What role does healthcare geographic accessibility play in the association between personal health responsibility and family doctor contract services?

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Jingjing Luo, Ziyu Liu, Chengchao Zhou This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6566826/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 12 You are reading this latest preprint version Abstract Background Limited research has examined the nexus between personal health responsibility and family doctor contract services, particularly the moderating role of healthcare geographic accessibility in this relationship. This study aimed to investigate the association between personal health responsibility and family doctor contract services and to determine how healthcare geographic accessibility shapes this relationship among rural older adults in China. Methods A cross-sectional study was conducted from July to August 2022 in Shandong Province in China. A total of 3,164 rural older adults were included in the analysis. Multivariable binary logistic regression models and the margins plot were used for the moderating effect analysis. Results The rates of signing up for family doctor contract services and support for personal health responsibility among rural older adults in Shandong Province were 64.85% and 61.54%, respectively. Participants who supported personal health responsibility were more likely to contract for family doctor services (OR = 1.38, 95% CI = 1.13–1.69) after controlling for confounding factors. Only among older adults with good healthcare geographic accessibility, personal health responsibility was associated with higher contracting rates for family doctor services (OR = 1.48, 95% CI = 1.20–1.82). Conclusions Our findings reveal a correlation between personal health responsibility and engagement with family doctor contract services, with healthcare geographic accessibility serving as a pivotal moderating factor. It is imperative for governmental authorities to amplify targeted educational campaigns and outreach for rural older adults. Elevating their understanding of personal health responsibilities and enhancing healthcare geographic accessibility are crucial steps to encourage their participation in family doctor services. Humanities/Health humanities Humanities/Medical humanities Social science/Social policy Personal health responsibility family doctor contract services healthcare geographic accessibility older adults Figures Figure 1 1. Introduction The aging population generates a heavy demand for the responsiveness and continuity of healthcare, posing a great challenge to global healthcare systems (Hambleton et al., 2023 ). Against this backdrop, China introduced the Family Doctor Contracting Services (FDCSs) in 2016, aiming to establish a long-term and stable doctor-patient relationship through a service agreement between residents and a team of primary care doctors. The FDCSs initiative involves a team of family doctors (usually general practitioners, nurses, public health practitioners, etc.) who provide contracted families or individuals with continuous, comprehensive, and personalized primary medical care, public health, and health management services (Council, 2016 ). Such an approach is instrumental in substantially alleviating the pressure on health resources, ensuring the provision of primary care at the grass-roots level, and facilitating a tiered system of diagnosis and treatment (Chen et al., 2022 ; Council, 2016 ; Pertusa-Martinez, 2006 ). This initiative is especially crucial in rural China, where healthcare resources are significantly less available compared to urban regions, and where older adults are at an increased risk of non-communicable diseases (NCDs). Despite the high willingness of rural older adults to engage with FDCSs, their actual utilization remains low which could be attributed to both structural factors (e.g., lack of well-trained family doctors) and agency-based factors (e.g., doctor reputation and the weak contractual relationships) (Zhang et al., 2023 ). Improving the level and quality of healthcare in rural areas has always been a priority for China’s healthcare development and needs to be addressed urgently. The FDCSs system is a critical initiative for improving rural primary healthcare and effectively safeguard the health needs of the population (Council, 2016 ). Thus, it is necessary to explore the influencing factors of FDCSs to provide scientific references for effectively improving the quality of health services for rural older adults and realizing healthy aging. Beyond the structural and systemic endeavors to enhance healthcare accessibility and delivery, the notion of personal health responsibility emerges as an integral strategy in combating NCDs, especially those associated with modifiable health behaviors, such as diet, physical activities, and adherence to treatments (Cockerham, 2005 ). Many countries have adopted personal health responsibility as one of the basic principles of public health action and health policy formulation to control healthcare costs and improve national health (Laverty and Harris, 2018 ; Pillutla et al., 2018 ; Schirmer and Michailakis, 2011 ; Schmidt et al., 2010 ; Traina and Feiring, 2022 ). Since 2014, China's national guiding documents have repeatedly mentioned the goal of “strengthening personal health responsibility” (China, 2014). In 2019, China formally incorporated the concept of “personal health responsibility” into its laws and regulations, highlighting that individuals are primarily responsible for their own health (China, 2020 ). Given that the concept of personal health responsibility may carry different connotations depending on its context and application (Vincent, 2011 ), for the purpose of this study, it primarily refers to individuals taking proactive steps to maintain and improve their own health. Specifically, this includes adopting healthy behaviors such as seeking health-related information, maintaining personal health resources, and consistently engaging in preventive practices (Borghian et al., 2023 ). Behavioral health theories, such as the Health Belief Model (HBM) and the Theory of Planned Behavior (TPB), provide valuable frameworks for understanding how individuals’ health behaviors are influenced by their beliefs, intentions, and perceived control over health outcomes (Ajzen, 1991 ; Rosenstock, 1974 ). These theories suggest that individuals who believe in the importance of taking responsibility for their health are more likely to engage in health-promoting behaviors, such as adopting FDCSs. For instance, under the HBM, personal health responsibility can be understood as part of perceived severity and perceived benefits, where individuals who recognize the importance of managing their own health may be more inclined to seek primary care services to prevent or manage chronic conditions. Similarly, the TPB highlights how individual attitudes toward health responsibility and perceived behavioral control influence intentions to engage with services like FDCSs. However, the extent to which individuals can effectively exercise personal health responsibility is largely contingent upon the accessibility of healthcare (Albertsen and Tsiakiri, 2023 ). Healthcare accessibility—encompassing geographic, economic, and social dimensions—can either facilitate or hinder the ability of older adults to engage with FDCSs. This study focuses on geographic accessibility to healthcare. In areas where healthcare are more accessible, individuals who prioritize personal responsibility for their health are more likely to engage with FDCSs. Conversely, in areas where healthcare access is limited, even those with a strong sense of personal health responsibility may struggle to adopt FDCSs due to geographic or financial constraints (Ford et al., 2016 ; Levesque et al., 2013 ). This moderating role of healthcare geographic accessibility is particularly relevant in rural China, where significant disparities in health infrastructure and service provision persist. While urban residents may have relatively easy access to healthcare, rural older adults often face greater difficulties due to the limited availability of healthcare professionals and facilities, compounded by logistical barriers such as distance and transportation (Fang et al., 2014 ; Yang et al., 2021 ). This context raises the question of how personal health responsibility interacts with these structural limitations to shape FDCSs adoption. By considering healthcare access as a moderating variable, this study aims to explore how structural inequalities affect the exercise of personal health responsibility in rural settings. The Health Lifestyle Theory (HLT) provides a broader framework for understanding the interaction between individual health behaviors and the structural conditions that shape them (Cockerham, 2023 ). The HLT posits that health outcomes are the result of both individual agency—such as the decision to take personal responsibility for one’s health—and structural factors like socioeconomic status, education, and the accessibility of healthcare. This theory underscores the fact that not all individuals have equal opportunities to engage in health-promoting behaviors, even if they are personally motivated to do so. In the case of rural China, older adults who are willing to take responsibility for their health may still face significant challenges in accessing FDCSs due to geographic or economic barriers. As such, the relationship between personal health responsibility and FDCSs utilization must be understood within the context of these broader structural constraints. This study aims to 1) explore the association between personal health responsibility and the engagement of FDCSs among rural older adults in Shandong Province, China, and 2) determine whether healthcare geographic accessibility moderates this relationship. By doing so, we aim to contribute to the empirical evidence supporting the expansion and optimization of FDCSs, ultimately promoting healthier aging in rural areas. Thus, we proposed the following specific hypotheses: H1. Older adults who prioritize personal health responsibility are more likely to engage with FDCSs. H2. Healthcare geographic accessibility moderates the association between personal health responsibility and the engagement of FDCSs. 2. Methods 2.1. Data Source and Participants This study leveraged cross-sectional data from the Shandong Rural Elderly Health Cohort (SREHC) survey, conducted in Shandong Province, China, from July to August 2022. We employed a multi-stage stratified cluster sampling method to select participants, which was also elaborated in our previous publications (Wang et al., 2021b ). Initially, counties in Shandong Province were categorized into three groups based on their per capita Gross Domestic Product (GDP) in 2018. One sample county was randomly selected from each category. In this study, three sample counties (Rushan in Weihai, Qufu in Jining, and Laoling in Dezhou) were selected as the study sites. Subsequently, five townships were randomly selected from each sampled county. From each township, four communities/villages were randomly selected, and older adults aged 60 years and above were randomly chosen from these communities or villages to ensure a diverse and representative sample of the rural elderly population. Data were collected through face-to-face interviews using structured questionnaires (Wang et al., 2021b ), administered by trained investigators with adequate medical knowledge. To ensure data completeness and accuracy, respondents were excluded if they: (1) could not communicate clearly in Chinese, (2) had a diagnosis of dementia or mental illness, or (3) were uncooperative during the survey. Besides, participants with missing primary variables (n = 87) were also excluded. Following these criteria, a total of 3,164 older adults aged 60 years and above were included in the study. 2.2. Measures 2.2.1. Family Doctor Contract Services Family Doctor Contract Services (FDCSs) were measured by the following question: "In 2021, did you contract for family doctor services?". Responses were categorized as a dichotomous variable (yes or no), with “yes” indicating that the respondent had contracted for services and “no” indicating otherwise. 2.2.2. Personal Health Responsibility Personal health responsibility was measured using two questions: (1) “To what extent do you believe that you have a responsibility to protect your health?” Responses were rated on a 5-point scale from “1 = not at all” to “5 = very much” (2) “To what extent do you agree with the following statement: If a person's disease is caused by modifiable causes, such as lung disease that may be caused by long-term smoking, then we should make him overpay for the treatment of the disease.” The response options were given on a 3-point scale, “1 = disagree”, “2 = indifferent (not sure)”, and “3 = agree” (Traina et al., 2019 ). Due to the skewed distribution of responses to the first question (95% of responses fell into categories 4 and 5), this question was not included in the regression analysis (Traina et al., 2019 ). 2.2.3. Healthcare Geographic Accessibility Healthcare geographic accessibility was measured by the question: “How many minutes does it take to get from your home to the nearest health facility (using the most accessible mode of transport rather than walking only)?” Time was categorized as ≤ 10 minutes or > 10 minutes (Ford et al., 2016 ; Levesque et al., 2013 ). 2.2.4. Covariates Previous studies have identified a range of influencing factors for family doctor contract services (Li et al. 2021 ; Shang et al. 2019 ; Yang et al. 2021 ). Drawing from the Anderson model, covariates were categorized into three groups (Andersen and Newman 1973 ; Li et al. 2021 ): (1) Predisposing Characteristics: age, gender (male, female), highest level of education (illiterate, primary school, middle school or above), and marital status (single, married); (2) Enabling Factors: household income (Q1, Q2, Q3, Q4, quartiles from poorest to richest) and health insurance (yes, no); Household income was measured by asking the total income of the respondent’s household in the previous year (2021). (3) Needs Factors: body mass index (BMI), chronic health conditions (no chronic condition, one chronic condition, multimorbidity), and activities of daily living (ADL). BMI was calculated as weight in kilograms divided by height in square meters (Zhou et al., 2002). ADL was assessed using the Katz index scale, with scores ranging from 14 to 56, where higher scores indicate worse activities of daily living (Katz et al., 1963 ). Additionally, indicators of healthcare utilization experiences, including two-week outpatient care (yes, no) and annual inpatient care (yes, no), were included as covariates due to their correlation with FDCSs utilization. 2.3. Statistical Analyses Statistical analyses were conducted using Stata 15.1 (Stata Corp, College Station, TX, USA). First, descriptive statistics were employed to summarize the basic characteristics of rural older adults, presented as means (standard deviations) for continuous variables and frequencies (percentages) for categorical variables. Student's t-test was used for continuous variables, while chi-square tests were applied to compare FDCSs status across different subgroups. Second, a binary logistic regression model was used to assess the relationship between personal health responsibility and FDCSs. Model 1 was unadjusted; Model 2 included adjustments for all predisposing characteristics, enabling factors, needs factors, and health behavior factors; Model 3 built on Model 2 by incorporating the interaction term (personal health responsibility × healthcare geographic accessibility) to examine the moderating effect of personal health responsibility and healthcare geographic accessibility on FDCSs further. Margins plots illustrated the predicted FDCSs status based on personal health responsibility and healthcare geographic accessibility. Third, after controlling for all influencing factors, a stratified analysis was conducted based on varying levels of healthcare geographic accessibility to identify potential differences across subgroups. Odds ratios (OR) and corresponding 95% confidence interval (95% CI) were reported, with statistical significance set at two-tailed P < 0.05. 2.4. Ethical consideration This study was reviewed and approved by the Ethics Committee of Shandong University (approval number, 20181228; approval date: December 28, 2018). All participants had signed informed consent prior and ethical approval to participate in the study. 3. Results 3.1. Characteristics of Participants Table 1 presents the demographic characteristics of the participants in this study. A total of 3,164 rural older adults aged 60 years and above participated, with a mean age of 72.40 years (SD = 5.90). Among the respondents, 1896 (59.92%) were women; 1216 (38.43%) were illiterate; and 2463 (77.84%) were married. Of these, 2052 (64.85%) participants reported contracting for FDCSs. Compared to non-contracting individuals, those who contracted for FDCSs were more likely to be women, married, with higher educational levels, and report multimorbidity. Additionally, 1947 participants (61.54%) expressed support for personal health responsibility. Table 1 Basic characteristic of the participants among older adults in rural Shandong, China, 2022 ( N = 3,164) Characteristic N (%) Family doctor contract services P -value Yes (%) No (%) Observations 3,164 2,052 (64.85) 1,112 (35.15) Age (years), mean ( SD ) 72.40 (5.90) 72.19 (5.70) 72.78 (6.23) 0.007 Gender < .001 Male 1,268 (40.08) 877 (42.74) 391 (35.16) Female 1,896 (59.92) 1,175 (57.26) 721 (64.84) Education < .001 Illiterate 1,216 (38.43) 733 (35.72) 483 (43.44) Primary school 1,259 (39.79) 827 (40.30) 432 (38.85) Middle school or above 689 (21.78) 492 (23.98) 197 (17.72) Marital status < .001 Single a 701 (22.16) 393 (19.15) 308 (27.70) Married 2,463 (77.84) 2,659 (80.85) 804 (72.30) Household income b 0.004 Q1 798 (25.22) 477 (23.25) 321 (28.87) Q2 795 (25.13) 531 (25.88) 264 (23.74) Q3 779 (24.62) 529 (25.78) 250 (22.48) Q4 792 (25.03) 515 (25.10) 277 (24.91) Health insurance < .001 No 111 (3.51) 48 (2.34) 63 (5.67) Yes 3,053 (96.49) 2,004 (97.66) 1,049 (94.33) Body mass index, mean ( SD ) 24.62 (3.76) 24.72 (3.76) 24.44 (3.75) 0.047 Chronic health conditions < .001 No chronic condition 479 (15.14) 281 (13.69) 198 (17.81) One chronic condition 838 (26.49) 522 (25.44) 316 (28.42) Multimorbidity 1,847 (58.38) 1,249 (60.87) 598 (53.78) Activities of daily living limitations, mean ( SD ) 17.42 (4.93) 17.18 (4.72) 17.86 (5.28) < .001 Outpatient care 0.641 Yes 292 (9.23) 193 (9.41) 99 (8.90) No 2,872 (90.77) 1,859 (90.59) 1,013 (91.10) Inpatient care 0.840 Yes 566 (17.89) 365 (17.79) 201 (18.08) No 2,598 (82.11) 1,687 (82.21) 911 (81.92) Healthcare geographic accessibility 0.003 ≤ 10 2,927 (92.51) 1,919 (93.52) 1,008 (90.65) > 10 237 (7.49) 133 (6.08) 104 (9.35) Personal health responsibility 0.001 Disagree 528 (16.69) 319 (15.55) 209 (18.79) Indifferent 689 (21.78) 421 (20.52) 268 (24.10) Agree 1,947 (61.54) 1,312 (63.94) 635 (57.10) Notes : a Singles include those who are unmarried, divorced and widowed; b Quartile 1 (Q1) was the poorest and Quartile 4 (Q4) was the richest. The total percentage may not equal to 100 due to rounding. Abbreviations: SD = Standard deviation. Statistically significant p < .05 values are indicated in bold. 3.2. Associations Between Personal Health Responsibility and FDCSs Table 2 demonstrates the logistic regression results examining the relationship between personal health responsibility and FDCSs among rural older adults. In Model 1, older adults who supported personal health responsibility were more likely to contract for FDCSs compared to those who did not (OR = 1.35,95% CI: 1.11,1.65). In Model 2, after adjusting for covariates, the significant positive association between personal health responsibility and FDCSs persisted (OR = 1.38,95% CI: 1.13,1.69). Table 2 Association between personal health responsibility and family doctor contract services among older adults ( N = 3,164) Characteristics Model 1 a Model 2 b Model 3 c OR (95% CI) P -value OR (95% CI) P -value OR (95% CI) P -value Main terms Personal health responsibility (Disagree Ref ) Indifferent 1.03 (0.82, 1.30) 0.808 1.13 (0.89, 1.44) 0.305 1.19 (0.93, 1.52) 0.178 Agree 1.35 (1.11, 1.65) 0.003 1.38 (1.13, 1.69) 0.002 1.48 (1.20, 1.82) 10 0.74 (0.56, 0.97) 0.032 1.49 (0.73, 3.07) 0.277 Interaction term Personal health responsibility×Healthcare geographic accessibility (Disagree× ≤ 10 minutes Ref ) Indifferent× > 10 minutes 0.52 (0.21, 1.28) 0.153 Agree× > 10 minutes 0.41 (0.18, 0.90) 0.028 Controls Age 1.00 (0.98, 1.01) 0.824 1.00 (0.98, 1.01) 0.802 Gender (Male Ref ) Female 0.78 (0.66, 0.93) 0.004 0.78 (0.66, 0.93) 0.005 Education (Illiterate Ref ) Primary school 1.08 (0.90, 1.28) 0.414 1.08 (0.90, 1.28) 0.404 Middle school or above 1.28 (1.02, 1.61) 0.030 1.29 (1.03, 1.61) 0.029 Marital status d (Single Ref ) Married 1.37 (1.13, 1.65) 0.001 1.37 (1.13, 1.65) 0.001 Household income e (Q1 Ref ) Q2 1.14 (0.92, 1.42) 0.231 1.14 (0.92, 1.42) 0.234 Q3 1.13 (0.90, 1.42) 0.280 1.12 (0.90, 1.41) 0.310 Q4 1.02 (0.82, 1.27) 0.850 1.02 (0.82, 1.27) 0.872 Health insurance (No Ref ) Yes 2.14 (1.45, 3.17) < .001 2.14 (1.44, 3.17) < .001 Body mass index 1.01 (0.99, 1.03) 0.471 1.01 (0.99, 1.03) 0.499 Chronic health conditions (No chronic condition Ref ) One chronic condition 1.23 (0.97, 1.55) 0.090 1.22 (0.96, 1.54) 0.104 Multimorbidity 1.65 (1.32, 2.05) < .001 1.64 (1.32, 2.05) < .001 Activities of daily living limitations 0.98 (0.97, 1.00) 0.044 0.98 (0.97, 1.00) 0.048 Outpatient care (No Ref ) Yes 1.07 (0.83, 1.40) 0.596 1.08 (0.83, 1.41) 0.557 Inpatient care (No Ref ) Yes 0.90 (0.74, 1.10) 0.372 0.91 (0.74, 1.11) 0.344 Notes : Statistically significant p < .05 values are indicated in bold. a Model 1: Unadjusted; b Model 2: Additionally adjusted for healthcare geographic accessibility, age, gender, education, marital status, household income, health insurance, body mass index, chronic health conditions, activities of daily living limitations, outpatient care, and inpatient care; c Model 3: Adjusted for model 2 criteria and the interaction between personal health responsibility and healthcare geographic accessibility; d Singles include those who are unmarried, divorced and widowed; e Quartile 1 (Q1) was the poorest and Quartile 4 (Q4) was the richest. 3.3. Interaction Effects Between Personal Health Responsibility and Healthcare Geographic Accessibility In Model 3, we incorporated an interaction term of personal health responsibility and healthcare geographic accessibility to further explore whether the relationship between personal health responsibility and FDCSs varied by healthcare geographic accessibility. Results indicated that older adults with poor healthcare geographic accessibility who supported personal health responsibility had a lower likelihood of signing up for FDCSs compared to those with good healthcare geographic accessibility (OR = 0.41, 95% CI: 0.18, 0.90). Furthermore, Fig. 1 illustrates that poor healthcare geographic accessibility diminished the likelihood of older adults who supported personal health responsibility contracting for FDCSs. 3.4. Association Between Personal Health Responsibility and FDCSs in Subgroups Table 3 reports the stratified analysis of the relationship between personal health responsibility and FDCSs based on healthcare geographic accessibility. The findings reveal that personal health responsibility was positively associated with higher contracting rates for FDCSs among older adults with good healthcare geographic accessibility (OR = 1.48, 95% CI: 1.20, 1.82, P < 0.001). In contrast, no statistically association was observed between personal health responsibility and FDCSs among older adults with poor healthcare geographic accessibility. Table 3 Association between personal health responsibility and family doctor contract services among older adults stratified by healthcare geographic accessibility Variable ≤ 10 minutes (n =2927) > 10 minutes (n = 237) Model 1 Model 2 Model 1 Model 2 OR (95% CI) P -value OR (95% CI) P -value OR (95% CI) P -value OR (95% CI) P -value Personal health responsibility Disagree 1.00 (reference) 1.00 (reference) 1.00 (reference) 1.00 (reference) Indifferent 1.08 (0.85, 1.38) 0.525 1.17 (0.92, 1.50) 0.202 0.57 (0.24, 1.34) 0.198 0.64 (0.25, 1.62) 0.345 Agree 1.45 (1.18, 1.79) < .001 1.48 (1.20, 1.82) < .001 0.56 (0.26, 1.20) 0.138 0.68 (0.30, 1.56) 0.365 Notes : Model 1 was unadjusted; Model 2 was adjusted for age, gender, education, marital status, household income, health insurance, body mass index, chronic health conditions, activities of daily living limitations, outpatient care, and inpatient care. Statistically significant p < .05 values are indicated in bold. 4. Discussion This study makes a substantial contribution to the understanding of the association between personal health responsibility and engagement with FDCSs among rural older adults in China, while also highlighting the moderating role of healthcare geographic accessibility. Our findings reveal a clear and robust association: older adults with a strong sense of personal health responsibility are more likely to engage with FDCSs. However, this association is complex and moderated by the geographic accessibility of healthcare, which can pose considerable barriers for those who prioritize their health. The strong association between personal health responsibility and FDCSs engagement persists even after controlling for a variety of demographic and health-related factors, highlighting the essential role of personal agency in shaping health-seeking behaviors. This aligns with previous literature, which suggests that a heightened sense of personal health responsibility fosters proactive engagement in health management, including seeking information and preventive care (Chan, 2019 ). In rural areas, where access to reliable health information may be limited, personal health responsibility becomes a critical driver of proactive engagement with health services, including FDCSs (Han et al., 2012 ). The ability of older adults to leverage personal health responsibility can lead to increased reliance on family doctors for guidance and health promotion, thus enhancing disease prevention efforts (Huang et al., 2018 ). Older adults who prioritize health responsibility are more likely to exhibit greater awareness of health maintenance practices, which can catalyze their engagement with the FDCSs system (Borghian et al., 2023 ; Horton, 2014 ). This proactive behavior not only increases familiarity with available services but also encourages participation in health-promoting activities (Horton, 2014 ; Yang et al., 2021 ; Zhao et al., 2017 ). Moreover, individuals with a strong commitment to personal health responsibility often advocate for improvements in healthcare systems, thereby contributing to the enhancement of public health infrastructure (Mariusz, 2017 ; Li, 2011 ). However, healthcare geographic accessibility plays a critical moderating role in this relationship. Our analysis demonstrates that limited access to healthcare diminishes the likelihood of older adults engaging with FDCSs, even when they have a strong sense of personal health responsibility. This challenge is particularly pronounced in rural areas, where underdeveloped transportation infrastructure and a lack of healthcare facilities exacerbate the barriers to healthcare access (Dai et al., 2019 ; Li et al., 2015 ). Furthermore, while family doctors do offer proactive home visits, these services are typically reserved for individuals who are disabled, bedridden, or otherwise mobility-impaired (Ma, 2020 ). As a result, older adults with less acute health conditions may face barriers in accessing care, especially in rural areas where healthcare resources and well-trained healthcare professionals are lacking (Wang et al., 2021a ). This highlights how structural barriers, such as healthcare geographic accessibility, significantly shape the actual uptake of FDCSs, despite individuals’ motivation to take responsibility for their health. These findings align closely with China’s national health policies, including Healthy China 2030 initiative and the newly enacted Basic Healthcare and Health Promotion Law (China, 2020 ), which emphasize the importance of personal health responsibility in addressing the dual burdens of an aging population and the rising prevalence of NCDs. Both policies aim to foster a culture of personal responsibility for health, encouraging individuals to adopt proactive health behaviors. However, as this study illustrates, the ability to exercise personal health responsibility is not solely dependent on individual motivation but is heavily shaped by healthcare geographic accessibility. In rural areas, where healthcare infrastructure remains underdeveloped, even individuals who are motivated to manage their health face significant challenges. This underscores the need for structural reforms to complement the goals of national health policies, particularly in rural regions where healthcare are less accessible (Schmidt, 2009 ; Traina and Feiring, 2022 ). The challenge of bridging the gap between policy aspirations and actual health behaviors can be further understood through the lens of HLT. HLT emphasizes that personal health behaviors are shaped not only by individual agency but also by structural factors, such as socioeconomic conditions and healthcare accessibility (Cockerham, 2023 ). In the context of our study, healthcare geographic accessibility serves as a crucial structural factor that either facilitates or constrains the ability of individuals to exercise their personal health responsibility. Even when older adults are motivated to take responsibility for their health, limited access to healthcare can undermine their ability to act on this motivation (Levesque et al., 2013 ). Thus, enhancing healthcare geographic accessibility, alongside fostering health responsibility, is essential for increasing engagement with FDCSs (Dai et al., 2019 ; Levesque et al., 2013 ). The need for improved healthcare geographic accessibility is particularly pressing for older adults with chronic conditions, who require integrated care, regular health monitoring and preventive interventions—services typically provided by family doctors (Council, 2016 ). However, in rural areas, where transportation and healthcare resources are often limited, logistical and financial barriers deter many from signing up for FDCSs, particularly those with less acute health conditions or from lower socioeconomic backgrounds (Dai et al., 2019 ; Li et al., 2015 ). This context further aligns with the conditional nature of personal health responsibility, as articulated in luck egalitarianism—a theory of justice that distinguishes between personal choices and circumstances beyond an individual’s control (Knight, 2009 ; Wang, 2013 ). From this perspective, personal health responsibility is not an absolute obligation but is contingent upon environmental and societal factors that shape an individual’s ability to take responsibility for their health (Liu, 2015 ). Healthcare geographic accessibility, therefore, becomes a critical factor that determines whether individuals can effectively exercise their health responsibilities. These findings offer important implications for the improvement of the FDCSs and the health outcomes of rural older adults in China. To address the barriers identified, policymakers should prioritize financial investment and policy support aimed at expanding healthcare geographic accessibility and strengthening the FDCSs infrastructure, particularly in underserved rural areas. This should include subsidies and financial incentives to alleviate the economic burden on rural populations, especially for older adults with chronic conditions, thereby facilitating greater participation in FDCSs. Furthermore, primary healthcare facilities in rural regions must develop personalized, long-term care plans that cater to the specific health needs of the elderly. Emphasis should be placed on integrated care for chronic disease management and preventive services, ensuring coordinated follow-ups and effective linkages between family doctors and specialized care. Moreover, local governments and community organizations should intensify health education campaigns to raise awareness of FDCSs and promote a culture of personal health responsibility. Educational initiatives should target older adults and their families, highlighting the importance of regular healthcare engagement and preventive practices. These campaigns should be delivered through accessible community platforms and telehealth services to ensure broad outreach, even in remote locations. Additionally, infrastructure improvements are critical to enabling effective FDCSs delivery. Investments in transportation networks and telemedicine infrastructure are necessary to overcome geographic barriers, allowing rural older adults to access care without the need for long-distance travel. Telemedicine can play a pivotal role in extending services to remote areas, ensuring timely consultations and follow-up care. In sum, addressing both structural and educational barriers will create a more equitable and sustainable FDCSs system that supports healthier aging in rural China. This study offers several strengths that enhance its contribution to understanding rural healthcare and personal health responsibility in China. First, it is one of the few empirical studies to examine the moderating role of healthcare geographic accessibility in the relationship between personal health responsibility and FDCSs engagement. This contributes to a more nuanced understanding of how structural factors, such as healthcare access, shape health-seeking behaviors, particularly in underserved rural areas. Second, by using a large, representative sample of rural older adults in China, the study provides valuable insights into the specific healthcare challenges faced by this population. The findings offer evidence-based insights that can inform policy interventions aimed at improving healthcare geographic accessibility and engagement with FDCSs in rural areas, which is crucial given the rising burden of chronic diseases and the aging population. Despite the insights provided by this study, several limitations must be acknowledged. First, the cross-sectional nature of the data limits our ability to establish causal relationships between personal health responsibility, healthcare geographic accessibility, and FDCSs engagement. Future research should focus on longitudinal designs to explore causal relationships and explore the mechanisms underlying these associations. Second, the use of self-reported data may introduce potential recall bias, potentially affecting the accuracy of key variables. Third, this study merely assessed the geographic dimension of healthcare accessibility due to constraints in data availability. Other important dimensions, such as economic accessibility and socio-cultural acceptability, were not captured and should be incorporated into future research to provide a more comprehensive understanding of healthcare accessibility. Lastly, the generalizability of our findings to different national contexts and healthcare systems requires further empirical validation. 5. Conclusions This study reveals a strong relationship between personal health responsibility and engagement with FDCSs among rural older adults in China, with healthcare geographic accessibility playing a critical moderating role. While individuals with higher levels of personal health responsibility are more likely to engage with FDCSs, limited healthcare geographic accessibility—particularly in rural areas—greatly reduces this likelihood. These findings emphasize the interplay between individual agency and structural barriers in shaping health-seeking behaviors. To address these challenges, policymakers should prioritize strengthening healthcare infrastructure in rural areas, including targeted investments in local health facilities, mobile health units, and telemedicine services to mitigate geographic barriers. Furthermore, financial incentives, such as subsidies for rural older adults and performance-based rewards for family doctors, should be adopted to promote FDCSs engagement. Comprehensive health education programs, particularly aimed at fostering personal health responsibility, are essential to promote the engagement and benefits of FDCSs. Moreover, it is also crucial to integrate FDCSs more effectively with local healthcare systems to ensure continuity of care. These combined efforts will help bridge the gap in healthcare access and promote healthier aging across rural populations. Abbreviations FDCSs Family Doctor Contracting Services NCDs Non-communicable Diseases HBM Health Belief Model TPB Theory of Planned Behavior HLT Health Lifestyle Theory SREHC Shandong Rural Elderly Health Cohort GDP Gross Domestic Product BMI Body Mass Index ADL Activities of Daily Living Declarations Competing interests The authors declare that they have no competing interests. Availability of data and materials The datasets used in the current study are not publicly available due to the confidential policy but are available from the corresponding author on reasonable request. Acknowledgements We thank the officials of health agencies, all participants and staffs at the study sites for their cooperation. Ethics approval This study was reviewed and approved by the Ethics Committee of the researchers’ university (approval number, 20181228; approval date, Dec 28, 2018). All procedures were in accordance with the ethical standards of the Helsinki Declaration. All participants provided written informed consent. All methods employed in the study were performed in accordance with the relevant international guidelines and regulations. Informed consent Before the survey, written informed consent was obtained from each participant, clarifying the purposes, significance, methods, and potential risks of the study. Consent for publication Not applicable. 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(2021b) Changes in psychological distress before and during the COVID-19 pandemic among older adults: The contribution of frailty transitions and multimorbidity. Age Ageing 50(4):1011-1018. https://doi.org/10.1093/ageing/afab061 Yang S, Li J, Fu P et al. (2021) Do older people with cardiovascular-metabolic multimorbidity prefer to sign contracts for family doctor services? Evidence from a cross-sectional study in rural Shandong, China. BMC Geriatr 21(1):579. https://doi.org/doi:10.1186/s12877-021-02543-w Zhang Z, Zhang R, Peng Y et al. (2023) Barriers and facilitators of family doctor contract services in caring for disabled older adults in Beijing, China: A mixed methods study. BMJ Open 13(6):e070130. https://doi.org/10.1136/bmjopen-2022-070130 Zhao Y, Lin J, Qiu Y et al. (2017) Demand and signing of general practitioner contract service among the urban elderly: A population-based analysis in Zhejiang Province, China. Int J Environ Res Public Health 14(4):356. https://doi.org/10.3390/ijerph14040356 Zhou BF, Cooperative Meta-analysis Grp W (2002) Predictive values of body mass index and waist circumference for risk factors of certain related diseases in Chinese adults: Study on optimal cut-off points of body mass index and waist circumference in Chinese adults. Biomed Environ Sci 15(1):83-96. Additional Declarations No competing interests reported. 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Introduction","content":"\u003cp\u003eThe aging population generates a heavy demand for the responsiveness and continuity of healthcare, posing a great challenge to global healthcare systems (Hambleton et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Against this backdrop, China introduced the Family Doctor Contracting Services (FDCSs) in 2016, aiming to establish a long-term and stable doctor-patient relationship through a service agreement between residents and a team of primary care doctors. The FDCSs initiative involves a team of family doctors (usually general practitioners, nurses, public health practitioners, etc.) who provide contracted families or individuals with continuous, comprehensive, and personalized primary medical care, public health, and health management services (Council, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Such an approach is instrumental in substantially alleviating the pressure on health resources, ensuring the provision of primary care at the grass-roots level, and facilitating a tiered system of diagnosis and treatment (Chen et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Council, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Pertusa-Martinez, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2006\u003c/span\u003e). This initiative is especially crucial in rural China, where healthcare resources are significantly less available compared to urban regions, and where older adults are at an increased risk of non-communicable diseases (NCDs). Despite the high willingness of rural older adults to engage with FDCSs, their actual utilization remains low which could be attributed to both structural factors (e.g., lack of well-trained family doctors) and agency-based factors (e.g., doctor reputation and the weak contractual relationships) (Zhang et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Improving the level and quality of healthcare in rural areas has always been a priority for China\u0026rsquo;s healthcare development and needs to be addressed urgently. The FDCSs system is a critical initiative for improving rural primary healthcare and effectively safeguard the health needs of the population (Council, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Thus, it is necessary to explore the influencing factors of FDCSs to provide scientific references for effectively improving the quality of health services for rural older adults and realizing healthy aging.\u003c/p\u003e \u003cp\u003eBeyond the structural and systemic endeavors to enhance healthcare accessibility and delivery, the notion of personal health responsibility emerges as an integral strategy in combating NCDs, especially those associated with modifiable health behaviors, such as diet, physical activities, and adherence to treatments (Cockerham, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2005\u003c/span\u003e). Many countries have adopted personal health responsibility as one of the basic principles of public health action and health policy formulation to control healthcare costs and improve national health (Laverty and Harris, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Pillutla et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Schirmer and Michailakis, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2011\u003c/span\u003e; Schmidt et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2010\u003c/span\u003e; Traina and Feiring, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Since 2014, China's national guiding documents have repeatedly mentioned the goal of \u0026ldquo;strengthening personal health responsibility\u0026rdquo; (China, 2014). In 2019, China formally incorporated the concept of \u0026ldquo;personal health responsibility\u0026rdquo; into its laws and regulations, highlighting that individuals are primarily responsible for their own health (China, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Given that the concept of personal health responsibility may carry different connotations depending on its context and application (Vincent, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2011\u003c/span\u003e), for the purpose of this study, it primarily refers to individuals taking proactive steps to maintain and improve their own health. Specifically, this includes adopting healthy behaviors such as seeking health-related information, maintaining personal health resources, and consistently engaging in preventive practices (Borghian et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Behavioral health theories, such as the Health Belief Model (HBM) and the Theory of Planned Behavior (TPB), provide valuable frameworks for understanding how individuals\u0026rsquo; health behaviors are influenced by their beliefs, intentions, and perceived control over health outcomes (Ajzen, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1991\u003c/span\u003e; Rosenstock, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e1974\u003c/span\u003e). These theories suggest that individuals who believe in the importance of taking responsibility for their health are more likely to engage in health-promoting behaviors, such as adopting FDCSs. For instance, under the HBM, personal health responsibility can be understood as part of perceived severity and perceived benefits, where individuals who recognize the importance of managing their own health may be more inclined to seek primary care services to prevent or manage chronic conditions. Similarly, the TPB highlights how individual attitudes toward health responsibility and perceived behavioral control influence intentions to engage with services like FDCSs.\u003c/p\u003e \u003cp\u003eHowever, the extent to which individuals can effectively exercise personal health responsibility is largely contingent upon the accessibility of healthcare (Albertsen and Tsiakiri, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Healthcare accessibility\u0026mdash;encompassing geographic, economic, and social dimensions\u0026mdash;can either facilitate or hinder the ability of older adults to engage with FDCSs. This study focuses on geographic accessibility to healthcare. In areas where healthcare are more accessible, individuals who prioritize personal responsibility for their health are more likely to engage with FDCSs. Conversely, in areas where healthcare access is limited, even those with a strong sense of personal health responsibility may struggle to adopt FDCSs due to geographic or financial constraints (Ford et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Levesque et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). This moderating role of healthcare geographic accessibility is particularly relevant in rural China, where significant disparities in health infrastructure and service provision persist. While urban residents may have relatively easy access to healthcare, rural older adults often face greater difficulties due to the limited availability of healthcare professionals and facilities, compounded by logistical barriers such as distance and transportation (Fang et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Yang et al., \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). This context raises the question of how personal health responsibility interacts with these structural limitations to shape FDCSs adoption. By considering healthcare access as a moderating variable, this study aims to explore how structural inequalities affect the exercise of personal health responsibility in rural settings.\u003c/p\u003e \u003cp\u003eThe Health Lifestyle Theory (HLT) provides a broader framework for understanding the interaction between individual health behaviors and the structural conditions that shape them (Cockerham, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). The HLT posits that health outcomes are the result of both individual agency\u0026mdash;such as the decision to take personal responsibility for one\u0026rsquo;s health\u0026mdash;and structural factors like socioeconomic status, education, and the accessibility of healthcare. This theory underscores the fact that not all individuals have equal opportunities to engage in health-promoting behaviors, even if they are personally motivated to do so. In the case of rural China, older adults who are willing to take responsibility for their health may still face significant challenges in accessing FDCSs due to geographic or economic barriers. As such, the relationship between personal health responsibility and FDCSs utilization must be understood within the context of these broader structural constraints.\u003c/p\u003e \u003cp\u003eThis study aims to 1) explore the association between personal health responsibility and the engagement of FDCSs among rural older adults in Shandong Province, China, and 2) determine whether healthcare geographic accessibility moderates this relationship. By doing so, we aim to contribute to the empirical evidence supporting the expansion and optimization of FDCSs, ultimately promoting healthier aging in rural areas. Thus, we proposed the following specific hypotheses:\u003c/p\u003e \u003cp\u003e \u003cb\u003eH1.\u003c/b\u003e Older adults who prioritize personal health responsibility are more likely to engage with FDCSs.\u003c/p\u003e \u003cp\u003e \u003cb\u003eH2.\u003c/b\u003e Healthcare geographic accessibility moderates the association between personal health responsibility and the engagement of FDCSs.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1. Data Source and Participants\u003c/h2\u003e \u003cp\u003eThis study leveraged cross-sectional data from the Shandong Rural Elderly Health Cohort (SREHC) survey, conducted in Shandong Province, China, from July to August 2022. We employed a multi-stage stratified cluster sampling method to select participants, which was also elaborated in our previous publications (Wang et al., \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2021b\u003c/span\u003e). Initially, counties in Shandong Province were categorized into three groups based on their per capita Gross Domestic Product (GDP) in 2018. One sample county was randomly selected from each category. In this study, three sample counties (Rushan in Weihai, Qufu in Jining, and Laoling in Dezhou) were selected as the study sites. Subsequently, five townships were randomly selected from each sampled county. From each township, four communities/villages were randomly selected, and older adults aged 60 years and above were randomly chosen from these communities or villages to ensure a diverse and representative sample of the rural elderly population.\u003c/p\u003e \u003cp\u003eData were collected through face-to-face interviews using structured questionnaires (Wang et al., \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2021b\u003c/span\u003e), administered by trained investigators with adequate medical knowledge. To ensure data completeness and accuracy, respondents were excluded if they: (1) could not communicate clearly in Chinese, (2) had a diagnosis of dementia or mental illness, or (3) were uncooperative during the survey. Besides, participants with missing primary variables (n\u0026thinsp;=\u0026thinsp;87) were also excluded. Following these criteria, a total of 3,164 older adults aged 60 years and above were included in the study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2. Measures\u003c/h2\u003e \u003cdiv id=\"Sec5\" class=\"Section3\"\u003e \u003ch2\u003e2.2.1. Family Doctor Contract Services\u003c/h2\u003e \u003cp\u003eFamily Doctor Contract Services (FDCSs) were measured by the following question: \"In 2021, did you contract for family doctor services?\". Responses were categorized as a dichotomous variable (yes or no), with \u0026ldquo;yes\u0026rdquo; indicating that the respondent had contracted for services and \u0026ldquo;no\u0026rdquo; indicating otherwise.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e \u003ch2\u003e2.2.2. Personal Health Responsibility\u003c/h2\u003e \u003cp\u003ePersonal health responsibility was measured using two questions: (1) \u0026ldquo;To what extent do you believe that you have a responsibility to protect your health?\u0026rdquo; Responses were rated on a 5-point scale from \u0026ldquo;1\u0026thinsp;=\u0026thinsp;not at all\u0026rdquo; to \u0026ldquo;5\u0026thinsp;=\u0026thinsp;very much\u0026rdquo; (2) \u0026ldquo;To what extent do you agree with the following statement: If a person's disease is caused by modifiable causes, such as lung disease that may be caused by long-term smoking, then we should make him overpay for the treatment of the disease.\u0026rdquo; The response options were given on a 3-point scale, \u0026ldquo;1\u0026thinsp;=\u0026thinsp;disagree\u0026rdquo;, \u0026ldquo;2\u0026thinsp;=\u0026thinsp;indifferent (not sure)\u0026rdquo;, and \u0026ldquo;3\u0026thinsp;=\u0026thinsp;agree\u0026rdquo; (Traina et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Due to the skewed distribution of responses to the first question (95% of responses fell into categories 4 and 5), this question was not included in the regression analysis (Traina et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2019\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e \u003ch2\u003e2.2.3. Healthcare Geographic Accessibility\u003c/h2\u003e \u003cp\u003eHealthcare geographic accessibility was measured by the question: \u0026ldquo;How many minutes does it take to get from your home to the nearest health facility (using the most accessible mode of transport rather than walking only)?\u0026rdquo; Time was categorized as \u0026le;\u0026thinsp;10 minutes or \u0026gt;\u0026thinsp;10 minutes (Ford et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Levesque et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2013\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003e2.2.4. Covariates\u003c/h2\u003e \u003cp\u003ePrevious studies have identified a range of influencing factors for family doctor contract services (Li et al. \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Shang et al. \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Yang et al. \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Drawing from the Anderson model, covariates were categorized into three groups (Andersen and Newman \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e1973\u003c/span\u003e; Li et al. \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2021\u003c/span\u003e): (1) Predisposing Characteristics: age, gender (male, female), highest level of education (illiterate, primary school, middle school or above), and marital status (single, married); (2) Enabling Factors: household income (Q1, Q2, Q3, Q4, quartiles from poorest to richest) and health insurance (yes, no); Household income was measured by asking the total income of the respondent\u0026rsquo;s household in the previous year (2021). (3) Needs Factors: body mass index (BMI), chronic health conditions (no chronic condition, one chronic condition, multimorbidity), and activities of daily living (ADL). BMI was calculated as weight in kilograms divided by height in square meters (Zhou et al., 2002). ADL was assessed using the Katz index scale, with scores ranging from 14 to 56, where higher scores indicate worse activities of daily living (Katz et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e1963\u003c/span\u003e). Additionally, indicators of healthcare utilization experiences, including two-week outpatient care (yes, no) and annual inpatient care (yes, no), were included as covariates due to their correlation with FDCSs utilization.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e2.3. Statistical Analyses\u003c/h2\u003e \u003cp\u003eStatistical analyses were conducted using Stata 15.1 (Stata Corp, College Station, TX, USA). First, descriptive statistics were employed to summarize the basic characteristics of rural older adults, presented as means (standard deviations) for continuous variables and frequencies (percentages) for categorical variables. Student's t-test was used for continuous variables, while chi-square tests were applied to compare FDCSs status across different subgroups. Second, a binary logistic regression model was used to assess the relationship between personal health responsibility and FDCSs. Model 1 was unadjusted; Model 2 included adjustments for all predisposing characteristics, enabling factors, needs factors, and health behavior factors; Model 3 built on Model 2 by incorporating the interaction term (personal health responsibility \u0026times; healthcare geographic accessibility) to examine the moderating effect of personal health responsibility and healthcare geographic accessibility on FDCSs further. Margins plots illustrated the predicted FDCSs status based on personal health responsibility and healthcare geographic accessibility. Third, after controlling for all influencing factors, a stratified analysis was conducted based on varying levels of healthcare geographic accessibility to identify potential differences across subgroups. Odds ratios (OR) and corresponding 95% confidence interval (95% CI) were reported, with statistical significance set at two-tailed \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e2.4. Ethical consideration\u003c/h2\u003e \u003cp\u003e This study was reviewed and approved by the Ethics Committee of Shandong University (approval number, 20181228; approval date: December 28, 2018). All participants had signed informed consent prior and ethical approval to participate in the study.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e3.1. Characteristics of Participants\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents the demographic characteristics of the participants in this study. A total of 3,164 rural older adults aged 60 years and above participated, with a mean age of 72.40 years (SD\u0026thinsp;=\u0026thinsp;5.90). Among the respondents, 1896 (59.92%) were women; 1216 (38.43%) were illiterate; and 2463 (77.84%) were married. Of these, 2052 (64.85%) participants reported contracting for FDCSs. Compared to non-contracting individuals, those who contracted for FDCSs were more likely to be women, married, with higher educational levels, and report multimorbidity. Additionally, 1947 participants (61.54%) expressed support for personal health responsibility.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBasic characteristic of the participants among older adults in rural Shandong, China, 2022 (\u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3,164)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eFamily doctor contract services\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eObservations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3,164\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2,052 (64.85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1,112 (35.15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years), mean (\u003cem\u003eSD\u003c/em\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e72.40 (5.90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e72.19 (5.70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e72.78 (6.23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.007\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,268 (40.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e877 (42.74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e391 (35.16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,896 (59.92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1,175 (57.26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e721 (64.84)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIlliterate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,216 (38.43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e733 (35.72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e483 (43.44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,259 (39.79)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e827 (40.30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e432 (38.85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMiddle school or above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e689 (21.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e492 (23.98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e197 (17.72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarital status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSingle \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e701 (22.16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e393 (19.15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e308 (27.70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2,463 (77.84)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2,659 (80.85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e804 (72.30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHousehold income \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.004\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e798 (25.22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e477 (23.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e321 (28.87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e795 (25.13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e531 (25.88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e264 (23.74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e779 (24.62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e529 (25.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e250 (22.48)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e792 (25.03)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e515 (25.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e277 (24.91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealth insurance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e111 (3.51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e48 (2.34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e63 (5.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3,053 (96.49)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2,004 (97.66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1,049 (94.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBody mass index, mean (\u003cem\u003eSD\u003c/em\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24.62 (3.76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24.72 (3.76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e24.44 (3.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.047\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChronic health conditions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo chronic condition\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e479 (15.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e281 (13.69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e198 (17.81)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOne chronic condition\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e838 (26.49)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e522 (25.44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e316 (28.42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMultimorbidity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,847 (58.38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1,249 (60.87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e598 (53.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eActivities of daily living limitations, mean (\u003cem\u003eSD\u003c/em\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17.42 (4.93)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17.18 (4.72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e17.86 (5.28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutpatient care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.641\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e292 (9.23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e193 (9.41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e99 (8.90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2,872 (90.77)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1,859 (90.59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1,013 (91.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInpatient care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.840\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e566 (17.89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e365 (17.79)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e201 (18.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2,598 (82.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1,687 (82.21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e911 (81.92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealthcare geographic accessibility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.003\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e\u0026le;\u003c/b\u003e\u0026thinsp;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2,927 (92.51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1,919 (93.52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1,008 (90.65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e\u0026gt;\u003c/b\u003e\u0026thinsp;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e237 (7.49)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e133 (6.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e104 (9.35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePersonal health responsibility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisagree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e528 (16.69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e319 (15.55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e209 (18.79)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndifferent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e689 (21.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e421 (20.52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e268 (24.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,947 (61.54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1,312 (63.94)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e635 (57.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cem\u003eNotes\u003c/em\u003e:\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003csup\u003ea\u003c/sup\u003e Singles include those who are unmarried, divorced and widowed;\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003csup\u003eb\u003c/sup\u003e Quartile 1 (Q1) was the poorest and Quartile 4 (Q4) was the richest.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eThe total percentage may not equal to 100 due to rounding.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eAbbreviations: SD\u0026thinsp;=\u0026thinsp;Standard deviation. Statistically significant \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05 values are indicated in bold.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e3.2. Associations Between Personal Health Responsibility and FDCSs\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e demonstrates the logistic regression results examining the relationship between personal health responsibility and FDCSs among rural older adults. In Model 1, older adults who supported personal health responsibility were more likely to contract for FDCSs compared to those who did not (OR\u0026thinsp;=\u0026thinsp;1.35,95% CI: 1.11,1.65). In Model 2, after adjusting for covariates, the significant positive association between personal health responsibility and FDCSs persisted (OR\u0026thinsp;=\u0026thinsp;1.38,95% CI: 1.13,1.69).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAssociation between personal health responsibility and family doctor contract services among older adults (\u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3,164)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eModel 1\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eModel 2\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eModel 3\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eOR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMain terms\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePersonal health responsibility (Disagree \u003csup\u003eRef\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndifferent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.03 (0.82, 1.30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.808\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.13 (0.89, 1.44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.305\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.19 (0.93, 1.52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.178\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.35 (1.11, 1.65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.003\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.38 (1.13, 1.69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.48 (1.20, 1.82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealthcare geographic accessibility (\u003cb\u003e\u0026le;\u003c/b\u003e\u0026thinsp;10 \u003csup\u003eRef\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e\u0026gt;\u003c/b\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.74 (0.56, 0.97)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.032\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.49 (0.73, 3.07)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.277\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eInteraction term\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003ePersonal health responsibility\u0026times;Healthcare geographic accessibility (Disagree\u0026times;\u003cb\u003e\u0026le;\u003c/b\u003e10 minutes \u003csup\u003eRef\u003c/sup\u003e )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndifferent\u0026times;\u003cb\u003e\u0026gt;\u003c/b\u003e10 minutes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.52 (0.21, 1.28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.153\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAgree\u0026times;\u003cb\u003e\u0026gt;\u003c/b\u003e10 minutes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.41 (0.18, 0.90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.028\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eControls\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.00 (0.98, 1.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.824\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.00 (0.98, 1.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.802\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender (Male \u003csup\u003eRef\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.78 (0.66, 0.93)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.004\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.78 (0.66, 0.93)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.005\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation (Illiterate \u003csup\u003eRef\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.08 (0.90, 1.28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.414\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.08 (0.90, 1.28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.404\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMiddle school or above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.28 (1.02, 1.61)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.030\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.29 (1.03, 1.61)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.029\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eMarital status \u003csup\u003ed\u003c/sup\u003e (Single \u003csup\u003eRef\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.37 (1.13, 1.65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.37 (1.13, 1.65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eHousehold income \u003csup\u003ee\u003c/sup\u003e (Q1 \u003csup\u003eRef\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.14 (0.92, 1.42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.231\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.14 (0.92, 1.42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.234\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.13 (0.90, 1.42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.280\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.12 (0.90, 1.41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.310\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.02 (0.82, 1.27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.850\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.02 (0.82, 1.27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.872\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealth insurance (No \u003csup\u003eRef\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.14 (1.45, 3.17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.14 (1.44, 3.17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBody mass index\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.01 (0.99, 1.03)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.471\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.01 (0.99, 1.03)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.499\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eChronic health conditions\u003c/p\u003e \u003cp\u003e(No chronic condition \u003csup\u003eRef\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eOne chronic condition\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.23 (0.97, 1.55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.090\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.22 (0.96, 1.54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.104\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMultimorbidity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.65 (1.32, 2.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.64 (1.32, 2.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eActivities of daily living limitations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.98 (0.97, 1.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.044\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.98 (0.97, 1.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.048\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutpatient care (No \u003csup\u003eRef\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.07 (0.83, 1.40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.596\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.08 (0.83, 1.41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.557\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInpatient care (No \u003csup\u003eRef\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.90 (0.74, 1.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.372\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.91 (0.74, 1.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.344\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u003cem\u003eNotes\u003c/em\u003e:\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eStatistically significant \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05 values are indicated in bold.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u003csup\u003ea\u003c/sup\u003e Model 1: Unadjusted;\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u003csup\u003eb\u003c/sup\u003e Model 2: Additionally adjusted for healthcare geographic accessibility, age, gender, education, marital status, household income, health insurance, body mass index, chronic health conditions, activities of daily living limitations, outpatient care, and inpatient care;\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u003csup\u003ec\u003c/sup\u003e Model 3: Adjusted for model 2 criteria and the interaction between personal health responsibility and healthcare geographic accessibility;\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u003csup\u003ed\u003c/sup\u003e Singles include those who are unmarried, divorced and widowed;\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u003csup\u003ee\u003c/sup\u003e Quartile 1 (Q1) was the poorest and Quartile 4 (Q4) was the richest.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e3.3. Interaction Effects Between Personal Health Responsibility and Healthcare Geographic Accessibility\u003c/h2\u003e \u003cp\u003eIn Model 3, we incorporated an interaction term of personal health responsibility and healthcare geographic accessibility to further explore whether the relationship between personal health responsibility and FDCSs varied by healthcare geographic accessibility. Results indicated that older adults with poor healthcare geographic accessibility who supported personal health responsibility had a lower likelihood of signing up for FDCSs compared to those with good healthcare geographic accessibility (OR\u0026thinsp;=\u0026thinsp;0.41, 95% CI: 0.18, 0.90). Furthermore, Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e illustrates that poor healthcare geographic accessibility diminished the likelihood of older adults who supported personal health responsibility contracting for FDCSs.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e3.4. Association Between Personal Health Responsibility and FDCSs in Subgroups\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e reports the stratified analysis of the relationship between personal health responsibility and FDCSs based on healthcare geographic accessibility. The findings reveal that personal health responsibility was positively associated with higher contracting rates for FDCSs among older adults with good healthcare geographic accessibility (OR\u0026thinsp;=\u0026thinsp;1.48, 95% CI: 1.20, 1.82, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). In contrast, no statistically association was observed between personal health responsibility and FDCSs among older adults with poor healthcare geographic accessibility.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAssociation between personal health responsibility and family doctor contract services among older adults stratified by healthcare geographic accessibility\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;10 minutes (n\u0026nbsp;=2927)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c9\" namest=\"c6\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;10 minutes (n\u0026nbsp;= 237)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eModel 1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eModel 2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eModel 1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eModel 2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eOR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eOR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePersonal health responsibility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisagree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.00 (reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.00 (reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.00 (reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.00 (reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndifferent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.08 (0.85, 1.38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.525\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.17 (0.92, 1.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.202\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.57 (0.24, 1.34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.198\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.64 (0.25, 1.62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.345\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.45 (1.18, 1.79)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.48 (1.20, 1.82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.56 (0.26, 1.20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.138\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.68 (0.30, 1.56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.365\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003e\u003cem\u003eNotes\u003c/em\u003e:\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003eModel 1 was unadjusted;\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003eModel 2 was adjusted for age, gender, education, marital status, household income, health insurance, body mass index, chronic health conditions, activities of daily living limitations, outpatient care, and inpatient care.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003eStatistically significant \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05 values are indicated in bold.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis study makes a substantial contribution to the understanding of the association between personal health responsibility and engagement with FDCSs among rural older adults in China, while also highlighting the moderating role of healthcare geographic accessibility. Our findings reveal a clear and robust association: older adults with a strong sense of personal health responsibility are more likely to engage with FDCSs. However, this association is complex and moderated by the geographic accessibility of healthcare, which can pose considerable barriers for those who prioritize their health.\u003c/p\u003e \u003cp\u003eThe strong association between personal health responsibility and FDCSs engagement persists even after controlling for a variety of demographic and health-related factors, highlighting the essential role of personal agency in shaping health-seeking behaviors. This aligns with previous literature, which suggests that a heightened sense of personal health responsibility fosters proactive engagement in health management, including seeking information and preventive care (Chan, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). In rural areas, where access to reliable health information may be limited, personal health responsibility becomes a critical driver of proactive engagement with health services, including FDCSs (Han et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). The ability of older adults to leverage personal health responsibility can lead to increased reliance on family doctors for guidance and health promotion, thus enhancing disease prevention efforts (Huang et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Older adults who prioritize health responsibility are more likely to exhibit greater awareness of health maintenance practices, which can catalyze their engagement with the FDCSs system (Borghian et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Horton, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). This proactive behavior not only increases familiarity with available services but also encourages participation in health-promoting activities (Horton, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Yang et al., \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Zhao et al., \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Moreover, individuals with a strong commitment to personal health responsibility often advocate for improvements in healthcare systems, thereby contributing to the enhancement of public health infrastructure (Mariusz, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Li, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2011\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHowever, healthcare geographic accessibility plays a critical moderating role in this relationship. Our analysis demonstrates that limited access to healthcare diminishes the likelihood of older adults engaging with FDCSs, even when they have a strong sense of personal health responsibility. This challenge is particularly pronounced in rural areas, where underdeveloped transportation infrastructure and a lack of healthcare facilities exacerbate the barriers to healthcare access (Dai et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Li et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). Furthermore, while family doctors do offer proactive home visits, these services are typically reserved for individuals who are disabled, bedridden, or otherwise mobility-impaired (Ma, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). As a result, older adults with less acute health conditions may face barriers in accessing care, especially in rural areas where healthcare resources and well-trained healthcare professionals are lacking (Wang et al., \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2021a\u003c/span\u003e). This highlights how structural barriers, such as healthcare geographic accessibility, significantly shape the actual uptake of FDCSs, despite individuals\u0026rsquo; motivation to take responsibility for their health.\u003c/p\u003e \u003cp\u003eThese findings align closely with China\u0026rsquo;s national health policies, including Healthy China 2030 initiative and the newly enacted Basic Healthcare and Health Promotion Law (China, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2020\u003c/span\u003e), which emphasize the importance of personal health responsibility in addressing the dual burdens of an aging population and the rising prevalence of NCDs. Both policies aim to foster a culture of personal responsibility for health, encouraging individuals to adopt proactive health behaviors. However, as this study illustrates, the ability to exercise personal health responsibility is not solely dependent on individual motivation but is heavily shaped by healthcare geographic accessibility. In rural areas, where healthcare infrastructure remains underdeveloped, even individuals who are motivated to manage their health face significant challenges. This underscores the need for structural reforms to complement the goals of national health policies, particularly in rural regions where healthcare are less accessible (Schmidt, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2009\u003c/span\u003e; Traina and Feiring, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe challenge of bridging the gap between policy aspirations and actual health behaviors can be further understood through the lens of HLT. HLT emphasizes that personal health behaviors are shaped not only by individual agency but also by structural factors, such as socioeconomic conditions and healthcare accessibility (Cockerham, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). In the context of our study, healthcare geographic accessibility serves as a crucial structural factor that either facilitates or constrains the ability of individuals to exercise their personal health responsibility. Even when older adults are motivated to take responsibility for their health, limited access to healthcare can undermine their ability to act on this motivation (Levesque et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). Thus, enhancing healthcare geographic accessibility, alongside fostering health responsibility, is essential for increasing engagement with FDCSs (Dai et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Levesque et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2013\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe need for improved healthcare geographic accessibility is particularly pressing for older adults with chronic conditions, who require integrated care, regular health monitoring and preventive interventions\u0026mdash;services typically provided by family doctors (Council, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). However, in rural areas, where transportation and healthcare resources are often limited, logistical and financial barriers deter many from signing up for FDCSs, particularly those with less acute health conditions or from lower socioeconomic backgrounds (Dai et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Li et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). This context further aligns with the conditional nature of personal health responsibility, as articulated in luck egalitarianism\u0026mdash;a theory of justice that distinguishes between personal choices and circumstances beyond an individual\u0026rsquo;s control (Knight, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2009\u003c/span\u003e; Wang, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). From this perspective, personal health responsibility is not an absolute obligation but is contingent upon environmental and societal factors that shape an individual\u0026rsquo;s ability to take responsibility for their health (Liu, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). Healthcare geographic accessibility, therefore, becomes a critical factor that determines whether individuals can effectively exercise their health responsibilities.\u003c/p\u003e \u003cp\u003eThese findings offer important implications for the improvement of the FDCSs and the health outcomes of rural older adults in China. To address the barriers identified, policymakers should prioritize financial investment and policy support aimed at expanding healthcare geographic accessibility and strengthening the FDCSs infrastructure, particularly in underserved rural areas. This should include subsidies and financial incentives to alleviate the economic burden on rural populations, especially for older adults with chronic conditions, thereby facilitating greater participation in FDCSs. Furthermore, primary healthcare facilities in rural regions must develop personalized, long-term care plans that cater to the specific health needs of the elderly. Emphasis should be placed on integrated care for chronic disease management and preventive services, ensuring coordinated follow-ups and effective linkages between family doctors and specialized care. Moreover, local governments and community organizations should intensify health education campaigns to raise awareness of FDCSs and promote a culture of personal health responsibility. Educational initiatives should target older adults and their families, highlighting the importance of regular healthcare engagement and preventive practices. These campaigns should be delivered through accessible community platforms and telehealth services to ensure broad outreach, even in remote locations. Additionally, infrastructure improvements are critical to enabling effective FDCSs delivery. Investments in transportation networks and telemedicine infrastructure are necessary to overcome geographic barriers, allowing rural older adults to access care without the need for long-distance travel. Telemedicine can play a pivotal role in extending services to remote areas, ensuring timely consultations and follow-up care. In sum, addressing both structural and educational barriers will create a more equitable and sustainable FDCSs system that supports healthier aging in rural China.\u003c/p\u003e \u003cp\u003eThis study offers several strengths that enhance its contribution to understanding rural healthcare and personal health responsibility in China. First, it is one of the few empirical studies to examine the moderating role of healthcare geographic accessibility in the relationship between personal health responsibility and FDCSs engagement. This contributes to a more nuanced understanding of how structural factors, such as healthcare access, shape health-seeking behaviors, particularly in underserved rural areas. Second, by using a large, representative sample of rural older adults in China, the study provides valuable insights into the specific healthcare challenges faced by this population. The findings offer evidence-based insights that can inform policy interventions aimed at improving healthcare geographic accessibility and engagement with FDCSs in rural areas, which is crucial given the rising burden of chronic diseases and the aging population.\u003c/p\u003e \u003cp\u003eDespite the insights provided by this study, several limitations must be acknowledged. First, the cross-sectional nature of the data limits our ability to establish causal relationships between personal health responsibility, healthcare geographic accessibility, and FDCSs engagement. Future research should focus on longitudinal designs to explore causal relationships and explore the mechanisms underlying these associations. Second, the use of self-reported data may introduce potential recall bias, potentially affecting the accuracy of key variables. Third, this study merely assessed the geographic dimension of healthcare accessibility due to constraints in data availability. Other important dimensions, such as economic accessibility and socio-cultural acceptability, were not captured and should be incorporated into future research to provide a more comprehensive understanding of healthcare accessibility. Lastly, the generalizability of our findings to different national contexts and healthcare systems requires further empirical validation.\u003c/p\u003e"},{"header":"5. Conclusions","content":"\u003cp\u003eThis study reveals a strong relationship between personal health responsibility and engagement with FDCSs among rural older adults in China, with healthcare geographic accessibility playing a critical moderating role. While individuals with higher levels of personal health responsibility are more likely to engage with FDCSs, limited healthcare geographic accessibility\u0026mdash;particularly in rural areas\u0026mdash;greatly reduces this likelihood. These findings emphasize the interplay between individual agency and structural barriers in shaping health-seeking behaviors.\u003c/p\u003e \u003cp\u003eTo address these challenges, policymakers should prioritize strengthening healthcare infrastructure in rural areas, including targeted investments in local health facilities, mobile health units, and telemedicine services to mitigate geographic barriers. Furthermore, financial incentives, such as subsidies for rural older adults and performance-based rewards for family doctors, should be adopted to promote FDCSs engagement. Comprehensive health education programs, particularly aimed at fostering personal health responsibility, are essential to promote the engagement and benefits of FDCSs. Moreover, it is also crucial to integrate FDCSs more effectively with local healthcare systems to ensure continuity of care. These combined efforts will help bridge the gap in healthcare access and promote healthier aging across rural populations.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFDCSs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFamily Doctor Contracting Services\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNCDs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNon-communicable Diseases\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHBM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHealth Belief Model\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTPB\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eTheory of Planned Behavior\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHLT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHealth Lifestyle Theory\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSREHC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eShandong Rural Elderly Health Cohort\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGDP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGross Domestic Product\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBMI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBody Mass Index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eADL\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eActivities of Daily Living\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used in the current study are not publicly available due to the confidential policy but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank the officials of health agencies, all participants and staffs at the study sites for their cooperation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was reviewed and approved by the Ethics Committee of the researchers\u0026rsquo; university (approval number, 20181228; approval date, Dec 28, 2018). All procedures were in accordance with the ethical standards of the Helsinki Declaration. All participants provided written informed consent. All methods employed in the study were performed in accordance with the relevant international guidelines and regulations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed consent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBefore the survey, written informed consent was obtained from each participant, clarifying the purposes, significance, methods, and potential risks of the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAjzen I (1991) The theory of planned behavior. 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Soc Sci Med 207:46-54. https://doi.org/10.1016/j.socscimed.2018.04.041\u003c/li\u003e\n\u003cli\u003eLevesque J-F, Harris MF, Russell G (2013) Patient-centred access to health care: Conceptualising access at the interface of health systems and populations. Int J Equity Health 12:18. https://doi.org/doi:10.1186/1475-9276-12-18\u003c/li\u003e\n\u003cli\u003eLi J, Li J, Fu P et al. (2021) Willingness of patients with chronic disease in rural China to contract with family doctors: Implication for targeting characteristics. BMC Fam Pract 22(11). https://doi.org/10.1186/s12875-021-01553-2\u003c/li\u003e\n\u003cli\u003eLi LW, Liu J, Zhang Z et al. (2015) Late-life depression in Rural China: Do village infrastructure and availability of community resources matter? 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Aten prim 37(3):178-179. https://doi.org/10.1157/13085339\u003c/li\u003e\n\u003cli\u003ePillutla V, Maslen H, Savulescu J (2018) Rationing elective surgery for smokers and obese patients: responsibility or prognosis? BMC Med Ethics 19(1):28. https://doi.org/10.1186/s12910-018-0272-7\u003c/li\u003e\n\u003cli\u003eRosenstock IM (1974) Health belief model and preventive health behavior. Health Educ Monogr 2(4):354-386. https://doi.org/10.1177/109019817400200405\u003c/li\u003e\n\u003cli\u003eSchirmer W, Michailakis D (2011) The responsibility principle. Contradictions of priority-setting in Swedish healthcare. Acta Sociol 54:267-282. https://doi.org/10.1177/0001699311412624\u003c/li\u003e\n\u003cli\u003eSchmidt H (2009) Personal responsibility in the NHS Constitution and the social determinants of health approach: Competitive or complementary? 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J Med Ethics 48(1):39-45. https://doi.org/10.1136/medethics-2019-105612\u003c/li\u003e\n\u003cli\u003eTraina G, Martinussen PE, Feiring E (2019) Being healthy, being sick, being responsible: Attitudes towards responsibility for health in a public healthcare system. Public Health Ethics 12(2):145-157. https://doi.org/10.1093/phe/phz009\u003c/li\u003e\n\u003cli\u003eVincent NA (2011) A structured taxonomy of responsibility concepts. In: Vincent NA, Poel vande I, van den Hoven J, eds Moral responsibility: beyond free will and determinism. Springer Netherlands, Dordrecht.\u003c/li\u003e\n\u003cli\u003eWang B (2013) Luck egalitarianism and personal responsibility for health: Taking smokers\u0026apos; personal responsibility as an example. Mor Civil (02):131-137\u003c/li\u003e\n\u003cli\u003eWang C, Yan S, Jiang H et al. (2021a) Residents\u0026rsquo; willingness to maintain contracts with family doctors: A cross-sectional study in China. J Gen Intern Med 36(3):622-631. https://doi.org/10.1007/s11606-020-06306-y\u003c/li\u003e\n\u003cli\u003eWang Y, Fu P, Li J et al. (2021b) Changes in psychological distress before and during the COVID-19 pandemic among older adults: The contribution of frailty transitions and multimorbidity. Age Ageing 50(4):1011-1018. https://doi.org/10.1093/ageing/afab061\u003c/li\u003e\n\u003cli\u003eYang S, Li J, Fu P et al. (2021) Do older people with cardiovascular-metabolic multimorbidity prefer to sign contracts for family doctor services? Evidence from a cross-sectional study in rural Shandong, China. BMC Geriatr 21(1):579. https://doi.org/doi:10.1186/s12877-021-02543-w\u003c/li\u003e\n\u003cli\u003eZhang Z, Zhang R, Peng Y et al. (2023) Barriers and facilitators of family doctor contract services in caring for disabled older adults in Beijing, China: A mixed methods study. BMJ Open 13(6):e070130. https://doi.org/10.1136/bmjopen-2022-070130\u003c/li\u003e\n\u003cli\u003eZhao Y, Lin J, Qiu Y et al. (2017) Demand and signing of general practitioner contract service among the urban elderly: A population-based analysis in Zhejiang Province, China. Int J Environ Res Public Health 14(4):356. https://doi.org/10.3390/ijerph14040356\u003c/li\u003e\n\u003cli\u003eZhou BF, Cooperative Meta-analysis Grp W (2002) Predictive values of body mass index and waist circumference for risk factors of certain related diseases in Chinese adults: Study on optimal cut-off points of body mass index and waist circumference in Chinese adults. Biomed Environ Sci 15(1):83-96.\u003cbr\u003e \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":"humanities-and-social-sciences-communications","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"palcomms","sideBox":"Learn more about [Humanities \u0026 Social Sciences Communications](http://www.nature.com/palcomms/)","snPcode":"41599","submissionUrl":"https://submission.springernature.com/new-submission/41599/3","title":"Humanities and Social Sciences Communications","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Nature AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Personal health responsibility, family doctor contract services, healthcare geographic accessibility, older adults","lastPublishedDoi":"10.21203/rs.3.rs-6566826/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6566826/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eLimited research has examined the nexus between personal health responsibility and family doctor contract services, particularly the moderating role of healthcare geographic accessibility in this relationship. This study aimed to investigate the association between personal health responsibility and family doctor contract services and to determine how healthcare geographic accessibility shapes this relationship among rural older adults in China.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA cross-sectional study was conducted from July to August 2022 in Shandong Province in China. A total of 3,164 rural older adults were included in the analysis. Multivariable binary logistic regression models and the margins plot were used for the moderating effect analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe rates of signing up for family doctor contract services and support for personal health responsibility among rural older adults in Shandong Province were 64.85% and 61.54%, respectively. Participants who supported personal health responsibility were more likely to contract for family doctor services (OR\u0026thinsp;=\u0026thinsp;1.38, 95% CI\u0026thinsp;=\u0026thinsp;1.13\u0026ndash;1.69) after controlling for confounding factors. Only among older adults with good healthcare geographic accessibility, personal health responsibility was associated with higher contracting rates for family doctor services (OR\u0026thinsp;=\u0026thinsp;1.48, 95% CI\u0026thinsp;=\u0026thinsp;1.20\u0026ndash;1.82).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eOur findings reveal a correlation between personal health responsibility and engagement with family doctor contract services, with healthcare geographic accessibility serving as a pivotal moderating factor. It is imperative for governmental authorities to amplify targeted educational campaigns and outreach for rural older adults. Elevating their understanding of personal health responsibilities and enhancing healthcare geographic accessibility are crucial steps to encourage their participation in family doctor services.\u003c/p\u003e","manuscriptTitle":"What role does healthcare geographic accessibility play in the association between personal health responsibility and family doctor contract services?","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-10 14:48:07","doi":"10.21203/rs.3.rs-6566826/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-06-25T15:30:02+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-23T04:41:30+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-16T02:49:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"202104571099565240330719722312465137462","date":"2025-06-06T01:30:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"267966475477617682007229919452066604813","date":"2025-06-05T09:57:14+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-05T02:56:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"160205882344642649935097600314800519602","date":"2025-06-04T13:00:23+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-04T11:16:14+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-05-30T15:27:06+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-28T16:19:37+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-28T16:19:32+00:00","index":"","fulltext":""},{"type":"submitted","content":"Humanities and Social Sciences Communications","date":"2025-04-30T16:45:11+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"humanities-and-social-sciences-communications","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"palcomms","sideBox":"Learn more about [Humanities \u0026 Social Sciences Communications](http://www.nature.com/palcomms/)","snPcode":"41599","submissionUrl":"https://submission.springernature.com/new-submission/41599/3","title":"Humanities and Social Sciences Communications","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Nature AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"4d07d313-7637-4c76-8c1b-eec61f906d5a","owner":[],"postedDate":"June 10th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":49612480,"name":"Humanities/Health humanities"},{"id":49612481,"name":"Humanities/Medical humanities"},{"id":49612482,"name":"Social science/Social policy"}],"tags":[],"updatedAt":"2026-04-03T02:09:13+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-10 14:48:07","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6566826","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6566826","identity":"rs-6566826","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}