Population aging in Taiwan is already occurring. Taiwan became an “aged society” in 2018, with more than 14% of the population ≥65 years old (1). The aged population is rapidly increasing and is expected to reach 20% or higher by 2025, which could make Taiwan become a “super-aged society” (1). As a result of changing demographics, chronic diseases are becoming more widespread. Over 85% of older adults in Taiwan suffer from at least one chronic condition (2). Chronic diseases such as cancer, heart disease, hypertension, diabetes, and cerebrovascular disease are already leading causes of death in Taiwan (3).

Health checkups help identify health issues and risk factors for disease or provide reassurance to people without a specific medical indication (4, 5). They may help address persistent health inequalities, expanding numbers of people living with long-term diseases, and the growing needs of an aging population (6). Routine health checkups are essential for reducing healthcare costs related to chronic diseases (7, 8). It is necessary to identify risk factors for conditions such as heart disease, diabetes, and stroke (7, 8). People with routine health checkups are more likely to get an early diagnosis if they develop a medical condition, leading to better outcomes and longer lifespans (9). Health checkups may also be referred to as medical screening, preventive or pre-symptomatic tests, or preventative examinations (10). They may be a cost-effective way of addressing the causes of illnesses before they develop into severe long-term conditions (6).

Despite the potential necessity and benefits of such health checkups, it is well-recognized that their uptake is largely sub-optimal. The Taipei City government has provided annual elderly health checkups (EHCP) at no cost for all seniors in Taipei since 2014. The EHCP cover physical assessments, depression screening, cognitive function assessments, a routine urine assay, a routine blood assay, biochemical assays (for albumin, globulin, uric acid, and blood urea nitrogen), a fecal occult blood test, and a fecal immunochemical test. Between 37,000 and 46,000 services are provided yearly (11). However, only a small group of people (fewer than 10% of older adults) participate in health checkups every year, and several provided services are not fully utilized (11). Differential uptake may make health inequities worse (12). Consequently, knowledge of the factors influencing health checkup attendance is fundamental if current services can be adequately changed to mitigate such inequities.

A few national and international studies have investigated factors influencing the decision to get a health checkup. Previous research revealed that sociodemographic characteristics, lifestyle factors, and a person's medical history were significant factors influencing the decision to get a checkup (13, 14). Another factor is an individual's health beliefs, based on values ascribed to health and a belief in the efficacy of health checkups (6, 15). However, little is known about factors that influence attendance of annual government-provided free health checkups. As a unique context, associations could differ. Furthermore, to target deficiencies in the EHCP, an investigation targeting population satisfaction is necessary.

This study aimed to extend current knowledge relating to the uptake of EHCP services and individuals' views of this service and thus contribute to improving healthcare service delivery and the further development of government policies. In particular, our study sought to address two questions:

This study investigated the EHCP in Taiwan in terms of satisfaction and determinants of participation. We found that the participants of the EHCP were more satisfied with it, and non-participants were mainly dissatisfied with the publicity methods, health checkup items, number of services provided, and the health checkup process. Additionally, satisfaction was found to be positively associated with healthcare service utilization, as a prior study also showed (18). As for satisfaction, there are still some aspects that could be improved. The primary publicity method is sending ads to eligible citizens by mail, which is a traditional way. It takes time to arrive, and the ad in the mailbox can easily be ignored. However, this method works well for targeting seniors, since they are comfortable engaging through this channel and still use it regularly. Other methods, such as making a phone call or advertising on the Internet, could also be effective because of the increasing smartphone use among seniors in Taiwan (19). As for health checkup items and processes, a former study suggested that a belief that screening procedures were too complicated to understand was one of the factors that reduced the willingness to participate in health screening in Taiwan (7). Additionally, bad experiences (e.g., a long waiting time) during a previous health checkup negatively influence attendance (7, 20). Every year, the city government offers a limited number of free health checkups for all senior residents and gives priority to more disadvantaged people, including residents who (1) are living alone; (2) live in low-income households or middle-low-income households; (3) have physical or mental disabilities, and (4) are indigenous residents. Other citizens can only competitively book a spot in the second round, which might be the reason that non-participants were dissatisfied with the number of services provided. To improve access to free health services, further study is needed to estimate the number of older adults who need annual health checkups to prevent diseases and provide suggestions to providers to make this free service more accessible.

The absence of sex or marital status differences in participation in the EHCP is interesting. This result differed from previous studies which examined factors predicting the use of other preventive or medical services. Females tend to use preventive and diagnostic services more frequently (21, 22), and the use of health services varies according to one's life stage, with women using the healthcare system more frequently during their childbearing years (23). One methodological reason for this phenomenon could be different definitions of preventative health checkups, including gynecological cancer examinations such as mammography and cervical cancer screening, which are otherwise excluded. Another reason men and women use preventative healthcare services equally today could be that gender-specific initiatives have transformed the general approach to illness and health (23, 24). Other studies indicated that marriage promotes screening attendance, and both a single and divorce status were considered factors that increased barriers to screening (25, 26). One potential explanation for the absence of an impact of the marital status could be that there is an interaction between marital status and sex, but no sex difference was found.

Results of a higher likelihood of EHCP participation by older adults with more than two chronic diseases compared to those without any are consistent with previous findings, as individuals suffering from at least one chronic disease or disorder engaged more in prevention than people without such complaints (24). Additionally, we found that individuals with diabetes or who had had a stroke had a higher probability of participation than those without, which is also in line with previous findings that individuals with diabetes were more likely to attend health checkups (27, 28). Possible explanations might be that (1) chronically diseased individuals who are regularly in contact with health professionals under permanent medical supervision may be easily informed about the EHCP; (2) susceptibility to potential health conditions or comorbidities might increase the likelihood of attending a free preventive health checkup, which is reasonable in the context of primary prevention; and alternatively, (3) annual or more frequent checkups are necessary for persons with a chronic disease, as research indicates that preventative care decreases the prevalence and progression of such conditions (29).

Other potential influencing factors identified in this study were educational level and age. Indigenous residents in Taiwan have a lower life expectancy and suffer more from alcoholism and other poor health outcomes than the general population (30). Despite having priority in participation of the EHCP, compared to individuals aged 66–75 years, they were less likely to attend health checkups. Our finding also indicates that there might still be a disparity in participation in the EHCP between indigenous residents and the general population. Age affects participation in health screening, with older seniors having relatively high participation rates, consistent with earlier research (31, 32). However, participation decreased with a higher education level, as another study suggested (31). This might be because highly educated people are more health-conscious and demand higher quality and quantity of health screening.

This is the first study to examine both participants' and non-participants' satisfaction with the EHCP in Taipei and estimate associations between personal characteristics and participation. Strengths of the present study include the large sample size and the comparative study design, which allowed distinct comparisons. In this study, the measurement (questionnaire for a telephone interview) was tested for reliability and validity, increasing the likelihood of data consistency. Because of the large number and random selection of interview participants, a high external validity of the results for Taiwan can be assumed.

One major methodological limitation of this study is the fact that the study was cross-sectional and lacked causal inferences for the associations we found. In addition, we defined non-participants as those who had participated in the EHCP within the last 3 years, including those who once participated in EHCP but withdrew for some reason and those who had never participated. Therefore, it ignored the differences between these two groups of people. However, this study mainly focuses on the differences between participants and non-participants of the EHCP. A deeper study was needed to further investigate the different opinions of the EHCP among different non-participants Additionally, personal characteristics were self-reported rather than taken from recorded data in the national healthcare system. No validation was carried out using a patient's medical charts. The questionnaire pre-set the personal characteristics and the influencing factors investigated were limited. In the analysis, the estimated associations were not adjusted for potential confounders, unlike other studies investigating predictors. An analytical study design rather than a descriptive study could further estimate associations between personal characteristics and health checkup participation.

From the present results, it can be concluded that the EHCP had a high proportion of satisfaction among participants, but the proportion was relatively low among non-participants. It is suggested that publicity methods, health checkup items, the number of services provided, and the health checkup process could be further improved. The findings suggest that age, educational level, chronic diseases, and subjective satisfaction were related to older persons' participation in Taipei's annual health checkup program. Preventive screening could benefit older adults by detecting diseases early and help them maintain their health. This study can help policymakers target non-participants or disadvantaged groups in the program and recommend measures to promote their uptake.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The studies involving human participants were reviewed and approved by Taipei Medical University-Joint Institutional Review Board (N201907066). Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.

Y-JC, C-FL, and H-LC contributed to conception and design of the study. C-FL, JF, and H-LC organized the database. JF performed the statistical analysis. Y-JC and C-FL wrote the first draft of the manuscript. Y-JC, C-FL, JF, and H-LC wrote sections of the manuscript. All authors contributed to manuscript revision, read, and approved the submitted version.