of them had deep thoughts about health and health education. The participants’ experiences and past experiences were incorporated into health education, and they gradually formed correct and unique opinions on health through long-term accumulation. These older people maintained positive attitudes toward health education, and they were very willing to accept any form of health education in any aspect.

“Because these things learned are truly useful, just like financial management, financial management is money investment, health knowledge is the body investment, the body is the most important to get the wealth.” (A5).

“That is, that now we have to cure the disease before it occurs, rather than having a disease and then go to the treatment, before it occurs to prevent it beforehand……. If there is no thought of curing the disease before it occurs, you can only let the disease develop, and then it will be too late to see a doctor.” (A6).

Wish to enjoy a good later life

Five participants said in the interviews that they wished they could live in good health and have a longer time to enjoy a happy life in their later years. They believed that living conditions have changed drastically compared to those of the past and that they are now catching up with good times. Moreover, when they were young, they were busy with their work and did not have time to enjoy their lives, or they had a new and deeper understanding of life after experiencing major trauma from illnesses. They are more interested in enjoying their lives within a limited period of time, and the prerequisite for enjoying their lives is to maintain a healthy body.

“I am retired and have more time, and I want to be in better health. If you take good care of your body, you will not get sick easily and can enjoy later years happily, but if you get sick, it will affect your quality of life and your mood” (A8).

“I am willing to live in this world, especially after going through illness and surgery; I feel that life is precious, and I would like to enjoy the days of my life. I’m getting older, and my days are numbered.” (A11).

Enthusiasm for learning

Some participants showed enthusiasm and anticipation for learning, saying that although they were old, they should continue to learn and not indulge themselves. They also revealed that their lives were dull and repetitive and that their free time was spent going out to the village square and talking to other people. They needed something new to add color to their lives, and education about health was something they needed and was happy to study.

“I think learning a little bit of health knowledge is helpful to people’s body and all aspects; can change my wrong ideas, change my bad habits, I also like to learn something new, haha.” (A10).

“Doctors come to give us health education is a good thing, ah, it is better than I play cards and gossip outside, free time to learn something is very useful… In addition, the more you use your brain, the more flexible it becomes. Learning is good, I’m still young now; if I do not learn, I will be eliminated by society.”(A5).

Do not want to add trouble to others

The participants interviewed generally cannot agree that they should not add trouble to their families, society or the state. According to the conception of the older generation in China, one should live to contribute to society and collectivity and to realize the value of one’s life. Even in their twilight years, they should continue to provide value to others, or at least they should remain in good health and not unnecessarily trouble others. They said that the state and society have already done much for the older people and that they should actively cooperate with the government and learn about health.

“People do not live only for themselves. In the future, we should gradually increase awareness of health, and older people can be less sick after they all understand it. This will not only reduce the burden on the state and society but also enable the older people to continue to work outside the home.” (A6).

“Good health also makes the children feel at ease outside the home; I cannot earn money. Being sick is just asking for trouble; the children are not at home; this is the plight of the empty-nest older people.” (A9).

Barriers

In terms of barriers at the microsystem level, we explored the following personal factors: inadequate awareness of health education, limited personal learning ability, and negative attitudes toward health.

Inadequate awareness of health education

Some of the participants mentioned that they were in a healthy condition and therefore did not know much about health education. They also thought that health education was not very useful, did not have a positive impact on their lives and that getting cured as soon as possible was the most important thing. Obviously, they neglected the role of other forms of health and illness in addition to medical treatment.

“I work at home every day, I have always thought that health knowledge is still useless for healthy people, I have never taken medication, and I do not need this irrelevant health knowledge.” (A1).

“I did not think that health education would bring any benefits to my life, and I did not deliberately approach health knowledge to change my habits; I did not feel uncomfortable following my own lifestyle.” (A14).

“High blood pressure is not a very serious disease; I think the easiest way to cure high blood pressure will be fine, and the cure is more useful than learning about health.” (A3).

Limited personal learning ability

Many of the participants interviewed indicated that lack of capacity and literacy were significant barriers to receiving health education. They believed that older people were not physically strong enough to sustain learning for long periods of time, although they may have good intentions and want to receive relevant health education. The physical function and learning ability of these individuals decline and cannot be improved in a short time, so there is resistance and inertia in education.

“I had a very little education and only went to school for three years as a child. I rarely take the initiative to learn this content in life because the literacy level cannot be reached.” (A9).

“It is complicated, and I cannot learn it. I did not do well in school, but now I’m older, my brain does not work, I cannot understand the technical terms people say. I’m a little deaf in one ear, I cannot hear clearly, and my eyes are blurred; I cannot see clearly, well, it is quite difficult for me.” (A4).

Negative attitudes toward health

Individuals believe that having a disease is equivalent to being sentenced and that accepting health knowledge does not help. In their opinion, the end of the disease cannot be changed by human influence but is firmly in the hands of fate. They overstated the role of fate and ignored the impact of human factors on health; thus, they thought it was advisable that older people not learn about health and not change bad habits.

“When you get this kind of disease (herpes zoster), it is all about destiny. Common people say that this is a “snake wrapped around the waist”; if a circle is formed, people will not live…and some people can be cured, while others are not forever.” (A1).

“People’s lives are predestined by God; when they get sick and when they leave the world, God has decided, so we should enjoy ourselves when we are alive and not treat ourselves badly because of disease.” (A12).

Mesosystem level

Influences at the mesosystem level are centered around family and group aspects and are similarly described as facilitators and barriers.

Facilitators

Among the facilitators at the mesosystem level, we derive the following results: having a sense of family responsibility, having ethical benefits to family members, reducing the financial burden of family, and villagers help each other.

Having a sense of family responsibility

Having a sense of family responsibility emerged as a significant facilitator of accepting health education. Some older people receive health education and learn about health because they want to help their sick family members. They show high motivation for health education, and their sense of family responsibility drives them to have greater acceptance of and compliance with health knowledge.

“My partner has diabetes, heart disease, arthritis… Ugh, she gets a lot of disease! I am in charge of her meals and medication every day; I need to learn about what is useful for my partner.” (A2).

“I just want to be healthier because my partner is not in good health, and she has to rely on me… without good health, I cannot take good care of her.” (A4).

Ethical benefits to family members

Chinese tradition tends to favor older people living with their children, and children supporting older people are regarded by neighbors as a sign of filial piety. Family members receive moral praise from others, so some older people feel that maintaining good health can benefit themselves and their families.

“People say that an old man in the family, everything is good. When I live a long and healthy life, neighbors say that my children are filial and that I also feel proud; the family is harmonious and happy.” (A11).

Reducing the financial burden of family

A considerable portion of the participants believed that they no longer had the ability to earn money to support their families, so they could not be sick and put additional pressure on their children; being healthy can reduce the financial burden on their families. Some participants also mentioned that health knowledge helped them avoid greater losses, mainly because they followed the advice of their doctors to check regularly.

“Patients must listen to the doctor; if you do not listen to the doctor, there will be a big trouble. If the disease progresses, it will cost a lot of money, and the body will suffer damage again. Of course, we check up on time, and the monthly medical costs are getting lower and lower.” (A2).

“Currently, the cost of hospitalization is so expensive, and serious illnesses will put a burden on the family, so it is better to take precautions through health education.” (A7).

Villagers help each other

Some of the participants told the researcher that they learned about health and were very happy to share with others. Due to the nature of the rural society of acquaintances, most rural older persons are more helpful. They tend to share information and resources and offer help to each other, both in terms of life and health.

“I learn these things; if someone has a need, I can tell him; it is a good thing to help others. Rural people communicate with each other to spread health information, and my friends have told me a lot before.”(A10).

“My partner died of heart disease. I did not know what to do when I was faced with this situation, and it was my neighbors who helped me call the hospital and my children. Later, I went to learn about health so that I could help when I encountered this situation in the future.” (A11).

Barriers

At the mesosystem level, together, these themes constitute barriers to health education for older adults: limitations on life’s chores, insufficient intergenerational support and social group interference.

Limitations on life’s chores

There is no clear retirement boundary for the rural older population, as old women tend to take care of their grandchildren, while men usually continue to work on farms or work outside the city; they are all busy with their daily chores. According to the participants, earning money and taking care of children are the top priorities, but they are still able to work. They described their daily lives as “tired” or “busy” and said they had no extra time or energy for health education.

“I cannot be idle in my spare time; I don’t need to do farm work now, but I have to work outside to earn money, and I am busy with work.” (A12).

“I help my son look after the grandchildren, I cook for them, and take them to school every day. I also have to do housework in my free time; my schedule is very full; you see, I do not have time to study.” (A14).

Insufficient intergenerational support

Many rural older people’s children work outside all year round, and there is insufficient intergenerational interaction and help. Eight of the interview subjects reported not having a smartphone or not being able to use a smartphone and lacked autonomy in seeking health pathways.

“My children are working outside, they bought me a smartphone, but most of the time my grandchildren play with it, I do not know how to search for health information, and there is no one to teach me.” (A14).

“It is just me and my partner at home; we have a TV, but I do not know how to look for health programs on it.” (A4).

Social group interference

The negative influence of family and friends on health education. Among the participants interviewed, more men said that their decades-old habits, such as smoking, drinking and a high-salt diet, could not be easily changed. The participants were surrounded by friends and relatives with similar bad habits, and everyone did so without many negative effects. If individuals choose to learn about health knowledge and change bad habits, they will appear very different in the group, and their lives and social interactions will also be adversely affected.

“My friends often call me to drink with them, and when we drink, we definitely want to smoke. I think drinking can make blood pressure lower, which is the opposite of health education.” (A3).

“There are a lot of relatives and friends who have high blood pressure, and no one is learning or following health knowledge. I have heard that people should eat less salt, but I do not know if that is right. My family likes salty food, we all eat together and do not change our dietary preferences because of one or two members.”(A13).

Macrosystem level

Facilitators

At the macrosystem level, the facilitators familiar to older people are help from the state and society in health care.

Help from the State and Society

In regard to current social welfare and access to health care, all older people agreed that the state and society give great help and have an enormous positive effect on health promotion. Older people welcome health education activities initiated by the government and social welfare organizations.

“The government pays me an old-age pension every month, the health center organizes free medical checkups every year, and the family doctor gives me some health message.”(A6).

“The country attaches great importance to old people, and now everyone knows that good health is the most important thing. The village committee broadcasts precautionary measures to the loudspeaker during the pneumonia pandemic.” (A12).

Barriers

With respect to the barriers to receiving health education at the macrosystem level, the lack of learning opportunities and resources, shortcomings in health education, and the complexity of the health communication environment, the emergence of these factors above has hindered older people.

Lack of learning opportunities and resources

According to the interviews, some participants suggested that there are insufficient facilities and few opportunities for health education in rural areas. They hoped that village councils could use abandoned elementary schools as a place for recreation and learning for older people and that all health facilities for older people in rural areas need to be upgraded. A lack of resources is an impediment to learning for older people, and older people will only be able to participate actively in health education if the facilities are in place.

“Life in the countryside is too boring; there are all sorts of activity centers for the older people in big cities, but there is nothing in the countryside; it is boring! Older people know that health is the most important thing, but just do not have the means to learn it.” (A8).

“We are in a remote location in our village, and we do not have easy access to transportation, so there is less health education, and we have to go to other villages a few miles away to see a doctor.” (A2).

Shortcomings in health education

Three participants with high blood glucose levels said that they were deeply troubled by sugar control, that there was a discrepancy between health education and their actual situation, that there were still difficulties in the implementation of specific measures for dietary management and that the effect of blood glucose control was unsatisfactory. Other participants expressed other shortcomings in health education and their expectations. They hoped that the forms of health education could be colorful and enjoyable and that the atmosphere could be enlivened while education was going on to increase older people’s enjoyment of learning.

“There is a blood glucose meter in my home, and I measure it once every two or three days, and the doctor told me that I can only eat a little staple food at a meal, but I am doing manual labor; I will be very hungry when I eat very little.” (A3).

“If people are afraid to eat anything, their bodies will fail, and they cannot just watch their blood sugar and delay other nutrition…I know the recommended healthy recipes; this diet is not common in rural areas, and there are some health food products that are quite expensive. With my standard of living and conditions, I would not buy these additionally.” (A7).

“When we participate in the physical examination, the doctor will organize people to listen to the lecture, is to sit there to listen to the doctor. I was a bit sleepy in the morning, and I did not know what the doctor was talking about. I hope the format will be more lively so that the older people will be interested.” (A11).

Complexity of the health communication environment

Very few participants showed a sense of mistrust of health education in the interviews because of previous experiences of being deceived by marketing. From their descriptions, the researcher learned that in the past, there was frequenting by for-profit organizations that conducted illegal activities by holding health seminars. Although the government has since cracked down on wrongdoers, such experiences have reduced the trust of older people in health education.

“Some people used to come here to give health talks and advertise their products… I feel insecure; older people are easily confused with too much information.” (A10).

Discussion

Facilitating factors are entry points for older adults to receive health education. The personal factors that promoted the acceptance of health education among the rural older adults in this study included the desire to maintain good health and enjoy a good life. This is likely because most of the participants interviewed had chronic diseases, and they were eager to improve their health management through learning about health as a way to slow the progression of their disease and improve their personal quality of life. This phenomenon reflects that rural older people are becoming increasingly more concerned about their health status, and their need for health education is becoming increasingly prominent [25], which is in line with the national policy of “taking responsibility for one’s own health” [26]. A study by Han Wei et al [27]showed that the motives for health education for older people include realizing the value of life, serving the family, and improving quality of life; these findings are similar to those of the present study, such as not wanting to add trouble, having a sense of family responsibility, family members’ common benefits, and reducing financial burdens. Due to the influence of traditional Chinese concepts and the collectivist idea of willingness to give, many older people prefer to maintain a healthy body and do not want to add burdens to the family or even society; at the same time, some older people whose partners are in poor health wish to use knowledge to protect the health of their family members more strongly. Therefore, before the implementation of health education, educators should have a full understanding of the target audience and start from facilitating factors to stimulate their intrinsic motivation to learn. The sense of family responsibility of older people should be further strengthened so that they realize that health education can not only help them stay healthy but also help them pass on health knowledge to their families and that they are responsible for the health of their families so that their families can experience a sense of benefit in the process of receiving health education.

During the interviews, participants provided many points that needed attention at the interpersonal level. First, we found that some rural older people are not motivated to receive health education and that the obstacles are the influence of social groups such as family, relatives and friends, which shows that the cognition and behaviors of the social group play a large role in their health perceptions. Similarly, in a study [28], the researcher found that negative habits and attitudes of family and friends negatively impacted the healthy lifestyles of the participants, who mentioned wanting to fit in socially, even at the cost of health. Therefore, pinpointing the groups behind individuals with negative perceptions and habits is the first step in health education. In contrast, a unique finding of our research is the existence of health mutual support groups among rural older adults, which are important health education facilitators. Currently, the Chinese government [29] and academics [30] advocate mutual assistance for old-age care, and on this basis, health education can be integrated into mutual assistance for old-age care through the use of neighborhood mutual aid platforms combined with peer support teaching methods. Educators encourage older adults to become “peer volunteers” in health education and to disseminate health information to the wider population.

Previous research has shown that intergenerational support can be effective at improving the health of older adults [31]. The unique finding of this study is that insufficient intergenerational support from the families of the participants interviewed was one of the factors that hindered rural older adults from receiving health education. Rural older adults do not receive support from their children, and there is a lack of communication and interaction, especially in relation to health education. Several researchers have noted that multigenerational and intergenerational learning helps to enhance the motivation and ability of older persons to participate in learning [32]. The family is the first gateway to health. Health education should not be limited to interventions for older people but should be centered on the families of older people. Considering the family environment and family members’ support and with the goal of improving health, children and parents should be included in health education programs to increase the interaction and participation of young children and their parents and to increase the acceptance of health education by older people so that health education can achieve twice the level of effort.

At the macro level, the lack of resources and opportunities in rural areas is a major barrier, with participants citing incomplete health facilities and fewer opportunities for health education in rural areas than in urban areas, which has also been reflected in other studies [33]. On the one hand, there is an imbalance in the development of health resources between urban and rural areas in China, and on the other hand, there is an inefficient allocation of health resources in rural areas [34]. Of course, the barriers to health education for rural older adults lie not only in the lack of objective health resources, but also in the subjective factors of individuals, which require equal attention. This study revealed that some of the participants lacked a correct understanding of health education and had a negative attitude toward health, which hindered their participation in health education to a certain extent. One study [35] found that the low utilization of health services by rural older persons was because rural older persons are deeply influenced by their subjective perceptions and life experiences and subjectively believe that health resources are inaccessible. Therefore, health education should also include a culturally competent component that reverses the mindset of older persons.

Participants in the study mentioned shortcomings in the content and format of their current health education, and other studies have also found this [36]. Therefore, before health education, investigating and making a list of the learning needs of older people is necessary [37]. In addition, drawing on a diverse range of education curricula and forms of education is conducive to attracting older persons to the learning process. For example, Marvin [38] used methods that resonate with men’s careers and habits to increase the participation rate of older men in his study. In China, rural older people are mostly engaged in farming, and opera is their favorite form of entertainment. Therefore, it is recommended that educators break away from traditional forms of education and innovatively incorporate elements of traditional Chinese opera into teaching activities. Moreover, with local characteristic folk culture as the background and farmers’ daily life as the main line, with the opportunity to attend traditional Chinese festivals, a health experience platform with rural characteristics was built for the rural older people. It expands the influence of health education and the dissemination of culture while enriching the forms and contents of health education.

Suggestions on promoting health education for rural older people

At the macro level, first of all, relevant laws and regulations should be issued successively at the national level to strictly control the dissemination channels and contents of health education, and to establish unified and standardized evaluation standards [39], and guarantee the right of older people to receive formal health education. Second, the government should strengthen the construction and management of rural health equipment, and increase the number of healthy devices, healthy parks, healthy houses and other facilities in rural areas [40]. The three aspects of physical activity, living environment [41] and indicator monitoring are combined with health education to form a complete health chain. Finally, the effectiveness of health education is closely related to teachers; however, there is a relative lack of research on the training and selection of health education teachers [42].Therefore, relevant departments should use the training of health education personnel as a source, learn from the implementation of the construction of foreign health education teachers, and cultivate health education composite talent with good communication skills and interprofessional backgrounds [43].

It is particularly important to mobilize educational resources within the families of rural older people at the meso-system level. In cooperation with three-tier medical associations, village committees should pay active attention to changes in the structure of rural older people’s families. Moreover, regular activities should be organized to promote the culture of filial piety and family bonding exchanges to enhance the awareness of filial piety among young people in rural areas. Health educators can create a digital narrative health education platform [44] to promote cultural feedback from children to older adults and leverage the power of children to strengthen self-care education for older adults. At the microsystem level, older people feel the inconvenience of reduced physical fitness, coupled with the fact that most older people have a low level of literacy and are clearly overwhelmed by health education; therefore, age-friendly health education materials need to be designed and promoted [45]. In addition, it is recommended that educators integrate health education into the lives of rural older adults by setting up a multiagent, digitally intelligent health education journey [46], changing the role of older persons from “educated person” to an active participant, and allowing older persons to become “health experience officers” with no barriers to accessing health education.

Limitations

First, our sampling strategy has several limitations: the sample for this study was drawn from only one city in Henan Province, and additional research is needed on rural older individuals in other regions. Second, this study interviewed only older people with hearing ability and speaking ability; thus, we do not know the facilitating or hindering factors of older people with limited hearing ability, and since older people who underwent free physical examination have basic mobility, we lacked the exploration of older people who have been sick in bed for several years. A follow-up study should expand the regional scope and include elders who have difficulties listening, speaking and mobility, and family members of these older adults should be included in the interview. Currently, we have explored only the attitudes of rural older adults toward health education. In the future, we plan to include stakeholders involved in rural health education, including village and township government officials, healthcare workers within the three-tier medical association, family doctors, and children of older adults, in the study to conduct multifaceted, multicenter interviews and develop a questionnaire.

Conclusion

The results of the interviews revealed that the acceptance of health education for rural older adults is numerous and complex. The thematic analysis of this study identified a total of 9 facilitators as well as 9 barriers to the acceptance of health education at three levels: the microsystem, the mesosystem, and the macrosystem. At the microsystem level and the macrosystem level, most participants mentioned corresponding facilitators and barriers, which we need to refine and improve at the individual motivational and macro levels. Our key finding is that facilitators and barriers at the meso-system level, these factors are relevant to socialization and family, e.g., family responsibilities, moral benefits, and financial burdens motivate people to pursue health, and corresponding family chores and intergenerational support need to be improved. At the same time, social groups and relatives have two sides, and we need to accurately identify and categorize these social groups with a combination of interventions.

Author contributions

Huizhong Zhang wrote the main manuscript text; Yuwen Yan prepared Table 1, and 2, Xizheng Li prepared Table 3; Fig. 1;Yan Zhang, Yutong Tian revise the manuscript text; All authors reviewed the manuscript.

Funding

Henan Provincial Social Science Circles Federation(SKL-2023-569)

Data availability

The qualitative datasets are not publicly available due to the data containing information that could compromise research participant privacy/consent, but are available from the researcher Huizhong Zhang (3156871248@qq.com) on reasonable request.

Data availability

The qualitative datasets generated and/or analyzed during the current study are not publicly available due to the lack of data containing information that could compromise research participant privacy/consent but are available from the researcher Huizhong Zhang (3156871248@qq.com) upon reasonable request.

Declarations

Ethics approval and consent to participate

Informed consent was obtained from all subjects and/or their legal guardians. This study was approved by the Life Sciences Ethics Review Committee of Zhengzhou University (Ethics Review No. ZZUIRB 2021 − 105).

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Statement

The study was carried out in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ).

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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