A community-based cross-sectional study was carried out in order to meet the proposed objectives. This type of study allowed for the collection of data at a point in time on the characteristics and behaviors of the target population, providing important insights for understanding health and behavioral issues. Cross-sectional analyses offer a snapshot of characteristics and associations in a population, allowing an initial and rapid understanding of patterns of health and disease (32). This study investigates the wellbeing, health literacy, and quality of life of older adults individuals in the Alentejo region. The research question is formulated using the PICO framework as follows: P (Population): Older adults individuals aged 65 and over registered in a Personalized Health Care Unit (UCSP) in the Alentejo; I (Intervention/Exposure): Multidimensional assessment involving quality of life, wellbeing, functionality, loneliness, and health literacy; C (Comparison): Differences between rural and urban residents, and between men and women; O (Outcome): Identification of key factors affecting wellbeing, health literacy, and quality of life to inform policy and interventions promoting healthy aging.

The sample was selected in a non-probabilistic way (33), participants were invited to participate by a health professional involved in their care process, based on availability and accessibility, contributing to this data collection process all health professionals from the unit, including a researcher.

The sample size was determined as 344 participants, the sample calculation was calculated with a sampling error of 0.05, taking into account that the prevalence of adherence is approximately 50% and using SurveyMonkey software, including a 20% margin for missing data.

To address the research question effectively, a series of hypotheses were formulated to explore potential differences and associations within the target population. These hypotheses will serve as a foundation for understanding the key determinants of wellbeing and health literacy. H1: Older adults individuals residing in rural areas experience lower wellbeing and quality of life compared to those in urban areas. H2: Women report higher levels of loneliness and lower health literacy compared to men. H3: Low health literacy is associated with reduced functionality and increased anxiety/depression among the older adults population.

Following the hypotheses, the main objectives of this research were outlined, which focus on evaluating the older adults population’s quality of life, wellbeing, and health literacy, while identifying specific areas that require targeted intervention. O1: To assess the quality of life, wellbeing, and health literacy of older adults individuals in Alentejo. O2: To analyze the impact of gender and geographic location (rural vs. urban) on wellbeing, loneliness, and health literacy. O3: To identify the primary factors influencing quality of life, including pain, mobility, and anxiety. O4: To provide recommendations for community-based interventions aimed at promoting active and healthy aging in rural regions.

The inclusion and exclusion criteria for this study were designed following the PICO framework to ensure a focused and relevant sample population. The inclusion criteria for this study were older adults individuals aged 65 and over residing in Alentejo, registered with a Personalized Health Care Unit (UCSP). Participants must have the cognitive ability to complete questionnaires, communicate in Portuguese, and have telephone contact available at the units. Participation in multidimensional assessments through validated questionnaires and scales. Exclusion criteria were individuals unable to provide informed consent. Those with severe cognitive impairments preventing the completion of questionnaires. Older adults individuals on waiting lists for National Continuing Care Network facilities or those who did not respond after three attempts to contact them by telephone.

The study was approved by the ARSA Ethics Committee (Advice 17/CE/2022), ensuring that it adhered to all ethical guidelines and requirements. Written informed consent was obtained from all participants, and confidentiality was maintained throughout the research process.

Data were collected opportunistically as participants attended UCSPs for routine activities, such as nursing appointments, treatments, or vaccinations. The data collection process, which took place between July 2023 and March 2024. Health professionals identified eligible participants and provided them with an explanation of the study’s objectives. Participants who agreed to participate were given informed consent forms and questionnaires. They had the option to complete the questionnaires at the UCSP or at home, with assistance from family members or healthcare professionals as needed.

This method of data collection made it possible to take advantage of the presence of older adults people in the UCSP and ensure that the process of participation was clear, consensual and convenient for the participants.

Validated tools were used to measure the key dimensions of wellbeing, quality of life, functionality, loneliness, and health literacy. These included:

Data were collected using Google Forms and subsequently exported to Excel for preliminary organization. The dataset was then analyzed using IBM SPSS Statistics 29.0.1.0. Descriptive statistics, such as means, medians, and standard deviations, were calculated for each variable. Graphical representations (e.g., boxplots) were used to illustrate data distributions.

Inferential statistics were used to explore relationships between variables. T-tests, Mann–Whitney U tests, and chi-square tests were employed to examine differences in wellbeing, quality of life, and health literacy between subgroups (e.g., gender, rural vs. urban). Bivariate analyses were conducted to identify significant associations between variables. Results were considered statistically significant when rejected Alpha at p < 0.05. Power analysis and sample size calculation were performed in advance using SurveyMonkey software.

The WHO-5 Wellbeing Index revealed an average score of 53 (SD = 4.29), indicating generally preserved wellbeing, but with notable variability (Table 2). Gender differences were significant, with men scoring higher on the wellbeing scale (mean = 14.35, SD = 3.32) compared to women (mean = 12.40, SD = 2.79), with a statistically significant difference (p < 0.001).

Wellbeing scores were also significantly higher for participants living in urban areas (mean = 14.12, SD = 2.90) compared to those in rural areas (mean = 12.75, SD = 3.21), with a significant Mann–Whitney U test result (p < 0.05).

The EQ-5D-3L scale provided insights into participants’ health-related quality of life across five dimensions: mobility, personal care, usual activities, pain/discomfort, and anxiety/depression. Chi-Square Test of Independence was conducted to analyze the association between the levels of problems across the five dimensions of the EQ-5D-3L profile: Mobility, Personal Care, Usual Activities, Pain/Discomfort, and Anxiety/Depression. The contingency table used for the analysis consisted of three levels of problems (“No Problems,” “Some Problems,” and “Severe Problems”) for each of the five dimensions, forming a 5×3 structure. The test results showed a highly significant association between the levels of problems across the dimensions, with χ²(8) = 155.37, p < 0.001. This indicates that the distribution of responses significantly differs among the dimensions analyzed.

Additionally, the expected frequencies for each cell in the contingency table were calculated to validate the test assumptions. Over 50% reported no issues with mobility and usual activities; however, 41.6% (n = 143) reported some problems with mobility, and 34.6% (n = 119) with usual activities. Pain and discomfort were prevalent, with 57.3% (n = 197) reporting some degree of pain, and 38.7% (n = 133) reporting no significant pain. Anxiety and depression affected 48.5% (n = 167) of participants, while 49.4% (n = 170) reported no issues (Table 3).

A Chi-Square Test of Independence was performed to assess the association between gender and mobility levels. The results revealed a statistically significant relationship, with χ²(2) = 9.46, p = 0.009. This finding indicates that mobility levels vary significantly across genders in the sample. The observed association suggests that gender may play a role in influencing mobility levels. On average, women report lower levels of mobility compared to men. The mean mobility score for women is 1.50, while for men it is 1.35. This indicates that women experience greater challenges with mobility in this sample. A Chi-Square Test of Independence was conducted to assess the association between habitation location (rural or urban) and levels of anxiety or depression. The analysis revealed no statistically significant relationship, with χ² (2) = 0.86, p = 0.652. These findings suggest that, within this sample, the location of habitation does not have a significant influence on levels of anxiety or depression.

Participants rated their overall health on the EQ-5D VAS with an average score of 68.09 (SD = 12.31) and a median of 70 (Figure 1). Men had significantly higher quality-of-life scores compared to women (p < 0.01), with men scoring an average of 1.35 points higher on the overall quality-of-life scale.

The Barthel Index showed that participants retained a high level of independence in activities of daily living (ADLs), with an average score of 15 (SD = 3.12). The activities with the highest level of independence included “Eating” (mean = 1.91, SD = 0.31), “Using the bathroom” (mean = 1.91, SD = 0.33), and “Bowel control” (mean = 1.94, SD = 0.26). However, dependence was more common in activities such as “Bathing” (mean = 0.88, SD = 0.33) and “Bladder control” (mean = 1.83, SD = 0.41). The most challenging activity was “Climbing stairs” (mean = 1.58, SD = 0.59) (Table 4). The Chi-square goodness-of-fit tests show statistically significant differences (p < 0.05) for all activities of daily living (ADLs) in the Barthel Index. This suggests that the observed distribution of scores deviates significantly from an equal distribution, indicating areas where participants’ performance varies.

On the Lawton and Brody IADL scale, participants demonstrated strong capacity in areas like “Taking care of the house” (mean = 2.92, SD = 1.25) and “Using the phone” (mean = 2.39, SD = 0.82). The lowest scores were observed in “Doing laundry” (mean = 1.37, SD = 0.70). Variability in abilities was noted, with “House care” showing the most variation across participants (Table 5).

Loneliness was prevalent, with 50.6% of participants (n = 174) scoring higher than 32 on the UCLA Loneliness Scale, indicating significant feelings of loneliness (mean score = 41.93, SD = 5.59). The remaining 49.4% (n = 170) had scores of 32 or below, indicating no significant loneliness (mean score = 24.65, SD = 4.89).

Women were more likely to experience loneliness than men, with a significant association between gender and loneliness (p < 0.05). The observed count of older adults people with loneliness was higher among women (n = 103) than among men (n = 71). Loneliness was also more prevalent among rural residents (n = 136) compared to urban residents (n = 38), with a statistically significant association between place of residence and loneliness (p < 0.05) (Table 6).

Health literacy results from the HLS19-Q12-pt indicated that only 6.39% of participants (n = 22) demonstrated excellent literacy, while 47.27% (n = 163) had sufficient literacy. Problematic literacy was found in 35.98% (n = 124) of participants, and 9.03% (n = 31) exhibited inadequate literacy (Figure 2). There was no significant association between gender and health literacy (p > 0.05). However, rural residents had significantly lower health literacy than urban residents (p < 0.05), indicating geographical disparities in health knowledge.

The findings indicate that while wellbeing is generally preserved among the older adults participants, there are significant disparities between men and women, as well as between urban and rural residents. Men reported higher wellbeing scores than women, a trend that aligns with previous research suggesting that older women are more vulnerable to emotional distress, possibly due to caregiving responsibilities, limited social engagement, and increased physical limitations in later life (29, 40). In particular, older women may benefit from social and recreational programs aimed at improving emotional wellbeing (41).

Similarly, rural residents reported lower wellbeing compared to urban residents, likely due to reduced access to healthcare services, social activities, and transportation (3). Although rural environments can offer benefits such as green spaces that contribute to health, the limited access to services in these areas poses a challenge. Improving transportation, healthcare access, and community engagement opportunities in rural areas could mitigate these issues (3, 42, 43).

In terms of quality of life, the EQ-5D-3L results revealed that mobility issues, pain/discomfort, and anxiety/depression were significant challenges for many participants, particularly in rural areas. These issues negatively impact quality of life and highlight the need for targeted interventions, such as pain management programs, mental health services, and mobility support (44, 45). Enhancing healthcare infrastructure in rural areas is crucial to addressing these challenges.

The high scores on the Barthel Index suggest that participants maintain significant independence in basic activities of daily living (ADLs), although mobility-related activities, such as climbing stairs, pose more difficulty. As physical decline is a natural part of aging, these results underscore the importance of interventions like physical therapy and rehabilitation programs that help older adults individuals maintain their independence (45).

Challenges were also evident in more complex instrumental activities of daily living (IADLs), such as house care and laundry. These findings are consistent with the literature, which shows that older adults often struggle with more demanding tasks (37). Community-based services that offer domestic support or transportation could enhance the independence and autonomy of older adults individuals.

The study revealed that over half of the participants experienced significant feelings of loneliness, with women and rural residents being particularly affected. Loneliness is a well-documented risk factor for mental and physical health problems in older adults, including depression and cardiovascular issues, and is linked to increased mortality rates (15–17). The greater prevalence of loneliness in rural areas is consistent with other findings, where geographical isolation reduces social opportunities (30, 43, 46).

Social prescription programs, which connect individuals with community-based activities, may be effective in alleviating loneliness, particularly in rural settings (47–49). Additionally, promoting digital literacy among older adults could provide alternative ways to maintain social connections, even in geographically isolated areas (25).

Low levels of health literacy were a significant concern in this study, with nearly half of the participants displaying problematic or inadequate literacy. This finding aligns with previous research showing that older adults, particularly those in rural areas, often struggle to understand health-related information, which can hinder effective health management (19–21).

Improving health literacy is essential for empowering older adults to manage their health more effectively. Tailored educational programs, simplified health communication, and the use of digital tools could help close the health literacy gap, especially in rural areas (22–25).

Based on the results of this study and existing literature, it is clear that community interventions play a crucial role in promoting active and healthy aging in rural regions. To achieve this goal, specific strategies must be implemented, including social prescribing, which is emerging as a promising approach to meeting the physical, social, and emotional needs of older adults (50). Social prescribing is an innovative practice that involves directing older adults to community activities and resources that promote health and wellbeing. Examples include participation in support groups, exercise classes, recreational activities, and other services offered by the community (47). These initiatives have been shown to be effective in increasing social engagement, promoting mental and physical health, and significantly reducing loneliness. Studies indicate that social prescription positively impacts the quality of life of older adults, connecting them to community support networks and significant opportunities for social interaction (48, 49).

The results of this study underscore the need for public health interventions that address the specific challenges faced by the older adults population in Alentejo, particularly women and rural residents.

To ensure healthy and active aging for the older adults in Alentejo and similar regions, the following public health policies should be prioritized:

Future studies should focus on longitudinal research to explore how these variables change over time and how effective interventions are in improving wellbeing and quality of life. Additional research is also needed to examine the specific challenges faced by older adults individuals in more remote areas and the role of emerging technologies, such as telemedicine, in improving access to care and social engagement.

While this study offers insights, it is necessary to acknowledge certain limitations. The study utilized a non-probabilistic convenience sampling method, involving users of the health unit where one of the researchers is employed, with authorization from the Ethics Committee limited to that specific unit. This may restrict the generalizability of the findings to the broader older adults population. Calculations were performed, allowing for a margin of error, to ensure that the sample was representative of the health unit’s population. Additionally, the cross-sectional design only provides a snapshot of participants’ conditions, meaning causal relationships cannot be inferred.

Despite these limitations, the study is a contribution to understanding the challenges faced by older adults individuals in rural areas, particularly in terms of health and social needs. The findings offer practical recommendations for promoting healthy aging in the Alentejo region and beyond.