Evaluation of Healthy Life Center Services within Primary Care: A Cross- Sectional Study of User Perspectives

Evaluation of Healthy Life Center Services within Primary Care: A Cross- Sectional Study of User Perspectives | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Evaluation of Healthy Life Center Services within Primary Care: A Cross- Sectional Study of User Perspectives Kerem Arısın, Zeynep Tüzün, Mehmet Akif Sezerol, Yusuf Çelik, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8888176/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background Primary healthcare services are the fundamental system that facilitates access to preventive healthcare services for the community and supports healthy lifestyle behaviours. Healthy Life Centers (HLCs) were established to protect individuals and the community from health-related risks, promote a healthy lifestyle, strengthen primary healthcare services, and facilitate access to these services. The acceptance of HLCs in the community is closely related to the existence of the service, how individuals evaluate this service, their level of satisfaction, and their willingness to continue using the service. This study was conducted to examine accessibility, perceived service quality, satisfaction, intention to continue using the service, recommendation behaviour, out-of-pocket expenditure, and willingness to pay for the service among individuals receiving services from HLCs. Method The study is a cross-sectional study conducted between August and September 2025. The study group consisted of individuals aged 18 and over who applied to the HLC, agreed to participate in the study, and could speak and understand Turkish. No separate sample size calculation was made for the study, and the aim was to include all individuals who applied to the HLC in the study. This research was approved by the Istanbul Medipol University Non-Interventional Clinical Research Ethics Committee. Data were collected using a semi-structured questionnaire administered through face-to-face interviews. It was conducted within the framework of the access model developed by Levesque and colleagues in order to evaluate the factors affecting access to HLC in a multidimensional manner. The form included questions on sociodemographic characteristics, use of HLC, perceived service quality, satisfaction, recommendation and intention to continue using the service, out-of-pocket expenditure, loss of income, and willingness to pay. In the analysis of the data, descriptive statistics were used; for categorical variables, the number and percentage were given, and for numerical variables, the median, interquartile range, minimum and maximum were given. Comparisons were made using the Chi-square test , Mann Whitney U test and the the logistic regression analysis. In all statistical analyses, the significance value was accepted as p<0.005. Results Results: In total, 567 participants were included; most reported high overall satisfaction with HLC services (88.9%) and stated they would recommend the center to others (89.2%), while 83.8% indicated an intention to continue using HLC services. Intention to continue use differed by educational status (p<0.001) and social security coverage (p=0.009) in bivariate analyses, while age was also associated with continuation tendency (p=0.007). In the multivariate logistic regression model for intention to continue using HLC services, having social security was independently associated with higher odds of intended continued use (OR=1.81, 95% CI 1.01–3.25; p=0.045). Compared with illiterate participants, high school graduates (OR=9.03, 95% CI 2.22–36.7; p=0.002) and university/postgraduate graduates (OR=4.30, 95% CI 1.04–17.77; p=0.043) were more likely to report intention to continue, whereas age was not significant in the adjusted model (OR=0.99, 95% CI 0.99–1.01; p=0.481). Conclusion The study demonstrates that HLCs generate high levels of satisfaction, recommendation, and willingness to continue the service within the community; this indicates that the services are valued by the community. Out-of-pocket expenditures are low, and direct income loss is limited. HLCs play a significant role in reducing health access issues arising from income inequality at the primary level. The findings show that HLCs perform a balancing function in accessing healthcare services, particularly for individuals with low levels of education and limited social security. Ensuring that individuals with low income levels or no social security can sustainably benefit from HLC services will both reduce inequalities and significantly protect public health. Increasing the awareness of HLCs within the community would also be an important step in this direction. The fact that our study was conducted at a single center limits its generalisability, and the fact that we only spoke to those who applied to the HLC and agreed to be interviewed limits it in terms of selection bias. Intention to continue the service Satisfaction Willingness to pay Healthy Life Center BACKGROUND Primary healthcare services are a fundamental structure that forms the first point of contact between the community and the healthcare system, based on the understanding that health is not merely the absence of disease but a state of complete physical, mental and social well-being. They provide participants with early, comprehensive and continuous care, combining preventive, curative and rehabilitative services( 1 , 2 ). These services enable the early detection of health problems, thereby reducing the need for secondary and tertiary healthcare services and supporting the cost-effectiveness of the system( 3 , 4 ). Based on the principles of equality and accessibility, primary healthcare services aim to ensure that participants can benefit equally from basic healthcare services regardless of differences in income, education or social status( 5 ). This approach aims to provide fair and balanced healthcare services in the community by reducing health access disparities arising from socio-economic conditions through the provision of free services, the promotion of preventive healthcare practices, and equal access for all segments of society ( 5 , 6 ). In this respect, it creates a structure that not only ensures access to services but also contributes to increasing participants opportunities to benefit from services and reducing indirect costs and out-of-pocket expenditure, thereby strengthening the equitable and sustainable functioning of the healthcare system( 2 ). Primary healthcare services in Turkey are delivered through District Health Directorates, Family Health Centers, Community Health Centers, and various units integrated into this structure(7). Healthy Life Centers (HLC), established in 2017 to strengthen this structure, were created to promote preventive services throughout the community and protect participants from health risk factors( 8 ). These centers focus on public health issues such as insufficient physical activity, unhealthy nutrition, obesity, tobacco use, and increasing mental health needs in order to respond to the disease burden shifting from infectious diseases to chronic and lifestyle-related diseases in line with the epidemiological transition process( 9 – 11 ). Healthy Life Centers (HLC), operating within District Health Directorates, offer multi-dimensional applications such as nutrition counselling, chronic disease management, physical activity and obesity counselling, mental health, women's and reproductive health, cancer screening, and child and adolescent health services. through tobacco and substance abuse prevention, healthy ageing, participant counselling, and community education programmes, they strengthen the preventive aspect of the primary healthcare system and contribute to improving health at the societal level ( 9 ). All the aforementioned services are provided free of charge at Healthy Life Centers in Turkey. The provision of free primary healthcare services creates significant opportunities for equality across broad sections of society; however, it does not entirely eliminate the indirect costs that may arise during the process of accessing the service( 12 ). Factors such as transportation difficulties, time loss, or the necessity for participants to temporarily leave those they are responsible for caring for can create indirect economic and social burdens on access to services( 13 ). Such indirect costs can negatively affect health service utilisation behaviour and the level of utilisation of preventive services, particularly among disadvantaged groups, thereby weakening the equitable nature of the service( 13 ). However, it is evident that access to services is not limited solely to physical and economic conditions; participants perceptions, expectations, and experiences regarding services also shape this process( 14 ). In this context, the quality of support provided, perceived adequacy, ease of access, the communication style of healthcare workers, the effectiveness of information processes, and the level of fulfilment of participant expectations are among the main factors determining not only the acceptance and sustainability of primary healthcare services in society but also participants propensity to seek services again and their general attitudes towards the healthcare system ( 15 ). Therefore, considering not only the structural characteristics of the services provided in PHCs, but also the participant experience, perceived service adequacy, and indirect cost dimensions together contributes to a comprehensive understanding of service effectiveness at the primary care level. The aim of this study is to evaluate the services provided by Healthy Life Centers operating within primary healthcare services, based on the experiences of users receiving these services, in terms of accessibility, perceived service quality and indirect costs. The study aims to analyse indirect costs that may arise during the service access process, such as transportation, time loss, or care responsibilities, as well as participants perceptions and experiences regarding the service. It further aims to reveal the contribution of Healthy Life Centers to primary-level preventive healthcare services, their effectiveness, and their implications for a sustainable healthcare system. MATERIALS AND METHODS Research Type and Design This study was conducted among participants aged 18 years or older who speak Turkish and who visited the Healthy Life Center (SHLC) in Sultanbeyli, the district with the lowest socio-economic development level in Istanbul, which has a population of approximately 370,000 (16). The SHLC is an important component of primary healthcare services and provides services through its psychologists, physiotherapists, dieticians, CEDSC (Cancer Early Diagnosis, Screening and Education Center) unit, and Mother and Child Health Unit. The study is a cross-sectional study evaluating the sociodemographic characteristics, health service utilisation status, and willingness to pay of participants applying to the SHLC. This study was conducted within the framework of the access model developed by Levesque and colleagues in order to conceptually explain access to health services and to evaluate the factors affecting access to the SHLC in a multidimensional manner(17). Within this framework, the Levesque model was used as an interpretive conceptual approach rather than a formal measurement tool. Study variables were subsequently mapped to the relevant access dimensions to facilitate multidimensional interpretation. The model addresses the structural characteristics of healthcare systems and participants access capabilities together, making system- and participant-related barriers visible. Accordingly, referral pathways and awareness of SHLC services were interpreted as indicators of the ability to perceive and seek care; visit duration and access-related characteristics as indicators of accessibility and the ability to reach; cost-related variables as indicators of affordability and the ability to pay; and satisfaction, intention to continue use, and willingness to recommend services as indicators of appropriateness and the ability to engage. No sampling was performed in the study; all participants who applied to the center during the research period and met the inclusion criteria were included in the study. Data were collected using face-to-face surveys, and a pilot study was conducted with a group of 90 participants to test the comprehensibility of the survey form prior to implementation. Data obtained through pilot interviews were not included in the analyses. A total of 581 participants were evaluated in the study, which was conducted between August and September 2025 Participants The study was conducted among users who applied to SHLC between 09:00 and 16:00 and agreed to participate in the research on a voluntary basis. Exclusion criteria were: participants under the age of 18, those who did not speak Turkish, and participants who were unable to fully answer the questions due to any health issues (neurological, psychiatric, etc.). Fourteen questionnaires that did not meet the inclusion criteria and were determined to have been deliberately filled out incorrectly were excluded from the study data prior to data processing. Ultimately, data collected through questionnaires administered to 567 participants were found suitable for analysis. Fifty-one participants who were illiterate were assisted by pre-trained SHLC staff, who read the questions impartially and provided support during the marking process. Illiterate participants were not excluded from the study in order to reflect the demographic profile of the SHLC service population. Data Collection Methods The data collection tool is a questionnaire that assesses participants sociodemographic characteristics, health status, existing illnesses, frequency of use of SHLC services, out-of-pocket health expenditures, productivity loss, and indirect costs. The questionnaire used in the study was developed in line with a literature review, with contributions from researchers specialising in health economics and practitioners actively working in the field. The content and scope of the questionnaire were reviewed by experts to ensure that the items adequately represented the study objectives and were appropriate for field application. Although the literature was used in creating the questions, no scale was directly used in the study (Appendix-1 Questionnaire Form). Rather than employing a standardized psychometric scale, the questionnaire was designed as a structured survey instrument to descriptively capture service utilization experiences, perceptions, and cost-related components. The final form was determined after a pilot study. Following the pilot application, participant feedback regarding clarity, comprehensibility, response options, and feasibility of administration was evaluated, and minor revisions were made to the wording of selected items before finalizing the questionnaire. The questions were prepared in single-choice, Likert-type, and open-ended formats. The first section included questions on age, sex, educational status, employment, and social security information; the second section included questions on the type, duration, and frequency of SHLC services used, health-related well-being, out-of-pocket expenditure, SHLC satisfaction, willingness to recommend the services to others, and perceived quality of SHLC services. Estimation of alternative cost of services provided by SHLC were based on participants’ self-reported estimates of the amount they believed they would have to pay per service if they were to receive care from private healthcare providers in the same specialty instead of the services offered at the Healthy Life Center (HLC). This variable was intended to capture the perceived substitution cost of HLC services and their potential economic protection effect for individuals. Per-visit expenses, on the other hand, encompassed all actual expenditures incurred by participants throughout the healthcare-seeking process, starting from leaving home to reaching the HLC and during the time spent within the center while receiving care. In this context, out-of-pocket expenditures and per-visit expenses were considered complementary indicators reflecting distinct economic dimensions of access to healthcare. An open-ended response field was provided for questions regarding cost information; participants were asked to specify any loss of income in Turkish lira (TL). Participants were informed that their responses would be kept confidential and would not affect their right to receive healthcare services. The collected data were transferred to Microsoft Excel and stored digitally in a manner accessible only to the researchers. The study adhered to the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) criteria (18). Data Analysis In the study, missing data were assessed using the Pairwise Deletion method. Data were summarised using descriptive statistics; categorical variables were presented as n (%), while continuous variables were presented as median (IQR). Statistical analyses included the Mann–Whitney U, Chi-square, and logistic regression tests. In the logistic regression analysis, sociodemographic variables and variables with a p-value <0.20 in binomial tests were included in the model. The final model included three key independent variables: age, social security entity, and educational status. Odds Ratio (OR) and 95% confidence intervals (CI) were calculated for the logistic regression results, and p<0.05 was considered statistically significant. Analyses were performed using IBM SPSS Statistics for Windows, Version 25.0. Although willingness to pay (WTP) was conceptually referenced within the economic accessibility framework of the study, no direct WTP measurement was obtained from participants. Instead, the analyses were based on self-reported out-of-pocket expenditures and income loss, representing realized direct and indirect costs related to SHLC service utilization. Binary variables were created from independent variables measured using five-point Likert scales. With respect to satisfaction level, willingness to recommend the service to others, intention to continue using the service, and assessment of the quality of other healthcare institutions, participants reporting positive evaluations were grouped together, while those reporting negative or undecided evaluations were classified into the other group. Undecided responses were considered to reflect the absence of a clear positive orientation toward service adoption, recommendation, or continued use and were therefore treated as behaviorally closer to negative evaluations in the context of service continuity and dissemination. This approach was adopted to distinguish responses indicating a clear positive inclination and to enhance the interpretability of the analyses. Ethical Approval Informed consent was obtained from all participants prior to the study. Ethical committee approval for the study was obtained from the Istanbul Medipol University Non-Interventional Clinical Research Ethics Committee on 31 July 2025, with protocol number 07.2025.883. The principles of the World Medical Association's Declaration of Helsinki were adhered to throughout the study, and there was no external funding or conflict of interest within the scope of the research. RESULTS A total of 567 participants were included in the study. Women constituted 91.2% of the participants, with a median age of 43 years (IQR=16). When examining the sociodemographic profile, it was observed that the vast majority of the group consisted of married, unemployed participants with primary education. Economically, over 90% of participants stated that their income was equal to or less than their expenses. Detailed sociodemographic data for the participants are presented in Table 1. Table 1: Participants Sociodemographic Information N (567) % Sex (N=559) Female 510 91.2 Male 49 8.8 Educational Status (N=563) Illiterate 51 9.0 Primary/secondary school 348 61.5 High school 112 19.8 University/postgraduate 55 9.8 Marital Status (N=563) Married 486 86.3 Not Married 77 13.7 Employment Status (N=552) Working 109 19.7 Not working 443 80.3 Income Status (N=535) My Income is Less than My Expenses 241 45.0 My Income is Equal to My Expenses 255 47.7 My Income is More than My Expenses 39 7.3 Social Security Coverage (N=533) No 113 21.2 Yes 420 78.8 Home Ownership Status (N=555) Living in their own home 354 63.8 Not living in their own home 201 36.2 Presence of Dependent Persons in the Household (N=545) No 338 62.0 Yes 207 38.0 Median IQR Age (Years) (N=545) 43 16 Number of Persons per Household (N=548) 4 2 Number of Children per Household (N=417) 2 1 Number of HLC Applications (N=504) 1 1 When participants' subjective perceptions of health were examined, 5.0% rated their health status as very good, 44.9% as good, 44.5% as fair, 5.0% as poor, and 0.6% as very poor. While 35.7% had a diagnosed health problem, 64.3% of participants stated that they did not have any health problems. When assessing the limitations experienced in daily life due to health problems, 7.4% of participants reported serious limitations, 32.0% reported limitations that were not serious, and 60.6% reported no limitations. When examining the types of services used by participants who applied to HLC, it was seen that the most common reason for application was the CEDSC service (39.1%). This was followed by applications for a dietician (27.7%), MCHFP (21.2%), psychological support (8.9%) and physical activity counselling (1.1%). When examining the sources of referral to SHLC, it was determined that 83.0% were referred by healthcare personnel, 16.8% by their social circle, and 0.2% via social media. The rate of previous hospital service use among participants was quite low (inpatient treatment n=7, outpatient service n=26). The median out-of-pocket expenditure made by participants for services received from other healthcare institutions prior to receiving services from SHLC was 3000 TL (IQR=4750), while the median income loss reported during SHLC visits was 0 TL (IQR = 60), indicating that the vast majority of participants did not experience any income loss, while income loss was observed only in a limited subgroup of participants. The median visit duration was 55 minutes (IQR=30), and the median out-of-pocket expenditure per visit was 54 TL (IQR=163). These expenditures do not represent payments for the SHLC services themselves; rather, they include visit-related ancillary costs such as transportation, food, and similar expenses. Participants' health conditions and HLC application characteristics are summarised in Table 2. Table 2: Participants Health Status and HLC Application Characteristics N (567) % Participants Subjective Health Perception (N= 537) Very Good 27 5.0 Good 241 44.9 Average 239 44.5 Poor 27 5.0 Very Poor 3 0.6 Presence of Diagnosed Health Problems (N= 535) No 344 64.3 Yes 191 35.7 Restrictions in Daily Life Due to Health Reasons (N= 516) Significantly Restricted 38 7.4 Restricted But Not Significantly 165 32.0 Not Restricted 313 60.6 Type of Service Sought at the HLC (N= 512) Dietitian 146 27.7 Psychological Support Needs 47 8.9 Physical Activity Counselling 6 1.1 MCHFP 112 21.2 CEDSC 201 39.1 Source Referring to the HLC (N= 546) Healthcare Personnel 453 83.0 Social Environment 92 16.8 Social Media 1 0.2 Median IQR Number of Outpatient Hospital Visits Due to the Same Problem (days) (N=84) 1 0 Number of Day-Case Hospital Treatments (<24 Hours) Due to The Same Problem (days) (N=7) 1 0 Number of Outpatient Hospital Services (days) (N=26) 1 1 Estimated Alternative Cost of Services (TL) (N=120) 3000 4750 Average Income Loss per SHLC Visit (TL) (N=213) 0 60 Time Spent Per SHLC Visit, Including Round Trip (minutes) (N=364) 55 30 Travel/Transport Expense per SHLC Visit (TL) (N=370) 54 163 HLC: Healthy Life Center MCHFP: Mother and Child Health and Family Planning Center CEDSC: Cancer Early Diagnosis, Screening and Education Center Note: “Expenses for visits” cover ancillary, visit-related costs (e.g., transportation) and exclude any SHLC service fees. “Income loss” is self-reported. Values are presented as median (IQR). N=denotes respondents with non-missing data; items were asked only of those answering “Yes,” where applicable. Income loss, time spent, and expenses are reported per SHLC visit (including round trip). When examining the service usage status of participants based on their reason for applying to the SHLC, it was determined that 31.1% had previously received outpatient services at a hospital due to the health issue that led them to the SHLC, 2.4% had received inpatient treatment at a hospital, and 9.7% had received day treatment services. The rate of medication use due to health problems as the reason for application was 7.6%, and 92.4% of participants reported that they did not use medication due to health problems as the reason for applying to SHLC. In terms of overall satisfaction, 62.5% of participants were satisfied with the services they received from SHLC, while 26.4% stated that they were very satisfied. Only 0.6% of participants stated that they were dissatisfied, while 10.5% were undecided. The vast majority of participants (89.2%) stated that they would recommend SHLC services to others. 61.8% of participants responded ‘I would recommend it,’ while 27.4% responded ‘I would definitely recommend it.’ When asked about their intention to continue using the healthcare services provided by SHLC, 83.8% of participants stated that they intended to continue using the service, 9.1% were undecided, and 6.9% stated that they did not intend to continue. More than half of the participants (51.5%) stated that SHLC services were of higher quality compared to other healthcare institutions, while 23.2% were undecided on this matter. The proportion of those who spent money out of pocket to access SHLC services was 1.0%, while among working participants, the proportion experiencing loss of productivity at work due to HLC visits was 10.9%, the proportion taking leave or sick leave was 23.8%, and the proportion experiencing loss of income was 5.0%. Participants' service usage trends and satisfaction levels are summarised in Table 3. Table 3: Participants Service Usage and Satisfaction Status N (567) % Visiting HLC Due to the Previous Visits to Outpatient Services at the Hospital (N= 515) No 355 68.9 Yes 160 31.1 Visiting HLC Due to the Previous Hospitalisation (N= 504) No 492 97.6 Yes 12 2.4 Visiting HLC Due to the Previous Day-Care Treatment (N= 507) No 458 90.3 Yes 49 9.7 Visiting HLC Due to Medication Use (N= 500) No 462 92.4 Yes 38 7.6 Overall Satisfaction Level with Services Received from HLC (N= 515) I am not at all satisfied 1 0.2 I am not satisfied 2 0.4 I am undecided 54 10.5 I am satisfied 322 62.5 I am very satisfied 136 26.4 Recommending HLC Services to Others (N= 526) I definitely do not recommend it 6 1.1 I do not recommend it 7 1.3 I am undecided 44 8.4 I recommend it 325 61.8 I definitely recommend it 144 27.4 Intention to Continue Using HLC Services (N= 525) I definitely don't think so 7 1.3 I don't think so 30 5.7 I'm undecided 48 9.1 I'm considering it 318 60.6 I definitely think so 122 23.2 I Think HLC Services Are of Higher Quality Compared to Other Healthcare Institutions (N= 513) I definitely disagree 9 1.8 I disagree 17 3.3 I am undecided 119 23.2 I agree 264 51.5 I definitely agree 104 20.3 Having Out-of-Pocket Expenditure Due to HLC Application (N= 499) No 494 99.0 Yes 5 1.0 Loss of Productivity at Work Due to HLC Application (N= 101)** No 90 89.1 Yes 11 10.9 Taking Leave or Reporting Sick from Work Due to HLC Visit (N= 101)** No 77 76.2 Yes 24 23.8 Loss of Income Due to HLC Visit (N= 101)** No 96 95.0 Yes 5 5.0 ** Only participating employees are included. The relationship between participants' satisfaction with the services provided by SHLC and their sociodemographic characteristics was examined using chi-square analysis. No significant relationship was found between participants' sociodemographic characteristics other than income, their use of HLC services, and their satisfaction levels. However, the analyses revealed that the relationship between participants' income status and satisfaction levels was statistically significant (p=0.046). The significant difference was found to stem from the high rate of dissatisfaction among participants who stated that their income was less than their expenses, compared to participants in other income groups. It was observed that satisfaction rates increased as income levels rose. 85.2% of those whose income was less than their expenditure, 91.7% of those whose income was equal to their expenditure, and 94.4% of those whose income was more than their expenditure stated that they were satisfied. Table 4: Relationship between Participants' Satisfaction Levels and Income Level of Participants Overall Satisfaction Level with Services Received from HLC Not Satisfied Satisfied N % N % P value Income Status My Income is Less than My Expenses 33 a [YÇ2] 14.8 190 b 85.2 0.046* My Income is Equal to My Expenses 19 a 8.3 211 a 91.7 My Income is More than My Expenses 2 a 5.6 34 a 94.4 HLC: Healthy Life Center *Chi-square test was used. Bonferroni correction was applied. Each subscript letter denotes a subset of categories whose column proportions do not differ significantly from each other at the .05 level. Groups bearing different subscripts are significantly different. In Table 5, the relationship between participants' sociodemographic characteristics and their intention to continue using SHLC services was tested using chi-square analysis, and only statistically significant characteristics and findings related to the intention to use SHLC services are presented. No significant relationship was found between participants' sex, income status, and marital status characteristics and their intention to use the services. However, a statistically significant relationship was found between participants' educational status, social security coverage, and age and their tendency to continue using SHLC services. As educational status increased, the intention to continue using HLC services increased (p<0.001). The rate of continuing to use the service among participants with social security coverage (86.9%) was found to be significantly higher than among those without social security coverage (76.2%) (p=0.009). Furthermore, the median age of those who did not intend to continue using the service was 45 years, while that of those who did intend to continue using the service was 43 years, and the difference was statistically significant (p=0.007). Table 5: Relationship between Sociodemographic Variables and the Intention to Continue Using SHLC Services Intention to Continue Using HLC Services Not considering it Considering it N / Median % / IQR N / Median % / IQR P value Educational Status Illiterate 13 a 27.1 35 b 72.9 <0.001* Primary/secondary school 66 a 20.6 255 b 79.4 High school 3 a 2.9 102 b 97.1 University/postgraduate 3 a 5.9 48 b 94.1 Social Security Entity No 24 23.8 77 76.2 0.009* Yes 52 13.1 344 86.9 Age 45 12 43 16 0.007** HLC: Healthy Life Center *Chi-square test was used. Bonferroni correction was applied. Each subscript letter denotes a subset of categories whose column proportions do not differ significantly from each other at the .05 level. Groups bearing different subscripts are significantly different. **Mann Whitney U test was used for continuous data. Table 6 evaluates the relationship between participants' sociodemographic variables and the perception that SHLC services are of higher quality compared to other healthcare institutions. Compared to those with primary/secondary education, those with secondary education are more likely to perceive SHLC services as higher quality. When evaluated in terms of income level, the perception that SHLC services are of better quality is higher among those who state that their income is equal to their expenditure compared to those who state that their income is less than their expenditure, and there is a statistically significant difference (p=0.001). Furthermore, the difference between non-participants with a median age of 45 years and participants with a median age of 43 years was found to be significant (p=0.036). Table 6: Relationship between Sociodemographic Variables and the Perception of HLC Service Quality Compared to Other Healthcare Institutions I Think HLC Services Are of Higher Quality Compared to Other Healthcare Institutions I Disagree I Agree N / Median % / IQR N / Median % / IQR P value Educational Status Illiterate 13 a 27.7 34 a 72.3 0.009* Primary/secondary school 104 a 32.9 212 b 67.1 High school 16 a 15.8 85 b 84.2 University/postgraduate 12 a 24.5 37 a 75.5 Income Status My Income is Less than My Expenses 77 a 34.5 146 b 65.5 0.001* My Income is Equal to My Expenses 46 a 20.1 183 b 79.9 My Income is More than My Expenses 13 a 36.1 23 a 63.9 Age 45 12 43 17 0.036** HLC: Healthy Life Center *Chi-square test was used. Bonferroni correction was applied. Each subscript letter denotes a subset of categories whose column proportions do not differ significantly from each other at the .05 level. Groups bearing different subscripts are significantly different. **Mann Whitney U test was used for continuous data. Table 7 presents the results of a multivariate logistic regression model aimed at identifying the factors influencing the intention to continue using the services provided by SHLC. The model includes the sociodemographic characteristics of participants identified as statistically significant in the chi-square analysis as affecting the tendency to use the services. These characteristics are the presence of social security, educational status, and age variables. Participants with social security were found to be significantly more likely to continue using HLC services than those without social security OR = 1.81 (95% CI: 1.01–3.25 p = 0.045). When the educational status variable was evaluated, high school graduates were found to be significantly more likely to continue using the service than those who were illiterate OR = 9.03 (95% CI 2.22–36.7, p = 0.002). Similarly, the likelihood was also significantly increased for university or postgraduate graduates OR = 4.30 (95% CI 1.04–17.77, p = 0.043). No significant effect of the age variable on the intention to continue HLC services was observed OR = 0.99 (95% CI 0.99–1.01, p = 0.481). Table 7. Factors Associated with the Intention to Continue Using HLC Services, Multivariate Analysis Intention to Continue Using HLC Services OR OR(95% CI) P value Social Security Entity No Ref. Yes 1.81 (1.01-3.25) 0.045 Educational Status Illiterate Ref. Primary/secondary school 1.34 (0.63-2.87) 0.441 High school 9.03 (2.22-36.7) 0.002 University/postgraduate 4.30 (1.04-17.77) 0.043 Age 0.99 (0.99-1.01) 0.481 OR: Odds Ratio CI: Confidence Interval DISCUSSION 1. The Role of HLC in Primary Healthcare Services This study quantitatively reveals who the adults applying to the Sultanbeyli Healthy Life Center are, how they access these services, and how they experience the services they receive. The findings show that the HLC is able to reach groups with lower income and education levels in particular, provide preventive and health-promoting services without incurring out-of-pocket expenditure, and generally achieve a high level of satisfaction. More than one-third of participants (35.7%) have a diagnosed health problem and apply to benefit from screening and preventive services. The fact that 39.1% of participants benefit from CEDSC, 27.7% from dietitian and 21.2% from services reveals that participants largely benefit from preventive and lifestyle-focused services. This shows that HLCs focus on disease prevention and the development of healthy lifestyle behaviours rather than disease treatment. The strongest aspect of primary care is its multidimensional and preventive role in contributing to health and health systems (19, 20). When interpreted within the framework of access to healthcare proposed by Levesque and colleagues, these findings suggest that SHLCs simultaneously support multiple dimensions of access. The fact that participants were predominantly informed about and referred to the services by healthcare professionals reflects the dimensions of the ability to perceive and the ability to seek care. Moreover, the predominant use of preventive services and the low rates of hospital utilization indicate that appropriate and timely care can largely be delivered at the primary care level (17). The study findings show that only 31.1% of participants received outpatient services due to health problems prior to applying to the HLC, while only 2.4% of those who applied to the HLC required hospitalisation, and the rate of medication use due to the illness associated with the application was also low (7.6%). These findings suggest that the HLC can largely meet participants health needs at the primary and preventive care levels; in this respect, it has the potential to limit the need for secondary and tertiary healthcare services (5). In this respect, HLC occupies a strategic position in terms of Turkey's long-standing goal of reducing the burden of hospital-centerd healthcare services. Strengthening preventive interventions at the primary level creates significant gains in terms of both resource efficiency and improvements in public health indicators(21). Similarly, international literature has shown that strong primary care systems reduce hospital admissions, facilitate chronic disease management, and increase cost-effectiveness(22). In our study, the fact that the vast majority of participants intend to continue using the service (83.8%) supports the long-term acceptance and sustainability potential of the HLC model within the community. This high continuation rate also indicates participants trust in and satisfaction with HLC(23). Furthermore, the 89.2% rate of ‘recommending the service’ is one of the factors that increases the adoption of HLC and, consequently, loyalty to the service system. A study conducted in Norway also found that participants managed to maintain their initial physical activity levels throughout the 24-month follow-up period. This finding has proven the potential of preventive health models to create long-term and sustainable behavioural change in participants in the international literature (24). The level of education and health literacy is one of the key factors in the sustainability of HLC service uptake. Our findings reveal that the tendency to continue using HLC services increases significantly as the level of education rises (p<0.001). While highly educated participants more easily grasp the integrity and long-term benefits of the services offered, low-educated participants perception of preventive services as a necessity or a bureaucratic step may negatively affect their perception of service quality(25). Compared to the literature, our finding is fully consistent with the health literacy model developed by Sørensen et al.(26). Sørensen et al. define health literacy not only as access to information but as a whole comprising the processes of understanding, evaluating, and applying information. Within this model, it can be said that participants with a higher level of education are able to more accurately assess the multidisciplinary service structure (dietitian, psychologist, physiotherapist, etc.) in the HLC and have higher motivation to apply this information to their lifestyle. Indeed, in our study, the fact that participants with a high school education or above were significantly more likely to continue using the service (OR=9.03 and OR=4.30) proves that education creates a “social gradient” on the continuity of preventive health services. This situation indicates that special intervention strategies to increase health literacy and simpler service explanations are needed to ensure the sustainability of the service in groups with low educational levels. Looking at international examples, similar models are seen to support sustainability. 2. Reducing Social Inequalities Dimension This study clearly demonstrates the capacity of HLCs to reach disadvantaged segments of society, as the vast majority of participants were women (91.2%), unemployed (80.3%), and participants with low income levels (45% had income below their expenses). Although 21.2% of participants had no social security, the fact that this group was also able to benefit from HLC services demonstrates that the free nature of HLC is an effective tool in reducing income-based health inequalities. The fact that 9% of participants are illiterate and 61.5% have only primary or secondary school education shows that the service can also be used effectively by participants with low educational attainment. This suggests that HLC acts as a critical bridge in accessing communities with low health literacy. The literature also emphasises that the widespread and free provision of preventive services plays a critical role in removing barriers to healthcare access for low-income and low-education groups(27). In this regard, the HLC model acts as a social equaliser, mitigating the negative effects of socio-economic disadvantages such as poverty, low education, and care burden on health. Similarly, the literature reports that the widespread and free provision of preventive services at the primary care level reduces income-based disparities in health outcomes (28, 29). From the Levesque model perspective, HLCs reduce physical and economic barriers and have the potential to inform and facilitate community participation. This contributes to reducing inequalities in access to healthcare services. 3. Willingness to Pay In this study, willingness to pay (WTP) was not directly measured; instead, the economic accessibility of Healthy Life Center (HLC) services was assessed through participants’ self-reported out-of-pocket expenditures and income loss, reflecting realized direct and indirect costs. The fact that only 1% of participants in the study reported making out-of-pocket expenditure due to HLC services indicates that these centers have a robust structure in terms of economic accessibility. The median expenditure per visit being 54 TL and the median loss of income being 0 TL reveals that HLC imposes almost no direct or indirect costs on the household budget. This finding shows that hidden economic barriers preventing low-income participants from benefiting from preventive health services are largely eliminated by the HLC service. When viewed from the perspective of access to healthcare and economic concerns, the literature shows that out-of-pocket expenditures limit service use, particularly in low-income households(30). The fact that the HLC model reduces these economic barriers demonstrates that it functions as a financial protection mechanism. In systems where healthcare services are based on out-of-pocket expenditure, low-income households can be driven into the medical poverty trap(13). Studies conducted in low- and middle-income countries reveal that healthcare expenditures, combined with loss of income, impoverish households and reduce the chances of economic recovery after illness for poor households(13). 4. Comparison with Alternatives Over half of the participants (51.5%) agreed with the statement, ‘I believe that Healthy Life Center services are of higher quality compared to other healthcare institutions.’ This indicates that the HLC, with its free, comprehensive, and multidisciplinary structure, has a strong reputation for quality within the community. The literature also reports that community-based primary care centers similar to the HLC are more accessible, reliable, and user-centerd compared to hospital-based services(31). The fact that the perception of HLC quality increased significantly with higher education levels (p=0.009) indicates that participants ability to evaluate healthcare services and health literacy are decisive factors in this perception. This finding supports the relationship between healthcare quality and health literacy in the primary care structure in Turkey. The significant difference identified according to income level (p=0.001) shows that although HLC is an indispensable service, especially for low-income participants, the quality perception of this group is relatively low. This situation may stem not only from economic differences but also from the meaning attributed to the service. For participants with low income levels, HLC is often a mandatory area of recourse; their limited access to alternatives may not diminish the value of the service but may weaken the perceived quality(32). In contrast, participants whose income is equal to or higher than their expenses may have evaluated the cost-free and comprehensive structure of HLC more positively, as they have the opportunity to experience both public and private healthcare services. 5. Satisfaction Participant satisfaction in healthcare services is a critical indicator of service quality and sustainability. Studies conducted specifically on HLC generally report high levels of satisfaction. According to our survey in Sultanbeyli, the percentage of those satisfied with HLC services is 88.9%. 89.2% of participants plan to recommend these services to others. Factors affecting participant satisfaction highlighted in the literature include the attitude and communication of service providers, service quality, physical environment and equipment, accessibility, free services, and meeting participants expectations(33). For example, in their study, Porsuk and Cerit (2023) emphasised that patient satisfaction is closely related to the behaviour of healthcare workers, the quality and suitability of the service provided, ease of access, the effectiveness of information provision processes, and physical infrastructure. Research conducted specifically on HLC also generally reports high levels of satisfaction(34). The literature indicates that illiteracy, lack of social security, and advanced age are interrelated variables(35). The study suggests that as the level of education increases, the intention to continue using HLC services increases (p<0.001), the rate of continuing the service is higher among participants with social security (p=0.009), and the median age of those who do not intend to continue the service is higher (p=0.007). These findings suggest that these variables may be related to the continuity of HLC service use and satisfaction. Considering the structure of HLC services and Turkey's demographic characteristics, this situation suggests that HLC services may be more suitable for literate, socially insured, and relatively younger participants, which may be related to the high satisfaction and service continuation tendencies observed in the study. When satisfaction levels were examined in terms of sociodemographic variables, no significant differences were found except for income status. The fact that satisfaction was higher in the high-income group may seem like an unexpected finding for a service model that is provided free of charge and generally prioritises disadvantaged groups(36). However, this situation can be interpreted as a negative reflection of the general dissatisfaction with life caused by low income on the experience of healthcare services. On the other hand, the fact that satisfaction levels remain high even in the group with income lower than expenditure proves that HLCs have successfully implemented the principles of economic accessibility and equity in healthcare. As emphasised by Gizaw and colleagues, ease of appointment, consultant interest, adequate service duration, and free access are key factors that increase satisfaction(20). Furthermore, as stated by Weingarten and colleagues, multidisciplinary and preventive service delivery also positively affects the perception of satisfaction(37). In this context, a high level of satisfaction is the most important outcome that strengthens the sustainability of the service, participants trust in the institution, and their willingness to recommend it. 6. Characteristics of the HLC target audience and media dimension The most important referral source for HLC applications is the transfer channels integrated into the healthcare system. In the Sultanbeyli example, 83% of participants came to HLC through referrals from healthcare personnel, while 16.8% applied based on recommendations from their social circle. In other words, the vast majority learned about HLC through family doctors or community health workers. Although the influence of the social environment is significant, media or digital platforms were only effective in 0.2% of referrals. The existing literature emphasises the critical role of mass communication campaign design and implementation in reaching the target audience; for example, Wakefield and colleagues have shown that large-scale media campaigns can bring about positive behavioural changes in large population groups(38). Similarly, it is noted that health promotions on social media platforms have the potential to change behaviour beyond raising awareness(39). In terms of health communication strategies, effective campaigns are generally based on behaviour change theories(40). These theoretical frameworks help to identify the right messages and reach the appropriate target audience. Currently, a large portion of promotional activities related to HLCs in Turkey are carried out through healthcare professionals. However, greater visibility in the media and effective use of digital communication channels have the potential to increase awareness of HLCs. It is known that behavioural change can be observed in public health campaigns when a solid theoretical foundation and sufficient media continuity are provided(38). Therefore, comprehensive media strategies prepared to promote HLCs can increase public awareness of health education and healthy living behaviours, as well as strengthen social environment guidance. CONCLUSION Healthy Life Centers, which provide free services at the primary level, stand out as a health service model that is accessible to the community, trusted, and significantly reduces socio-economic barriers through their holistic structure. The findings of the study show that HLCs are particularly able to reach disadvantaged groups, that the services are largely accepted, and that a significant proportion of participants are inclined to continue using the service and recommend it to others. When evaluated in terms of the policy-making process, HLCs are seen to strengthen preventive services, have the potential to reduce hospital-centerd referrals, and offer an economically accessible structure. Although the findings are generally positive, a structural limitation regarding the prevalence of the service should also be considered. The current capacity and geographical distribution of HLCs may remain at a level that could restrict access to the service, particularly in densely populated areas. In this context, increasing the number of HLCs and ensuring a more balanced geographical distribution is important in terms of strengthening the accessibility of the service. From the perspective of the Levesque access model, the relatively long travel time to the center and the fact that people mostly learn about HLCs through their social environment or healthcare personnel indicate a need for more effective use of digital and media-based information channels. Consequently, this study demonstrates that HLCs represent a significant public health investment at the primary level; it indicates that the cost-effectiveness of HLCs should be evaluated in the future, their impact on specific health outcomes such as chronic disease management and obesity should be measured using quantitative data, and their contribution to long-term health expenditures should be examined. STRENGTHS AND LIMITATIONS This study is unique in that it evaluates Healthy Life Centers (HLCs) not only through service delivery but also through participants’ experiences, satisfaction levels, and their tendencies to continue using and recommend the services. Satisfaction is not considered as a single-dimensional construct; rather, addressing it alongside three distinct behavioural outcomes provides a more meaningful picture of the model’s acceptability and sustainability. The large sample size and the reflection of real-world experiences of actual service participants represent important strengths of the study. Furthermore, the study’s execution by a multidisciplinary team has enabled the simultaneous consideration of perspectives from health economics, health management, and public health. However, several limitations should be acknowledged. The study was conducted in a single HLC located in one of Istanbul’s socioeconomically disadvantaged districts, using a convenience sampling approach during daytime hours, which limits the direct generalisability of the findings to other provinces, settings, or service delivery contexts. In addition, the sample consisted predominantly of female participants (91%), which may restrict the applicability of the results to male participants and other demographic groups. Individuals who attend HLC services outside regular daytime hours, such as in the evenings or on weekends, may be underrepresented.Moreover, due to the cross-sectional design of the study, the observed associations between variables cannot be interpreted in terms of causality. The reliance on self-reported data may have introduced social desirability bias and recall bias. Future research would benefit from multi-center designs, extended data collection periods (including evenings and weekends), and more demographically balanced samples to enhance the generalisability of findings and to better capture diverse patterns of HLC service use. Declarations Ethics approval and consent to participate : Informed consent was obtained from all participants prior to the study. Ethical committee approval was obtained from the Istanbul Medipol University Non-Interventional Clinical Research Ethics Committee on July 31, 2025 (protocol number 07.2025.883). Consent for publication : At the beginning of the interviews, the participants were informed about the purpose and process of the research, and permission was obtained from the participants to record the interviews. Participants were assured that the confidentiality and anonymity of the information they provided would be guaranteed. Availability of data and materials : The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests : The authors declare that they have no competing interests Funding: None Authors' contributions : KA, ZT, MAS, YÇ, YB,KYE and SH contributed to the conception and design of the study, data acquisition, analysis, and interpretation. All authors participated in drafting and critically revising the manuscript for important intellectual content. All authors approved the submitted version (and any substantially modified version that involves their contribution to the study). All authors agreed to be personally accountable for their own contributions and to ensure that any questions related to the accuracy or integrity of any part of the work, even those in which they were not personally involved, are appropriately investigated, resolved, and documented in the literature. Acknowledgements : Not applicable References Khatri RB, Wolka E, Nigatu F, Zewdie A, Erku D, Endalamaw A, et al. People-centred primary health care: a scoping review. BMC Prim Care. 2023;24(1):236. Khatri RB, Endalamaw A, Erku D, Wolka E, Nigatu F, Zewdie A, et al. Contribution of health system governance in delivering primary health care services for universal health coverage: A scoping review. PLoS One. 2025;20(2):e0318244. Rosano A, Loha CA, Falvo R, van der Zee J, Ricciardi W, Guasticchi G, et al. The relationship between avoidable hospitalization and accessibility to primary care: a systematic review. Eur J Public Health. 2013;23(3):356-60. Aoki T, Sugiyama Y, Mutai R, Matsushima M. Impact of Primary Care Attributes on Hospitalization During the COVID-19 Pandemic: A Nationwide Prospective Cohort Study in Japan. Ann Fam Med. 2023;21(1):27-32. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83(3):457-502. Sözmen K, Ünal B. Explaining inequalities in Health Care Utilization among Turkish adults: Findings from Health Survey 2008. Health Policy. 2016;120(1):100-10. Söyler S, Öztürk YE. Birinci Basamak Sağlık Hizmetlerinde Yeni Bir Uygulama: Sağlıklı Hayat Merkezlerinde Hizmet Sunumu, Yaşanan Sorunlar ve Çözüm Önerileri. Ekonomi İşletme Siyaset ve Uluslararası İlişkiler Dergisi. 2021;7(2):403-18. Yelsiz M, Sezer Korucu K, Eke E. SAĞLIK HİZMETLERİNDE SAĞLIKLI HAYAT MERKEZLERİ FARKINDALIĞI ÜZERİNE BİR ARAŞTIRMA: ISPARTA ÖRNEĞİ. Avrasya Sosyal ve Ekonomi Araştırmaları Dergisi. 2023;10(3):523-44. SHM Nedir? https://shm.saglik.gov.tr/ shm-nedir.html. Accessed 10 Feb 2026. Omran AR. The epidemiologic transition: a theory of the epidemiology of population change. 1971. Milbank Q. 2005;83(4):731-57. Gulis G, Zidkova R, Meier Z. Changes in disease burden and epidemiological transitions. Sci Rep. 2025;15(1):8961. Sans-Corrales M, Pujol-Ribera E, Gené-Badia J, Pasarín-Rua MI, Iglesias-Pérez B, Casajuana-Brunet J. Family medicine attributes related to satisfaction, health and costs. Fam Pract. 2006;23(3):308-16. McIntyre D, Thiede M, Dahlgren G, Whitehead M. What are the economic consequences for households of illness and of paying for health care in low- and middle-income country contexts? Soc Sci Med. 2006;62(4):858-65. Kringos DS, Boerma WG, Spaan E, Pellny M. A snapshot of the organization and provision of primary care in Turkey. BMC Health Serv Res. 2011;11:90. Longhini J, Canzan F, Mezzalira E, Leardini C, Saiani L, Di Falco A, et al. Exploring user experiences in a novel primary care center: a qualitative grounded theory study. BMC Health Serv Res. 2025;25(1):1174. Altaş ZM, Sezerol MA. Prevalence and Associated Factors of Dental Caries in Syrian Immigrant Children Aged 6-12 Years. Children (Basel). 2023;10(6). Levesque JF, Harris MF, Russell G. Patient-centred access to health care: conceptualising access at the interface of health systems and populations. Int J Equity Health. 2013;12:18. Tekindal MA, Babaoğlu AB, Tekindal M, Büyükuysal MÇ, Tözün M, Elmalı F, et al. Epidemiyolojide Gözlemsel Çalışmaların Raporlanması: STROBE Kriterlerinin Türkçe Uyarlaması. Medical Journal of Western Black Sea. 2021;5(1):86-93. Shi L. The Impact of Primary Care: A Focused Review. Scientifica. 2012;2012. Gizaw Z, Astale T, Kassie GM. What improves access to primary healthcare services in rural communities? A systematic review. BMC Primary Care. 2022;23(1):313. Bisak A, Stafström M. Unleashing the potential of Health Promotion in primary care—a scoping literature review. Health Promotion International. 2024;39(3). Martinez C, Bacigalupe G, Cortada JM, Grandes G, Sanchez A, Pombo H, et al. The implementation of health promotion in primary and community care: a qualitative analysis of the ‘Prescribe Vida Saludable’ strategy. BMC Family Practice. 2017;18(1):23. Li L, Zhu L, Zhou X, Zeng G, Huang H, Gan Y, et al. Patients’ trust and associated factors among primary care institutions in China: a cross-sectional study. BMC Primary Care. 2022;23(1):109. Gryte OH, Meland E, Samdal GB, Fadnes LT, Vold JH, Mildestvedt T. Physical activity and sedentary time after lifestyle interventions at the Norwegian Healthy Life Centres. Prim Health Care Res Dev. 2024;25:e4. Değer MS, İşsever H. Service Quality and Related Factors in Primary Health Care Services: A Cross-Sectional Study. Healthcare. 2024;12(10):965. Sørensen K, Van den Broucke S, Fullam J, Doyle G, Pelikan J, Slonska Z, et al. Health literacy and public health: a systematic review and integration of definitions and models. BMC Public Health. 2012;12:80. Niessen LW, Mohan D, Akuoku JK, Mirelman AJ, Ahmed S, Koehlmoos TP, et al. Tackling socioeconomic inequalities and non-communicable diseases in low-income and middle-income countries under the Sustainable Development agenda. The Lancet. 2018;391(10134):2036-46. Haque M, Islam T, Rahman NAA, McKimm J, Abdullah A, Dhingra S. Strengthening Primary Health-Care Services to Help Prevent and Control Long-Term (Chronic) Non-Communicable Diseases in Low- and Middle-Income Countries. Risk Manag Healthc Policy. 2020;13:409-26. Kaya Kaçar H, Köse ED, Okuyucu K. Voices from a healthy life centre: a qualitative investigation of clients' nutrition and physical activity experiences. Journal of Health Sciences and Medicine. 2025;8(1):97-102. Falkingham J. Poverty, out-of-pocket payments and access to health care: evidence from Tajikistan. Social science & medicine (1982). 2004;58(2):247-58. Cho Y, Chung H, Joo H, Park HJ, Joh HK, Kim JW, et al. Comparison of patient perceptions of primary care quality across healthcare facilities in Korea: A cross-sectional study. PLoS One. 2020;15(3):e0230034. Shi J, Jin H, Shi L, Chen C, Ge X, Lu Y, et al. The quality of primary care in community health centers: comparison among urban, suburban and rural users in Shanghai, China. BMC Fam Pract. 2020;21(1):178. Porsuk AO, Cerit C. Assessment of satisfaction with a healthy life center, a new service model. Niger J Clin Pract. 2023;26(1):23-30. Alhajri SM, Aljehani NM, El Dalatony MM, Alsuwayt SS, Alhumaidany TM, Aldossary MS. Patients' Satisfaction With the Quality of Services at Primary Healthcare Centers in Saudi Arabia. Cureus. 2023;15(9):e45066. Lima ACP, Maximiano-Barreto MA, Martins TCR, Luchesi BM. Factors associated with poor health literacy in older adults: A systematic review. Geriatric Nursing. 2024;55:242-54. Mohamed EY, Sami W, Alotaibi A, Alfarag A, Almutairi A, Alanzi F. Patients' Satisfaction with Primary Health Care Centers' Services, Majmaah, Kingdom of Saudi of Saudi Arabia. Int J Health Sci (Qassim). 2015;9(2):163-70. Weingarten SR, Stone E, Green A, Pelter M, Nessim S, Huang H, et al. A study of patient satisfaction and adherence to preventive care practice guidelines. Am J Med. 1995;99(6):590-6. Wakefield MA, Loken B, Hornik RC. Use of mass media campaigns to change health behaviour. Lancet. 2010;376(9748):1261-71. Ghahramani A, de Courten M, Prokofieva M. “The potential of social media in health promotion beyond creating awareness: an integrative review”. BMC Public Health. 2022;22(1):2402. Michie S, van Stralen MM, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci. 2011;6:42. Additional Declarations No competing interests reported. Supplementary Files Appendix.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 29 Mar, 2026 Reviews received at journal 26 Mar, 2026 Reviewers agreed at journal 22 Mar, 2026 Reviewers agreed at journal 18 Mar, 2026 Reviewers agreed at journal 17 Mar, 2026 Reviewers invited by journal 17 Mar, 2026 Editor invited by journal 20 Feb, 2026 Editor assigned by journal 16 Feb, 2026 Submission checks completed at journal 16 Feb, 2026 First submitted to journal 15 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8888176","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":608235461,"identity":"a67493e3-930b-43b4-a74f-539bbb1e0edc","order_by":0,"name":"Kerem Arısın","email":"","orcid":"","institution":"Marmara University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Kerem","middleName":"","lastName":"Arısın","suffix":""},{"id":608235463,"identity":"feed435a-1d66-4a5b-bd12-595a124fc20f","order_by":1,"name":"Zeynep Tüzün","email":"","orcid":"","institution":"Marmara University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Zeynep","middleName":"","lastName":"Tüzün","suffix":""},{"id":608235465,"identity":"edaf7ab2-29b4-401c-bb82-28654c1e00f7","order_by":2,"name":"Mehmet Akif Sezerol","email":"","orcid":"","institution":"University of Health Sciences","correspondingAuthor":false,"prefix":"","firstName":"Mehmet","middleName":"Akif","lastName":"Sezerol","suffix":""},{"id":608235468,"identity":"1efbb796-c56c-4d22-b237-df1923f635a6","order_by":3,"name":"Yusuf Çelik","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABFklEQVRIie2RsWrDMBCGzwjOU+NVJW3cR7AxhEAgzyJjsJeSUrp4MK0mdWnpI/QV8giCUmXRA6hbunjKkC6lS0ukUAotdrJ20Ae33OnT/UIAHs9/pbY1IBisACgDYK5H9ivaFhIkyW8FDymASGF3/oCSmKqlEmYjDLGsP5rJPLotnhdQT3Me36+6lfOxVYrMBlMvd4peUd2WBnSVcwyTHgWHG5C5IKEwR5zm3F5iAvFkle5k38HkjVMuP63yaC7eTfC1T2EumGQuGHFbFnavCXi/cqzX2UQmRSoIFsMT+5ZUt2PDVJUJLDuVwbJ6NbKexVGk0rd1cz0fLYvWbJrp6QNRncqZ3MX722bQ/5Mx7xl4PB6P54ctZvBfdvgn05wAAAAASUVORK5CYII=","orcid":"","institution":"Acıbadem Mehmet Ali Aydınlar University","correspondingAuthor":true,"prefix":"","firstName":"Yusuf","middleName":"","lastName":"Çelik","suffix":""},{"id":608235470,"identity":"6381fb8b-5d59-4982-96e6-6c644d582666","order_by":4,"name":"Yusuf Baktır","email":"","orcid":"","institution":"Üsküdar University","correspondingAuthor":false,"prefix":"","firstName":"Yusuf","middleName":"","lastName":"Baktır","suffix":""},{"id":608235472,"identity":"9edb58b3-2332-4cd6-8e02-5769ee17573a","order_by":5,"name":"Kezban Yavuz Emik","email":"","orcid":"","institution":"Sultanbeyli District Health Directorate","correspondingAuthor":false,"prefix":"","firstName":"Kezban","middleName":"Yavuz","lastName":"Emik","suffix":""},{"id":608235473,"identity":"f83f695a-4832-4330-b20f-a498c2a5e0d8","order_by":6,"name":"Seyhan Hıdıroğlu","email":"","orcid":"","institution":"Marmara University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Seyhan","middleName":"","lastName":"Hıdıroğlu","suffix":""}],"badges":[],"createdAt":"2026-02-15 19:53:25","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8888176/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8888176/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":105035267,"identity":"aa079f5f-c9f2-4ebd-a9fd-d6ca883385c1","added_by":"auto","created_at":"2026-03-20 07:25:46","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1783887,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8888176/v1/5409c443-f119-41fc-962c-53d079f32d42.pdf"},{"id":105008604,"identity":"acaeccf3-d281-43cb-b889-12387c4a99be","added_by":"auto","created_at":"2026-03-19 19:21:28","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":33314,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix.docx","url":"https://assets-eu.researchsquare.com/files/rs-8888176/v1/d14472be367c6d1fcb7bfdcf.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Evaluation of Healthy Life Center Services within Primary Care: A Cross- Sectional Study of User Perspectives","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003ePrimary healthcare services are a fundamental structure that forms the first point of contact between the community and the healthcare system, based on the understanding that health is not merely the absence of disease but a state of complete physical, mental and social well-being. They provide participants with early, comprehensive and continuous care, combining preventive, curative and rehabilitative services(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). These services enable the early detection of health problems, thereby reducing the need for secondary and tertiary healthcare services and supporting the cost-effectiveness of the system(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Based on the principles of equality and accessibility, primary healthcare services aim to ensure that participants can benefit equally from basic healthcare services regardless of differences in income, education or social status(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). This approach aims to provide fair and balanced healthcare services in the community by reducing health access disparities arising from socio-economic conditions through the provision of free services, the promotion of preventive healthcare practices, and equal access for all segments of society (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). In this respect, it creates a structure that not only ensures access to services but also contributes to increasing participants opportunities to benefit from services and reducing indirect costs and out-of-pocket expenditure, thereby strengthening the equitable and sustainable functioning of the healthcare system(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePrimary healthcare services in Turkey are delivered through District Health Directorates, Family Health Centers, Community Health Centers, and various units integrated into this structure(7). Healthy Life Centers (HLC), established in 2017 to strengthen this structure, were created to promote preventive services throughout the community and protect participants from health risk factors(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). These centers focus on public health issues such as insufficient physical activity, unhealthy nutrition, obesity, tobacco use, and increasing mental health needs in order to respond to the disease burden shifting from infectious diseases to chronic and lifestyle-related diseases in line with the epidemiological transition process(\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Healthy Life Centers (HLC), operating within District Health Directorates, offer multi-dimensional applications such as nutrition counselling, chronic disease management, physical activity and obesity counselling, mental health, women's and reproductive health, cancer screening, and child and adolescent health services. through tobacco and substance abuse prevention, healthy ageing, participant counselling, and community education programmes, they strengthen the preventive aspect of the primary healthcare system and contribute to improving health at the societal level (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). All the aforementioned services are provided free of charge at Healthy Life Centers in Turkey.\u003c/p\u003e \u003cp\u003eThe provision of free primary healthcare services creates significant opportunities for equality across broad sections of society; however, it does not entirely eliminate the indirect costs that may arise during the process of accessing the service(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Factors such as transportation difficulties, time loss, or the necessity for participants to temporarily leave those they are responsible for caring for can create indirect economic and social burdens on access to services(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Such indirect costs can negatively affect health service utilisation behaviour and the level of utilisation of preventive services, particularly among disadvantaged groups, thereby weakening the equitable nature of the service(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). However, it is evident that access to services is not limited solely to physical and economic conditions; participants perceptions, expectations, and experiences regarding services also shape this process(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). In this context, the quality of support provided, perceived adequacy, ease of access, the communication style of healthcare workers, the effectiveness of information processes, and the level of fulfilment of participant expectations are among the main factors determining not only the acceptance and sustainability of primary healthcare services in society but also participants propensity to seek services again and their general attitudes towards the healthcare system (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Therefore, considering not only the structural characteristics of the services provided in PHCs, but also the participant experience, perceived service adequacy, and indirect cost dimensions together contributes to a comprehensive understanding of service effectiveness at the primary care level.\u003c/p\u003e \u003cp\u003eThe aim of this study is to evaluate the services provided by Healthy Life Centers operating within primary healthcare services, based on the experiences of users receiving these services, in terms of accessibility, perceived service quality and indirect costs. The study aims to analyse indirect costs that may arise during the service access process, such as transportation, time loss, or care responsibilities, as well as participants perceptions and experiences regarding the service. It further aims to reveal the contribution of Healthy Life Centers to primary-level preventive healthcare services, their effectiveness, and their implications for a sustainable healthcare system.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cp\u003e\u003cstrong\u003eResearch Type and Design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted among participants\u0026nbsp;aged 18 years or older who speak Turkish and who visited the Healthy Life Center (SHLC) in Sultanbeyli, the district with the lowest socio-economic development level in Istanbul, which has a population of approximately 370,000 (16). The SHLC is an important component of primary healthcare services and provides services through its psychologists, physiotherapists, dieticians, CEDSC (Cancer Early Diagnosis, Screening and Education Center) unit, and Mother and Child Health Unit. The study is a cross-sectional study evaluating the sociodemographic characteristics, health service utilisation status, and willingness to pay of participants applying to the SHLC. This study was conducted within the framework of the access model developed by Levesque and colleagues in order to conceptually explain access to health services and to evaluate the factors affecting access to the SHLC in a multidimensional manner(17). Within this framework, the Levesque model was used as an interpretive conceptual approach rather than a formal measurement tool. Study variables were subsequently mapped to the relevant access dimensions to facilitate multidimensional interpretation. The model addresses the structural characteristics of healthcare systems and participants\u0026nbsp;access capabilities together, making system- and participant-related barriers visible. Accordingly, referral pathways and awareness of SHLC services were interpreted as indicators of the ability to perceive and seek care; visit duration and access-related characteristics as indicators of accessibility and the ability to reach; cost-related variables as indicators of affordability and the ability to pay; and satisfaction, intention to continue use, and willingness to recommend services as indicators of appropriateness and the ability to engage. No sampling was performed in the study; all participants who applied to the center during the research period and met the inclusion criteria were included in the study. Data were collected using face-to-face surveys, and a pilot study was conducted with a group of 90 participants\u0026nbsp;to test the comprehensibility of the survey form prior to implementation. Data obtained through pilot interviews were not included in the analyses. A total of 581 participants\u0026nbsp;were evaluated in the study, which was conducted between August and September 2025\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eParticipants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted among users\u0026nbsp;who applied to SHLC between 09:00 and 16:00 and agreed to participate in the research on a voluntary basis. Exclusion criteria were: participants\u0026nbsp;under the age of 18, those who did not speak Turkish, and participants\u0026nbsp;who were unable to fully answer the questions due to any health issues (neurological, psychiatric, etc.). Fourteen questionnaires that did not meet the inclusion criteria and were determined to have been deliberately filled out incorrectly were excluded from the study data prior to data processing. Ultimately, data collected through questionnaires administered to 567 participants were found suitable for analysis. Fifty-one participants\u0026nbsp;who were illiterate were assisted by pre-trained SHLC staff, who read the questions impartially and provided support during the marking process. Illiterate participants were not excluded from the study in order to reflect the demographic profile of the SHLC service population.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Collection Methods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data collection tool is a questionnaire that assesses participants sociodemographic characteristics, health status, existing illnesses, frequency of use of SHLC services, out-of-pocket health expenditures, productivity loss, and indirect costs. The questionnaire used in the study was developed in line with a literature review, with contributions from researchers specialising in health economics and practitioners actively working in the field. The content and scope of the questionnaire were reviewed by experts to ensure that the items adequately represented the study objectives and were appropriate for field application. Although the literature was used in creating the questions, no scale was directly used in the study (Appendix-1 Questionnaire Form). Rather than employing a standardized psychometric scale, the questionnaire was designed as a structured survey instrument to descriptively capture service utilization experiences, perceptions, and cost-related components.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe final form was determined after a pilot study. Following the pilot application, participant feedback regarding clarity, comprehensibility, response options, and feasibility of administration was evaluated, and minor revisions were made to the wording of selected items before finalizing the questionnaire. The questions were prepared in single-choice, Likert-type, and open-ended formats. The first section included questions on age, sex, educational status, employment, and social security information; the second section included questions on the type, duration, and frequency of SHLC services used, health-related well-being, out-of-pocket expenditure, SHLC satisfaction, willingness to recommend the services to others, and perceived quality of SHLC services.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEstimation of alternative cost of services provided by SHLC were based on participants’ self-reported estimates of the amount they believed they would have to pay per service if they were to receive care from private healthcare providers in the same specialty instead of the services offered at the Healthy Life Center (HLC). This variable was intended to capture the perceived substitution cost of HLC services and their potential economic protection effect for individuals. Per-visit expenses, on the other hand, encompassed all actual expenditures incurred by participants throughout the healthcare-seeking process, starting from leaving home to reaching the HLC and during the time spent within the center while receiving care. In this context, out-of-pocket expenditures and per-visit expenses were considered complementary indicators reflecting distinct economic dimensions of access to healthcare. An open-ended response field was provided for questions regarding cost information; participants were asked to specify any loss of income in Turkish lira (TL). Participants were informed that their responses would be kept confidential and would not affect their right to receive healthcare services. The collected data were transferred to Microsoft Excel and stored digitally in a manner accessible only to the researchers. The study adhered to the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) criteria (18).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn the study, missing data were assessed using the Pairwise Deletion method. Data were summarised using descriptive statistics; categorical variables were presented as n (%), while continuous variables were presented as median (IQR). Statistical analyses included the Mann–Whitney U, Chi-square, and logistic regression tests. In the logistic regression analysis, sociodemographic variables and variables with a p-value \u0026lt;0.20 in binomial tests were included in the model. The final model included three key independent variables: age, social security entity, and educational status. Odds Ratio (OR) and 95% confidence intervals (CI) were calculated for the logistic regression results, and p\u0026lt;0.05 was considered statistically significant. Analyses were performed using IBM SPSS Statistics for Windows, Version 25.0.\u003c/p\u003e\n\u003cp\u003eAlthough willingness to pay (WTP) was conceptually referenced within the economic accessibility framework of the study, no direct WTP measurement was obtained from participants. Instead, the analyses were based on self-reported out-of-pocket expenditures and income loss, representing realized direct and indirect costs related to SHLC service utilization. Binary variables were created from independent variables measured using five-point Likert scales. With respect to satisfaction level, willingness to recommend the service to others, intention to continue using the service, and assessment of the quality of other healthcare institutions, participants reporting positive evaluations were grouped together, while those reporting negative or undecided evaluations were classified into the other group. Undecided responses were considered to reflect the absence of a clear positive orientation toward service adoption, recommendation, or continued use and were therefore treated as behaviorally closer to negative evaluations in the context of service continuity and dissemination. This approach was adopted to distinguish responses indicating a clear positive inclination and to enhance the interpretability of the analyses.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all participants prior to the study. Ethical committee approval for the study was obtained from the Istanbul Medipol University Non-Interventional Clinical Research Ethics Committee on 31 July 2025, with protocol number 07.2025.883. The principles of the World Medical Association's Declaration of Helsinki were adhered to throughout the study, and there was no external funding or conflict of interest within the scope of the research.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eA total of 567 participants were included in the study. Women constituted 91.2% of the participants, with a median age of 43 years (IQR=16). When examining the sociodemographic profile, it was observed that the vast majority of the group consisted of married, unemployed participants\u0026nbsp;with primary education. Economically, over 90% of participants stated that their income was equal to or less than their expenses. Detailed sociodemographic data for the participants are presented in Table 1.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1: Participants Sociodemographic Information\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"614\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 378px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eN (567)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e%\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eSex (N=559)\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e510\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e91.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e8.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eEducational Status (N=563)\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eIlliterate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e9.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003ePrimary/secondary school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e348\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e61.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eHigh school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e112\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e19.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eUniversity/postgraduate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e9.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eMarital Status (N=563)\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e486\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e86.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eNot Married\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e13.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eEmployment Status (N=552)\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u0026nbsp;Working\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e109\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e19.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eNot working\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e443\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e80.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eIncome Status (N=535)\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eMy Income is Less than My Expenses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e241\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e45.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eMy Income is Equal to My Expenses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e255\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e47.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eMy Income is More than My Expenses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e7.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eSocial Security Coverage (N=533)\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e113\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e21.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e420\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e78.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eHome Ownership Status (N=555)\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eLiving in their own home\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e354\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e63.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eNot living in their own home\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e201\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e36.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003ePresence of Dependent Persons in the Household (N=545)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e338\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e62.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e207\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e38.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eMedian\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eIQR\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003eAge (Years) (N=545)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003eNumber of Persons per Household (N=548)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003eNumber of Children per Household (N=417)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003eNumber of HLC Applications (N=504)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eWhen participants\u0026apos; subjective perceptions of health were examined, 5.0% rated their health status as very good, 44.9% as good, 44.5% as fair, 5.0% as poor, and 0.6% as very poor. While 35.7% had a diagnosed health problem, 64.3% of participants stated that they did not have any health problems. When assessing the limitations experienced in daily life due to health problems, 7.4% of participants reported serious limitations, 32.0% reported limitations that were not serious, and 60.6% reported no limitations. When examining the types of services used by participants who applied to HLC, it was seen that the most common reason for application was the CEDSC service (39.1%). This was followed by applications for a dietician (27.7%), MCHFP (21.2%), psychological support (8.9%) and physical activity counselling (1.1%). When examining the sources of referral to SHLC, it was determined that 83.0% were referred by healthcare personnel, 16.8% by their social circle, and 0.2% via social media. The rate of previous hospital service use among participants was quite low (inpatient treatment n=7, outpatient service n=26). The median out-of-pocket expenditure made by participants for services received from other healthcare institutions prior to receiving services from SHLC was 3000 TL (IQR=4750), while the median income loss reported during SHLC visits was 0 TL (IQR = 60), indicating that the vast majority of participants did not experience any income loss, while income loss was observed only in a limited subgroup of participants. The median visit duration was 55 minutes (IQR=30), and the median out-of-pocket expenditure per visit was 54 TL (IQR=163). These expenditures do not represent payments for the SHLC services themselves; rather, they include visit-related ancillary costs such as transportation, food, and similar expenses. Participants\u0026apos; health conditions and HLC application characteristics are summarised in Table 2.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: Participants Health Status and HLC Application Characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"586\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 387px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 91px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eN (567)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 107px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e%\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eParticipants\u003c/strong\u003e \u003cstrong\u003eSubjective Health Perception (N= 537)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 218px;\"\u003e\n \u003cp\u003eVery Good\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e5.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 218px;\"\u003e\n \u003cp\u003eGood\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e241\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e44.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 218px;\"\u003e\n \u003cp\u003eAverage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e239\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e44.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 218px;\"\u003e\n \u003cp\u003ePoor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e5.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 218px;\"\u003e\n \u003cp\u003eVery Poor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePresence of Diagnosed Health Problems (N= 535)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 218px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e344\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e64.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 218px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e191\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e35.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRestrictions in Daily Life Due to Health Reasons\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(N= 516)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 218px;\"\u003e\n \u003cp\u003eSignificantly Restricted\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e7.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 218px;\"\u003e\n \u003cp\u003eRestricted But Not Significantly\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e165\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e32.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 218px;\"\u003e\n \u003cp\u003eNot Restricted\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e313\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e60.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eType of Service Sought at the HLC (N= 512)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 218px;\"\u003e\n \u003cp\u003eDietitian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e146\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e27.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 218px;\"\u003e\n \u003cp\u003ePsychological Support Needs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e8.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 218px;\"\u003e\n \u003cp\u003ePhysical Activity Counselling\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 218px;\"\u003e\n \u003cp\u003eMCHFP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e112\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e21.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 218px;\"\u003e\n \u003cp\u003eCEDSC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e201\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e39.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSource Referring to the HLC (N= 546)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 218px;\"\u003e\n \u003cp\u003eHealthcare Personnel\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e453\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e83.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 218px;\"\u003e\n \u003cp\u003eSocial Environment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e16.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 218px;\"\u003e\n \u003cp\u003eSocial Media\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e0.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 387px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eMedian\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eIQR\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 387px;\"\u003e\n \u003cp\u003eNumber of Outpatient Hospital Visits Due to the Same Problem (days) (N=84)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 387px;\"\u003e\n \u003cp\u003eNumber of Day-Case Hospital Treatments (\u0026lt;24 Hours) Due to The Same Problem (days) (N=7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 387px;\"\u003e\n \u003cp\u003eNumber of Outpatient Hospital Services (days) (N=26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 387px;\"\u003e\n \u003cp\u003eEstimated Alternative Cost of Services (TL) (N=120)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e3000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e4750\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 387px;\"\u003e\n \u003cp\u003eAverage Income Loss per SHLC Visit (TL) (N=213)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 387px;\"\u003e\n \u003cp\u003eTime Spent Per SHLC Visit, Including Round Trip (minutes) \u0026nbsp;(N=364)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 387px;\"\u003e\n \u003cp\u003eTravel/Transport Expense per SHLC Visit (TL) (N=370)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e163\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eHLC: Healthy Life Center\u003c/p\u003e\n\u003cp\u003eMCHFP: Mother and Child Health and Family Planning Center\u003c/p\u003e\n\u003cp\u003eCEDSC: Cancer Early Diagnosis, Screening and Education Center\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNote: \u0026ldquo;Expenses for visits\u0026rdquo; cover ancillary, visit-related costs (e.g., transportation) and exclude any SHLC service fees. \u0026ldquo;Income loss\u0026rdquo; is self-reported. Values are presented as median (IQR). N=denotes respondents with non-missing data; items were asked only of those answering \u0026ldquo;Yes,\u0026rdquo; where applicable. Income loss, time spent, and expenses are reported per SHLC visit (including round trip).\u003c/p\u003e\n\u003cp\u003eWhen examining the service usage status of participants based on their reason for applying to the SHLC, it was determined that 31.1% had previously received outpatient services at a hospital due to the health issue that led them to the SHLC, 2.4% had received inpatient treatment at a hospital, and 9.7% had received day treatment services. The rate of medication use due to health problems as the reason for application was 7.6%, and 92.4% of participants reported that they did not use medication due to health problems as the reason for applying to SHLC. In terms of overall satisfaction, 62.5% of participants were satisfied with the services they received from SHLC, while 26.4% stated that they were very satisfied. Only 0.6% of participants stated that they were dissatisfied, while 10.5% were undecided. The vast majority of participants (89.2%) stated that they would recommend SHLC services to others. 61.8% of participants responded \u0026lsquo;I would recommend it,\u0026rsquo; while 27.4% responded \u0026lsquo;I would definitely recommend it.\u0026rsquo; When asked about their intention to continue using the healthcare services provided by SHLC, 83.8% of participants stated that they intended to continue using the service, 9.1% were undecided, and 6.9% stated that they did not intend to continue. More than half of the participants (51.5%) stated that SHLC services were of higher quality compared to other healthcare institutions, while 23.2% were undecided on this matter. The proportion of those who spent money out of pocket to access SHLC services was 1.0%, while among working participants, the proportion experiencing loss of productivity at work due to HLC visits was 10.9%, the proportion taking leave or sick leave was 23.8%, and the proportion experiencing loss of income was 5.0%. Participants\u0026apos; service usage trends and satisfaction levels are summarised in Table 3.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3: Participants Service Usage and Satisfaction Status\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"605\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 397px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 109px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eN (567)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e%\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVisiting HLC Due to the Previous Visits to Outpatient Services at the Hospital (N= 515)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e355\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e68.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e160\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e31.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVisiting HLC Due to the Previous Hospitalisation (N= 504)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e492\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e97.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e2.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVisiting HLC Due to the Previous Day-Care Treatment (N= 507)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e458\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e90.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e9.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVisiting HLC Due to Medication Use (N= 500)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e462\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e92.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e7.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOverall Satisfaction Level with Services Received from HLC (N= 515)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eI am not at all satisfied\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e0.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eI am not satisfied\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eI am undecided\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e10.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eI am satisfied\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e322\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e62.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eI am very satisfied\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e136\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e26.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRecommending HLC Services to Others (N= 526)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eI definitely do not recommend it\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eI do not recommend it\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eI am undecided\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e8.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eI recommend it\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e325\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e61.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eI definitely recommend it\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e144\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e27.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIntention to Continue Using HLC Services (N= 525)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eI definitely don\u0026apos;t think so\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eI don\u0026apos;t think so\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e5.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eI\u0026apos;m undecided\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e9.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eI\u0026apos;m considering it\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e318\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e60.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eI definitely think so\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e122\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e23.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eI Think HLC Services Are of Higher Quality Compared to Other Healthcare Institutions (N= 513)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eI definitely disagree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e1.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eI disagree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e3.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eI am undecided\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e119\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e23.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eI agree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e264\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e51.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eI definitely agree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e104\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e20.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHaving Out-of-Pocket Expenditure Due to HLC Application (N= 499)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e494\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e99.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLoss of Productivity at Work Due to HLC Application\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(N= 101)**\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e89.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e10.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTaking Leave or Reporting Sick from Work Due to HLC Visit\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(N= 101)**\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e76.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e23.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLoss of Income Due to HLC Visit (N= 101)**\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e95.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e5.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e** \u0026nbsp;Only participating employees are included.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe relationship between participants\u0026apos; satisfaction with the services provided by SHLC and their sociodemographic characteristics was examined using chi-square analysis. No significant relationship was found between participants\u0026apos; sociodemographic characteristics other than income, their use of HLC services, and their satisfaction levels. However, the analyses revealed that the relationship between participants\u0026apos; income status and satisfaction levels was statistically significant (p=0.046). The significant difference was found to stem from the high rate of dissatisfaction among participants who stated that their income was less than their expenses, compared to participants in other income groups. It was observed that satisfaction rates increased as income levels rose. 85.2% of those whose income was less than their expenditure, 91.7% of those whose income was equal to their expenditure, and 94.4% of those whose income was more than their expenditure stated that they were satisfied.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4: Relationship between Participants\u0026apos; Satisfaction Levels and Income Level of Participants\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"624\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" rowspan=\"3\" valign=\"bottom\" style=\"width: 229px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 281px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOverall Satisfaction Level with Services Received from HLC\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 137px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eNot Satisfied\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eSatisfied\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eN\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e%\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eN\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e%\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP value\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIncome Status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eMy Income is Less than My Expenses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e33\u003cstrong\u003e\u003csup\u003ea\u003c/sup\u003e\u003c/strong\u003e\u003ca id=\"_anchor_2\" onmouseover=\"msoCommentShow('_anchor_2','_com_2')\" onmouseout=\"msoCommentHide('_com_2')\" href=\"#_msocom_2\" language=\"JavaScript\" name=\"_msoanchor_2\"\u003e[Y\u0026Ccedil;2]\u003c/a\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e14.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e190\u003cstrong\u003e\u003csup\u003e\u0026nbsp;b\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e85.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.046*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eMy Income is Equal to My Expenses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e19\u003cstrong\u003e\u003csup\u003e\u0026nbsp;a\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e8.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e211\u003cstrong\u003e\u003csup\u003e\u0026nbsp;a\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e91.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eMy Income is More than My Expenses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e2\u003cstrong\u003e\u003csup\u003e\u0026nbsp;a\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e5.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e34\u003cstrong\u003e\u003csup\u003e\u0026nbsp;a\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e94.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eHLC: Healthy Life Center\u003c/p\u003e\n\u003cp\u003e*Chi-square test was used. Bonferroni correction was applied. Each subscript letter denotes a subset of categories whose column proportions do not differ significantly from each other at the .05 level. Groups bearing different subscripts are significantly different.\u003c/p\u003e\n\u003cp\u003eIn Table 5, the relationship between participants\u0026apos; sociodemographic characteristics and their intention to continue using SHLC services was tested using chi-square analysis, and only statistically significant characteristics and findings related to the intention to use SHLC services are presented. No significant relationship was found between participants\u0026apos; sex, income status, and marital status characteristics and their intention to use the services. However, a statistically significant relationship was found between participants\u0026apos; educational status, social security coverage, and age and their tendency to continue using SHLC services. As educational status increased, the intention to continue using HLC services increased (p\u0026lt;0.001). The rate of continuing to use the service among participants with social security coverage (86.9%) was found to be significantly higher than among those without social security coverage (76.2%) (p=0.009). Furthermore, the median age of those who did not intend to continue using the service was 45 years, while that of those who did intend to continue using the service was 43 years, and the difference was statistically significant (p=0.007).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5: Relationship between Sociodemographic Variables and the Intention to Continue Using SHLC Services\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"624\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" rowspan=\"3\" valign=\"bottom\" style=\"width: 236px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 321px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIntention to Continue Using HLC Services\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eNot considering it\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eConsidering it\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eN / Median\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e% / IQR\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eN / Median\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e% / IQR\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP value\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducational Status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eIlliterate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e13\u003cstrong\u003e\u003csup\u003e\u0026nbsp;a\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e27.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e35\u003cstrong\u003e\u003csup\u003e\u0026nbsp;b\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e72.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003ePrimary/secondary school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e66\u003cstrong\u003e\u003csup\u003e\u0026nbsp;a\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e20.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e255\u003cstrong\u003e\u003csup\u003e\u0026nbsp;b\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e79.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eHigh school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e3\u003cstrong\u003e\u003csup\u003e\u0026nbsp;a\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e2.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e102\u003cstrong\u003e\u003csup\u003e\u0026nbsp;b\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e97.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eUniversity/postgraduate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e3\u003cstrong\u003e\u003csup\u003e\u0026nbsp;a\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e5.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e48\u003cstrong\u003e\u003csup\u003e\u0026nbsp;b\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e94.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSocial Security Entity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e23.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e76.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.009*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e13.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e344\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e86.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.007**\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eHLC: Healthy Life Center\u003c/p\u003e\n\u003cp\u003e*Chi-square test was used. Bonferroni correction was applied. Each subscript letter denotes a subset of categories whose column proportions do not differ significantly from each other at the .05 level. Groups bearing different subscripts are significantly different.\u003c/p\u003e\n\u003cp\u003e**Mann Whitney U test was used for continuous data.\u003c/p\u003e\n\u003cp\u003eTable 6 evaluates the relationship between participants\u0026apos; sociodemographic variables and the perception that SHLC services are of higher quality compared to other healthcare institutions. Compared to those with primary/secondary education, those with secondary education are more likely to perceive SHLC services as higher quality. When evaluated in terms of income level, the perception that SHLC services are of better quality is higher among those who state that their income is equal to their expenditure compared to those who state that their income is less than their expenditure, and there is a statistically significant difference (p=0.001). Furthermore, the difference between non-participants with a median age of 45 years and participants with a median age of 43 years was found to be significant (p=0.036).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 6: Relationship between Sociodemographic Variables and the Perception of HLC Service Quality Compared to Other Healthcare Institutions\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"624\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" rowspan=\"3\" valign=\"bottom\" style=\"width: 236px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 331px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eI Think HLC Services Are of Higher Quality Compared to Other Healthcare Institutions\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eI Disagree\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eI Agree\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eN / Median\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e% / IQR\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eN / Median\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e% / IQR\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP value\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducational Status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eIlliterate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e13\u003cstrong\u003e\u003csup\u003e\u0026nbsp;a\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e27.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e34\u003cstrong\u003e\u003csup\u003e\u0026nbsp;a\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e72.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.009*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003ePrimary/secondary school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e104\u003cstrong\u003e\u003csup\u003e\u0026nbsp;a\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e32.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e212\u003cstrong\u003e\u003csup\u003e\u0026nbsp;b\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e67.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eHigh school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e16\u003cstrong\u003e\u003csup\u003e\u0026nbsp;a\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e15.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e85\u003cstrong\u003e\u003csup\u003e\u0026nbsp;b\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e84.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eUniversity/postgraduate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e12\u003cstrong\u003e\u003csup\u003e\u0026nbsp;a\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e24.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e37\u003cstrong\u003e\u003csup\u003e\u0026nbsp;a\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e75.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIncome Status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eMy Income is Less than My Expenses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e77\u003cstrong\u003e\u003csup\u003e\u0026nbsp;a\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e34.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e146\u003cstrong\u003e\u003csup\u003e\u0026nbsp;b\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e65.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eMy Income is Equal to My Expenses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e46\u003cstrong\u003e\u003csup\u003e\u0026nbsp;a\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e20.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e183\u003cstrong\u003e\u003csup\u003e\u0026nbsp;b\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e79.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eMy Income is More than My Expenses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e13\u003cstrong\u003e\u003csup\u003e\u0026nbsp;a\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e36.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e23\u003cstrong\u003e\u003csup\u003e\u0026nbsp;a\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e63.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.036**\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eHLC: Healthy Life Center\u003c/p\u003e\n\u003cp\u003e*Chi-square test was used. Bonferroni correction was applied. Each subscript letter denotes a subset of categories whose column proportions do not differ significantly from each other at the .05 level. Groups bearing different subscripts are significantly different.\u003c/p\u003e\n\u003cp\u003e**Mann Whitney U test was used for continuous data.\u003c/p\u003e\n\u003cp\u003eTable 7 presents the results of a multivariate logistic regression model aimed at identifying the factors influencing the intention to continue using the services provided by SHLC. The model includes the sociodemographic characteristics of participants identified as statistically significant in the chi-square analysis as affecting the tendency to use the services. These characteristics are the presence of social security, educational status, and age variables. Participants\u0026nbsp;with social security were found to be significantly more likely to continue using HLC services than those without social security OR = 1.81 (95% CI: 1.01\u0026ndash;3.25 p = 0.045). When the educational status variable was evaluated, high school graduates were found to be significantly more likely to continue using the service than those who were illiterate OR = 9.03 (95% CI 2.22\u0026ndash;36.7, p = 0.002). Similarly, the likelihood was also significantly increased for university or postgraduate graduates OR = 4.30 (95% CI 1.04\u0026ndash;17.77, p = 0.043). No significant effect of the age variable on the intention to continue HLC services was observed OR = 0.99 (95% CI 0.99\u0026ndash;1.01, p = 0.481).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 7. Factors Associated with the Intention to Continue Using HLC Services, Multivariate Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 397px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIntention to Continue Using HLC Services\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eOR\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eOR(95% CI)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP value\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 604px;\"\u003e\n \u003cp\u003eSocial Security Entity\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eRef.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e1.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e(1.01-3.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.045\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 604px;\"\u003e\n \u003cp\u003eEducational Status\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eIlliterate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eRef.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003ePrimary/secondary school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e1.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e(0.63-2.87)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.441\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eHigh school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e9.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e(2.22-36.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.002\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eUniversity/postgraduate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e4.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e(1.04-17.77)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.043\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e0.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e(0.99-1.01)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.481\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eOR: Odds Ratio CI: Confidence Interval\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003e\u003cstrong\u003e1. The Role of HLC in Primary Healthcare Services\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study quantitatively reveals who the adults applying to the Sultanbeyli Healthy Life Center are, how they access these services, and how they experience the services they receive. The findings show that the HLC is able to reach groups with lower income and education levels in particular, provide preventive and health-promoting services without incurring out-of-pocket expenditure, and generally achieve a high level of satisfaction. More than one-third of participants (35.7%) have a diagnosed health problem and apply to benefit from screening and preventive services. The fact that 39.1% of participants benefit from CEDSC, 27.7% from dietitian and 21.2% from \u0026nbsp; services reveals that participants\u0026nbsp;largely benefit from preventive and lifestyle-focused services. This shows that HLCs focus on disease prevention and the development of healthy lifestyle behaviours rather than disease treatment. The strongest aspect of primary care is its multidimensional and preventive role in contributing to health and health systems (19, 20).\u003c/p\u003e\n\u003cp\u003eWhen interpreted within the framework of access to healthcare proposed by Levesque and colleagues, these findings suggest that SHLCs simultaneously support multiple dimensions of access. The fact that participants were predominantly informed about and referred to the services by healthcare professionals reflects the dimensions of the ability to perceive and the ability to seek care. Moreover, the predominant use of preventive services and the low rates of hospital utilization indicate that appropriate and timely care can largely be delivered at the primary care level (17).\u003c/p\u003e\n\u003cp\u003eThe study findings show that only 31.1% of participants received outpatient services due to health problems prior to applying to the HLC, while only 2.4% of those who applied to the HLC required hospitalisation, and the rate of medication use due to the illness associated with the application was also low (7.6%). These findings suggest that the HLC can largely meet participants\u0026nbsp;health needs at the primary and preventive care levels; in this respect, it has the potential to limit the need for secondary and tertiary healthcare services (5). In this respect, HLC occupies a strategic position in terms of Turkey's long-standing goal of reducing the burden of hospital-centerd healthcare services. Strengthening preventive interventions at the primary level creates significant gains in terms of both resource efficiency and improvements in public health indicators(21). Similarly, international literature has shown that strong primary care systems reduce hospital admissions, facilitate chronic disease management, and increase cost-effectiveness(22).\u003c/p\u003e\n\u003cp\u003eIn our study, the fact that the vast majority of participants intend to continue using the service (83.8%) supports the long-term acceptance and sustainability potential of the HLC model within the community. This high continuation rate also indicates participants trust in and satisfaction with HLC(23). Furthermore, the 89.2% rate of ‘recommending the service’ is one of the factors that increases the adoption of HLC and, consequently, loyalty to the service system. A study conducted in Norway also found that participants managed to maintain their initial physical activity levels throughout the 24-month follow-up period. This finding has proven the potential of preventive health models to create long-term and sustainable behavioural change in\u0026nbsp;participants\u0026nbsp;in the international literature\u0026nbsp;(24).\u003c/p\u003e\n\u003cp\u003eThe level of education and health literacy is one of the key factors in the sustainability of HLC service uptake. Our findings reveal that the tendency to continue using HLC services increases significantly as the level of education rises (p\u0026lt;0.001). While highly educated participants\u0026nbsp;more easily grasp the integrity and long-term benefits of the services offered, low-educated participants\u0026nbsp;perception of preventive services as a necessity or a bureaucratic step may negatively affect their perception of service quality(25). Compared to the literature, our finding is fully consistent with the health literacy model developed by Sørensen et al.(26). Sørensen et al. define health literacy not only as access to information but as a whole comprising the processes of understanding, evaluating, and applying information. Within this model, it can be said that participants\u0026nbsp;with a higher level of education are able to more accurately assess the multidisciplinary service structure (dietitian, psychologist, physiotherapist, etc.) in the HLC and have higher motivation to apply this information to their lifestyle. Indeed, in our study, the fact that participants\u0026nbsp;with a high school education or above were significantly more likely to continue using the service (OR=9.03 and OR=4.30) proves that education creates a “social gradient” on the continuity of preventive health services. This situation indicates that special intervention strategies to increase health literacy and simpler service explanations are needed to ensure the sustainability of the service in groups with low educational levels. Looking at international examples, similar models are seen to support sustainability.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2. Reducing Social Inequalities Dimension\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study clearly demonstrates the capacity of HLCs to reach disadvantaged segments of society, as the vast majority of participants were women (91.2%), unemployed (80.3%), and participants\u0026nbsp;with low income levels (45% had income below their expenses). Although 21.2% of participants had no social security, the fact that this group was also able to benefit from HLC services demonstrates that the free nature of HLC is an effective tool in reducing income-based health inequalities. The fact that 9% of participants are illiterate and 61.5% have only primary or secondary school education shows that the service can also be used effectively by participants\u0026nbsp;with low educational attainment. This suggests that HLC acts as a critical bridge in accessing communities with low health literacy. The literature also emphasises that the widespread and free provision of preventive services plays a critical role in removing barriers to healthcare access for low-income and low-education groups(27). In this regard, the HLC model acts as a social equaliser, mitigating the negative effects of socio-economic disadvantages such as poverty, low education, and care burden on health. Similarly, the literature reports that the widespread and free provision of preventive services at the primary care level reduces income-based disparities in health outcomes (28, 29). From the Levesque model perspective, HLCs reduce physical and economic barriers and have the potential to inform and facilitate community participation. This contributes to reducing inequalities in access to healthcare services.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3. Willingness to Pay\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn this study, willingness to pay (WTP) was not directly measured; instead, the economic accessibility of Healthy Life Center (HLC) services was assessed through participants’ self-reported out-of-pocket expenditures and income loss, reflecting realized direct and indirect costs. The fact that only 1% of participants in the study reported making out-of-pocket expenditure due to HLC services indicates that these centers have a robust structure in terms of economic accessibility. The median expenditure per visit being 54 TL and the median loss of income being 0 TL reveals that HLC imposes almost no direct or indirect costs on the household budget. This finding shows that hidden economic barriers preventing low-income participants\u0026nbsp;from benefiting from preventive health services are largely eliminated by the HLC service. When viewed from the perspective of access to healthcare and economic concerns, the literature shows that out-of-pocket expenditures limit service use, particularly in low-income households(30). The fact that the HLC model reduces these economic barriers demonstrates that it functions as a financial protection mechanism. In systems where healthcare services are based on out-of-pocket expenditure, low-income households can be driven into the medical poverty trap(13). Studies conducted in low- and middle-income countries reveal that healthcare expenditures, combined with loss of income, impoverish households and reduce the chances of economic recovery after illness for poor households(13).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4. Comparison with Alternatives\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOver half of the participants (51.5%) agreed with the statement, ‘I believe that Healthy Life Center services are of higher quality compared to other healthcare institutions.’ This indicates that the HLC, with its free, comprehensive, and multidisciplinary structure, has a strong reputation for quality within the community. The literature also reports that community-based primary care centers similar to the HLC are more accessible, reliable, and user-centerd compared to hospital-based services(31). The fact that the perception of HLC quality increased significantly with higher education levels (p=0.009) indicates that participants\u0026nbsp;ability to evaluate healthcare services and health literacy are decisive factors in this perception. This finding supports the relationship between healthcare quality and health literacy in the primary care structure in Turkey. The significant difference identified according to income level (p=0.001) shows that although HLC is an indispensable service, especially for low-income participants, the quality perception of this group is relatively low. This situation may stem not only from economic differences but also from the meaning attributed to the service. For participants\u0026nbsp;with low income levels, HLC is often a mandatory area of recourse; their limited access to alternatives may not diminish the value of the service but may weaken the perceived quality(32). In contrast, participants\u0026nbsp;whose income is equal to or higher than their expenses may have evaluated the cost-free and comprehensive structure of HLC more positively, as they have the opportunity to experience both public and private healthcare services.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e5. Satisfaction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipant satisfaction in healthcare services is a critical indicator of service quality and sustainability. Studies conducted specifically on HLC generally report high levels of satisfaction. According to our survey in Sultanbeyli, the percentage of those satisfied with HLC services is 88.9%. 89.2% of participants plan to recommend these services to others. Factors affecting participant satisfaction highlighted in the literature include the attitude and communication of service providers, service quality, physical environment and equipment, accessibility, free services, and meeting participants expectations(33).\u0026nbsp;For example, in their study, Porsuk and Cerit (2023) emphasised that patient satisfaction is closely related to the behaviour of healthcare workers, the quality and suitability of the service provided, ease of access, the effectiveness of information provision processes, and physical infrastructure. Research conducted specifically on HLC also generally reports high levels of satisfaction(34). The literature indicates that illiteracy, lack of social security, and advanced age are interrelated variables(35). The study suggests that as the level of education increases, the intention to continue using HLC services increases (p\u0026lt;0.001), the rate of continuing the service is higher among\u0026nbsp;participants\u0026nbsp;with social security (p=0.009), and the median age of those who do not intend to continue the service is higher (p=0.007). These findings suggest that these variables may be related to the continuity of HLC service use and satisfaction. Considering the structure of HLC services and Turkey's demographic characteristics, this situation suggests that HLC services may be more suitable for literate, socially insured, and relatively younger\u0026nbsp;participants, which may be related to the high satisfaction and service continuation tendencies observed in the study.\u003c/p\u003e\n\u003cp\u003eWhen satisfaction levels were examined in terms of sociodemographic variables, no significant differences were found except for income status. The fact that satisfaction was higher in the high-income group may seem like an unexpected finding for a service model that is provided free of charge and generally prioritises disadvantaged groups(36). However, this situation can be interpreted as a negative reflection of the general dissatisfaction with life caused by low income on the experience of healthcare services. On the other hand, the fact that satisfaction levels remain high even in the group with income lower than expenditure proves that HLCs have successfully implemented the principles of economic accessibility and equity in healthcare. As emphasised by Gizaw and colleagues, ease of appointment, consultant interest, adequate service duration, and free access are key factors that increase satisfaction(20). Furthermore, as stated by Weingarten and colleagues, multidisciplinary and preventive service delivery also positively affects the perception of satisfaction(37). In this context, a high level of satisfaction is the most important outcome that strengthens the sustainability of the service, participants trust in the institution, and their willingness to recommend it.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e6. Characteristics of the HLC target audience and media dimension\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe most important referral source for HLC applications is the transfer channels integrated into the healthcare system. In the Sultanbeyli example, 83% of participants came to HLC through referrals from healthcare personnel, while 16.8% applied based on recommendations from their social circle. In other words, the vast majority learned about HLC through family doctors or community health workers. Although the influence of the social environment is significant, media or digital platforms were only effective in 0.2% of referrals. The existing literature emphasises the critical role of mass communication campaign design and implementation in reaching the target audience; for example, Wakefield and colleagues have shown that large-scale media campaigns can bring about positive behavioural changes in large population groups(38). Similarly, it is noted that health promotions on social media platforms have the potential to change behaviour beyond raising awareness(39).\u003c/p\u003e\n\u003cp\u003eIn terms of health communication strategies, effective campaigns are generally based on behaviour change theories(40). These theoretical frameworks help to identify the right messages and reach the appropriate target audience. Currently, a large portion of promotional activities related to HLCs in Turkey are carried out through healthcare professionals. However, greater visibility in the media and effective use of digital communication channels have the potential to increase awareness of HLCs. It is known that behavioural change can be observed in public health campaigns when a solid theoretical foundation and sufficient media continuity are provided(38). Therefore, comprehensive media strategies prepared to promote HLCs can increase public awareness of health education and healthy living behaviours, as well as strengthen social environment guidance.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eHealthy Life Centers, which provide free services at the primary level, stand out as a health service model that is accessible to the community, trusted, and significantly reduces socio-economic barriers through their holistic structure. The findings of the study show that HLCs are particularly able to reach disadvantaged groups, that the services are largely accepted, and that a significant proportion of participants are inclined to continue using the service and recommend it to others. When evaluated in terms of the policy-making process, HLCs are seen to strengthen preventive services, have the potential to reduce hospital-centerd referrals, and offer an economically accessible structure. Although the findings are generally positive, a structural limitation regarding the prevalence of the service should also be considered. The current capacity and geographical distribution of HLCs may remain at a level that could restrict access to the service, particularly in densely populated areas. In this context, increasing the number of HLCs and ensuring a more balanced geographical distribution is important in terms of strengthening the accessibility of the service.\u003c/p\u003e\n\u003cp\u003eFrom the perspective of the Levesque access model, the relatively long travel time to the center and the fact that people mostly learn about HLCs through their social environment or healthcare personnel indicate a need for more effective use of digital and media-based information channels. Consequently, this study demonstrates that HLCs represent a significant public health investment at the primary level; it indicates that the cost-effectiveness of HLCs should be evaluated in the future, their impact on specific health outcomes such as chronic disease management and obesity should be measured using quantitative data, and their contribution to long-term health expenditures should be examined.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSTRENGTHS AND LIMITATIONS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study is unique in that it evaluates Healthy Life Centers (HLCs) not only through service delivery but also through participants’ experiences, satisfaction levels, and their tendencies to continue using and recommend the services. Satisfaction is not considered as a single-dimensional construct; rather, addressing it alongside three distinct behavioural outcomes provides a more meaningful picture of the model’s acceptability and sustainability. The large sample size and the reflection of real-world experiences of actual service participants represent important strengths of the study. Furthermore, the study’s execution by a multidisciplinary team has enabled the simultaneous consideration of perspectives from health economics, health management, and public health.\u003c/p\u003e\n\u003cp\u003eHowever, several limitations should be acknowledged. The study was conducted in a single HLC located in one of Istanbul’s socioeconomically disadvantaged districts, using a convenience sampling approach during daytime hours, which limits the direct generalisability of the findings to other provinces, settings, or service delivery contexts. In addition, the sample consisted predominantly of female participants (91%), which may restrict the applicability of the results to male participants and other demographic groups. Individuals who attend HLC services outside regular daytime hours, such as in the evenings or on weekends, may be underrepresented.Moreover, due to the cross-sectional design of the study, the observed associations between variables cannot be interpreted in terms of causality. The reliance on self-reported data may have introduced social desirability bias and recall bias. Future research would benefit from multi-center designs, extended data collection periods (including evenings and weekends), and more demographically balanced samples to enhance the generalisability of findings and to better capture diverse patterns of HLC service use.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e: Informed consent was obtained from all participants prior to the study. Ethical committee approval was obtained from the Istanbul Medipol University \u0026nbsp;Non-Interventional Clinical Research Ethics Committee \u0026nbsp;on July 31, 2025 (protocol number 07.2025.883).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e: At the beginning of the interviews, the participants were informed about the purpose and process of the research, and permission was obtained from the participants to record the interviews. Participants were assured that the confidentiality and anonymity of the information they provided would be guaranteed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e:\u0026nbsp;The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e: The authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e None\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e: KA, ZT, MAS, YÇ, YB,KYE and SH contributed to the conception and design of the study, data acquisition, analysis, and interpretation. All authors participated in drafting and critically revising the manuscript for important intellectual content. All authors approved the submitted version (and any substantially modified version that involves their contribution to the study). All authors agreed to be personally accountable for their own contributions and to ensure that any questions related to the accuracy or integrity of any part of the work, even those in which they were not personally involved, are appropriately investigated, resolved, and documented in the literature.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e: Not applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKhatri RB, Wolka E, Nigatu F, Zewdie A, Erku D, Endalamaw A, et al. People-centred primary health care: a scoping review. BMC Prim Care. 2023;24(1):236.\u003c/li\u003e\n\u003cli\u003eKhatri RB, Endalamaw A, Erku D, Wolka E, Nigatu F, Zewdie A, et al. Contribution of health system governance in delivering primary health care services for universal health coverage: A scoping review. PLoS One. 2025;20(2):e0318244.\u003c/li\u003e\n\u003cli\u003eRosano A, Loha CA, Falvo R, van der Zee J, Ricciardi W, Guasticchi G, et al. The relationship between avoidable hospitalization and accessibility to primary care: a systematic review. Eur J Public Health. 2013;23(3):356-60.\u003c/li\u003e\n\u003cli\u003eAoki T, Sugiyama Y, Mutai R, Matsushima M. Impact of Primary Care Attributes on Hospitalization During the COVID-19 Pandemic: A Nationwide Prospective Cohort Study in Japan. Ann Fam Med. 2023;21(1):27-32.\u003c/li\u003e\n\u003cli\u003eStarfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83(3):457-502.\u003c/li\u003e\n\u003cli\u003eS\u0026ouml;zmen K, \u0026Uuml;nal B. Explaining inequalities in Health Care Utilization among Turkish adults: Findings from Health Survey 2008. Health Policy. 2016;120(1):100-10.\u003c/li\u003e\n\u003cli\u003eS\u0026ouml;yler S, \u0026Ouml;zt\u0026uuml;rk YE. Birinci Basamak Sağlık Hizmetlerinde Yeni Bir Uygulama: Sağlıklı Hayat Merkezlerinde Hizmet Sunumu, Yaşanan Sorunlar ve \u0026Ccedil;\u0026ouml;z\u0026uuml;m \u0026Ouml;nerileri. Ekonomi İşletme Siyaset ve Uluslararası İlişkiler Dergisi. 2021;7(2):403-18.\u003c/li\u003e\n\u003cli\u003eYelsiz M, Sezer Korucu K, Eke E. SAĞLIK HİZMETLERİNDE SAĞLIKLI HAYAT MERKEZLERİ FARKINDALIĞI \u0026Uuml;ZERİNE BİR ARAŞTIRMA: ISPARTA \u0026Ouml;RNEĞİ. Avrasya Sosyal ve Ekonomi Araştırmaları Dergisi. 2023;10(3):523-44.\u003c/li\u003e\n\u003cli\u003eSHM Nedir? https://shm.saglik.gov.tr/ shm-nedir.html. Accessed 10 Feb 2026.\u003c/li\u003e\n\u003cli\u003eOmran AR. The epidemiologic transition: a theory of the epidemiology of population change. 1971. Milbank Q. 2005;83(4):731-57.\u003c/li\u003e\n\u003cli\u003eGulis G, Zidkova R, Meier Z. Changes in disease burden and epidemiological transitions. Sci Rep. 2025;15(1):8961.\u003c/li\u003e\n\u003cli\u003eSans-Corrales M, Pujol-Ribera E, Gen\u0026eacute;-Badia J, Pasar\u0026iacute;n-Rua MI, Iglesias-P\u0026eacute;rez B, Casajuana-Brunet J. Family medicine attributes related to satisfaction, health and costs. Fam Pract. 2006;23(3):308-16.\u003c/li\u003e\n\u003cli\u003eMcIntyre D, Thiede M, Dahlgren G, Whitehead M. What are the economic consequences for households of illness and of paying for health care in low- and middle-income country contexts? Soc Sci Med. 2006;62(4):858-65.\u003c/li\u003e\n\u003cli\u003eKringos DS, Boerma WG, Spaan E, Pellny M. A snapshot of the organization and provision of primary care in Turkey. BMC Health Serv Res. 2011;11:90.\u003c/li\u003e\n\u003cli\u003eLonghini J, Canzan F, Mezzalira E, Leardini C, Saiani L, Di Falco A, et al. Exploring user experiences in a novel primary care center: a qualitative grounded theory study. BMC Health Serv Res. 2025;25(1):1174.\u003c/li\u003e\n\u003cli\u003eAltaş ZM, Sezerol MA. Prevalence and Associated Factors of Dental Caries in Syrian Immigrant Children Aged 6-12 Years. Children (Basel). 2023;10(6).\u003c/li\u003e\n\u003cli\u003eLevesque JF, Harris MF, Russell G. Patient-centred access to health care: conceptualising access at the interface of health systems and populations. Int J Equity Health. 2013;12:18.\u003c/li\u003e\n\u003cli\u003eTekindal MA, Babaoğlu AB, Tekindal M, B\u0026uuml;y\u0026uuml;kuysal M\u0026Ccedil;, T\u0026ouml;z\u0026uuml;n M, Elmalı F, et al. Epidemiyolojide G\u0026ouml;zlemsel \u0026Ccedil;alışmaların Raporlanması: STROBE Kriterlerinin T\u0026uuml;rk\u0026ccedil;e Uyarlaması. Medical Journal of Western Black Sea. 2021;5(1):86-93.\u003c/li\u003e\n\u003cli\u003eShi L. The Impact of Primary Care: A Focused Review. Scientifica. 2012;2012.\u003c/li\u003e\n\u003cli\u003eGizaw Z, Astale T, Kassie GM. What improves access to primary healthcare services in rural communities? A systematic review. BMC Primary Care. 2022;23(1):313.\u003c/li\u003e\n\u003cli\u003eBisak A, Stafstr\u0026ouml;m M. Unleashing the potential of Health Promotion in primary care\u0026mdash;a scoping literature review. Health Promotion International. 2024;39(3).\u003c/li\u003e\n\u003cli\u003eMartinez C, Bacigalupe G, Cortada JM, Grandes G, Sanchez A, Pombo H, et al. The implementation of health promotion in primary and community care: a qualitative analysis of the \u0026lsquo;Prescribe Vida Saludable\u0026rsquo; strategy. BMC Family Practice. 2017;18(1):23.\u003c/li\u003e\n\u003cli\u003eLi L, Zhu L, Zhou X, Zeng G, Huang H, Gan Y, et al. Patients\u0026rsquo; trust and associated factors among primary care institutions in China: a cross-sectional study. BMC Primary Care. 2022;23(1):109.\u003c/li\u003e\n\u003cli\u003eGryte OH, Meland E, Samdal GB, Fadnes LT, Vold JH, Mildestvedt T. Physical activity and sedentary time after lifestyle interventions at the Norwegian Healthy Life Centres. Prim Health Care Res Dev. 2024;25:e4.\u003c/li\u003e\n\u003cli\u003eDeğer MS, İşsever H. Service Quality and Related Factors in Primary Health Care Services: A Cross-Sectional Study. Healthcare. 2024;12(10):965.\u003c/li\u003e\n\u003cli\u003eS\u0026oslash;rensen K, Van den Broucke S, Fullam J, Doyle G, Pelikan J, Slonska Z, et al. Health literacy and public health: a systematic review and integration of definitions and models. BMC Public Health. 2012;12:80.\u003c/li\u003e\n\u003cli\u003eNiessen LW, Mohan D, Akuoku JK, Mirelman AJ, Ahmed S, Koehlmoos TP, et al. Tackling socioeconomic inequalities and non-communicable diseases in low-income and middle-income countries under the Sustainable Development agenda. The Lancet. 2018;391(10134):2036-46.\u003c/li\u003e\n\u003cli\u003eHaque M, Islam T, Rahman NAA, McKimm J, Abdullah A, Dhingra S. Strengthening Primary Health-Care Services to Help Prevent and Control Long-Term (Chronic) Non-Communicable Diseases in Low- and Middle-Income Countries. Risk Manag Healthc Policy. 2020;13:409-26.\u003c/li\u003e\n\u003cli\u003eKaya Ka\u0026ccedil;ar H, K\u0026ouml;se ED, Okuyucu K. Voices from a healthy life centre: a qualitative investigation of clients\u0026amp;#039; nutrition and physical activity experiences. Journal of Health Sciences and Medicine. 2025;8(1):97-102.\u003c/li\u003e\n\u003cli\u003eFalkingham J. Poverty, out-of-pocket payments and access to health care: evidence from Tajikistan. Social science \u0026amp;amp; medicine (1982). 2004;58(2):247-58.\u003c/li\u003e\n\u003cli\u003eCho Y, Chung H, Joo H, Park HJ, Joh HK, Kim JW, et al. Comparison of patient perceptions of primary care quality across healthcare facilities in Korea: A cross-sectional study. PLoS One. 2020;15(3):e0230034.\u003c/li\u003e\n\u003cli\u003eShi J, Jin H, Shi L, Chen C, Ge X, Lu Y, et al. The quality of primary care in community health centers: comparison among urban, suburban and rural users in Shanghai, China. BMC Fam Pract. 2020;21(1):178.\u003c/li\u003e\n\u003cli\u003ePorsuk AO, Cerit C. Assessment of satisfaction with a healthy life center, a new service model. Niger J Clin Pract. 2023;26(1):23-30.\u003c/li\u003e\n\u003cli\u003eAlhajri SM, Aljehani NM, El Dalatony MM, Alsuwayt SS, Alhumaidany TM, Aldossary MS. Patients\u0026apos; Satisfaction With the Quality of Services at Primary Healthcare Centers in Saudi Arabia. Cureus. 2023;15(9):e45066.\u003c/li\u003e\n\u003cli\u003eLima ACP, Maximiano-Barreto MA, Martins TCR, Luchesi BM. Factors associated with poor health literacy in older adults: A systematic review. Geriatric Nursing. 2024;55:242-54.\u003c/li\u003e\n\u003cli\u003eMohamed EY, Sami W, Alotaibi A, Alfarag A, Almutairi A, Alanzi F. Patients\u0026apos; Satisfaction with Primary Health Care Centers\u0026apos; Services, Majmaah, Kingdom of Saudi of Saudi Arabia. Int J Health Sci (Qassim). 2015;9(2):163-70.\u003c/li\u003e\n\u003cli\u003eWeingarten SR, Stone E, Green A, Pelter M, Nessim S, Huang H, et al. A study of patient satisfaction and adherence to preventive care practice guidelines. Am J Med. 1995;99(6):590-6.\u003c/li\u003e\n\u003cli\u003eWakefield MA, Loken B, Hornik RC. Use of mass media campaigns to change health behaviour. Lancet. 2010;376(9748):1261-71.\u003c/li\u003e\n\u003cli\u003eGhahramani A, de Courten M, Prokofieva M. \u0026ldquo;The potential of social media in health promotion beyond creating awareness: an integrative review\u0026rdquo;. BMC Public Health. 2022;22(1):2402.\u003c/li\u003e\n\u003cli\u003eMichie S, van Stralen MM, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci. 2011;6:42.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Intention to continue the service, Satisfaction, Willingness to pay, Healthy Life Center","lastPublishedDoi":"10.21203/rs.3.rs-8888176/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8888176/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePrimary healthcare services are the fundamental system that facilitates access to preventive healthcare services for the community and supports healthy lifestyle behaviours. Healthy Life Centers (HLCs) were established to protect individuals and the community from health-related risks, promote a healthy lifestyle, strengthen primary healthcare services, and facilitate access to these services. The acceptance of HLCs in the community is closely related to the existence of the service, how individuals evaluate this service, their level of satisfaction, and their willingness to continue using the service. This study was conducted to examine accessibility, perceived service quality, satisfaction, intention to continue using the service, recommendation behaviour, out-of-pocket expenditure, and willingness to pay for the service among individuals receiving services from HLCs.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethod\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study is a cross-sectional study conducted between August and September 2025. The study group consisted of individuals aged 18 and over who applied to the HLC, agreed to participate in the study, and could speak and understand Turkish. No separate sample size calculation was made for the study, and the aim was to include all individuals who applied to the HLC in the study. This research was approved by the Istanbul Medipol University Non-Interventional Clinical Research Ethics Committee. Data were collected using a semi-structured questionnaire administered through face-to-face interviews. It was conducted within the framework of the access model developed by Levesque and colleagues in order to evaluate the factors affecting access to HLC in a multidimensional manner. The form included questions on sociodemographic characteristics, use of HLC, perceived service quality, satisfaction, recommendation and intention to continue using the service, out-of-pocket expenditure, loss of income, and willingness to pay. In the analysis of the data, descriptive statistics were used; for categorical variables, the number and percentage were given, and for numerical variables, the median, interquartile range, minimum and maximum were given. Comparisons were made using the Chi-square test , Mann Whitney U test and the the logistic regression analysis. In all statistical analyses, the significance value was accepted as p\u0026lt;0.005.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eResults: In total, 567 participants were included; most reported high overall satisfaction with HLC services (88.9%) and stated they would recommend the center to others (89.2%), while 83.8% indicated an intention to continue using HLC services. Intention to continue use differed by educational status (p\u0026lt;0.001) and social security coverage (p=0.009) in bivariate analyses, while age was also associated with continuation tendency (p=0.007). In the multivariate logistic regression model for intention to continue using HLC services, having social security was independently associated with higher odds of intended continued use (OR=1.81, 95% CI 1.01–3.25; p=0.045). Compared with illiterate participants, high school graduates (OR=9.03, 95% CI 2.22–36.7; p=0.002) and university/postgraduate graduates (OR=4.30, 95% CI 1.04–17.77; p=0.043) were more likely to report intention to continue, whereas age was not significant in the adjusted model (OR=0.99, 95% CI 0.99–1.01;\u003c/p\u003e\n\u003cp\u003ep=0.481).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study demonstrates that HLCs generate high levels of satisfaction, recommendation, and willingness to continue the service within the community; this indicates that the services are valued by the community. Out-of-pocket expenditures are low, and direct income loss is limited. HLCs play a significant role in reducing health access issues arising from income inequality at the primary level. The findings show that HLCs perform a balancing function in accessing healthcare services, particularly for individuals with low levels of education and limited social security. Ensuring that individuals with low income levels or no social security can sustainably benefit from HLC services will both reduce inequalities and significantly protect public health. Increasing the awareness of HLCs within the community would also be an important step in this direction. The fact that our study was conducted at a single center limits its generalisability, and the fact that we only spoke to those who applied to the HLC and agreed to be interviewed limits it in terms of selection bias.\u003c/p\u003e","manuscriptTitle":"Evaluation of Healthy Life Center Services within Primary Care: A Cross- Sectional Study of User Perspectives","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-19 19:21:24","doi":"10.21203/rs.3.rs-8888176/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-03-29T12:13:52+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-26T07:44:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"116643968370297009430745770797728427932","date":"2026-03-22T14:07:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"246869695846687452938137683701109570669","date":"2026-03-18T11:49:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"170552508791929981950744789450285450477","date":"2026-03-17T09:00:34+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-17T08:48:43+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-20T05:27:45+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-16T23:48:35+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-16T23:48:16+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Primary Care","date":"2026-02-15T19:46:45+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5fd0270e-ef98-47e7-9069-79f91128be6c","owner":[],"postedDate":"March 19th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-19T19:21:24+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-19 19:21:24","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8888176","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8888176","identity":"rs-8888176","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}