This study provides valuable insights into the health status and utilization of preventive health services among older adults living in rural and urban areas of Northeast Hungary, addressing a current data gap in CEE countries. Consistent with findings from other CEE countries [9, 10, 26, 27], our study reveals generally poor health status among older adults in Hungary. A significant proportion of participants rated their health as fair, poor, or very poor, with no significant difference in self-perceived health status between urban and rural areas, although urban residents reported slightly better health status. The role of social network and social participation in influencing self-rated health has been observed in urban residents, while loneliness is associated with declining self-rated health in rural residents [26]. Moreover, limitations in daily activities were more prevalent among rural residents, aligning with previous research [28]. Urban residents exhibited a higher prevalence of chronic diseases [26, 29], which may be attributed to better access to healthcare facilities, accurate diagnosis, and a higher likelihood of seeking medical care.

Our study highlights low participation rates in preventive health services such as dentist visits, influenza vaccination, and cancer screening programs, while GP visits, cardiometabolic preventive services, and COVID-19 vaccination showed relatively high utilization rates. Significant disparities were observed in the utilization of health services between rural and urban areas. However, after adjusting for potential confounders, only certain cardiometabolic preventive services, laboratory tests, and colorectal cancer screening by faecal occult blood test demonstrated significant differences between rural and urban residents.

Controlling cardiometabolic risk factors is crucial in reducing the risk of cardiovascular diseases [30], improving life expectancy [31], and mitigating physical limitations [32] in older age. Our study reveals a relatively high utilization rate of cardiometabolic preventive services, particularly among rural residents. The presence of a higher density of GPs in urban areas may result in lower opportunity costs for care, including travel expenses and waiting time [33], thereby increasing the likelihood of utilizing preventive services [34]. Notably, a high proportion of participants visited a GP within the past year, which may explain the higher utilization of services for the prevention of cardiometabolic diseases among them.

Participation in breast and cervical cancer screening is recommended for women under 65 years in Hungary. However, since a significant proportion of cases is diagnosed in older ages, continued screening would result in increased life expectancy [35,36,37]. Our study found low participation rates in mammography and cervical cancer screening among older adults, which were considerably lower than reported by the OECD in the target age group [38]. Similarly low participation rates were observed for colorectal cancer screenings. Although breast and colon cancer screening services were significantly lower among rural residents, adjusting for demographic, socioeconomic, and health status variables eliminated the significance, except for faecal occult blood testing. Limited availability of cancer screening technology and human resource shortages, particularly in less developed regions, remain significant challenges in cancer care in Hungary [38, 39].

No significant differences were found in COVID-19 and influenza vaccination rates between rural and urban residents. Although influenza vaccination is free for the population aged 65 years and over in Hungary, vaccination coverage (27%) was far from the recommended level (75% according to WHO recommendation). Even though influenza vaccination is a cost-effective way to reduce premature mortality, the vaccination rate against influenza among older people is low in CEE countries [6], which could be explained by socio-demographic factors, health status and health behaviour [40], and the lack of perceived need and recommendation by their physician for vaccine [6]. COVID-19 vaccination rate was at around 90% in the study population. Although the proportion of those vaccinated against COVID-19 did not differ between rural and urban residents, our analysis showed significantly higher mortality rates due to COVID-19 among females in all age groups and among males aged 75 years and older in rural areas. Rural areas generally have an older population with a higher prevalence of pre-existing conditions and comorbidities, which are known risk factors for severe COVID-19 illness and death including cardiovascular disease (CVD), hypertension, diabetes and obesity [41,42,43]. In addition, a recent study highlighted that the dysfunction of the heart-brain axis during SARS‐CoV‐2 infection may worsen the outcome of the COVID-19 patients through neurotropism or by increasing the susceptibility to psychosocial factors that may lead to neurological and stress-related diseases associated with CVD [44]. Although, the outcome of heart and brain disease in COVID-19 patients depends on their sex [45]. Furthermore, previous research conducted in Hungary has revealed that residents of more deprived municipalities face a higher risk of COVID-19 mortality, even though they are less likely to be identified as confirmed COVID-19 cases [46]. These findings underscore the presence of significant regional disparities in healthcare access and outcomes.

Previous studies have highlighted the health inequalities that exist between rural and urban populations. A cross-sectional study, focusing on 11 high-income countries investigated health disparities across 10 indicators and found differences between rural and urban areas, particularly in access to primary care [47]. Nevertheless, our study showed no difference in the frequency of GP’s visits between urban and rural residents. Others found a higher prevalence of smoking among those living in urban areas [48], which was not supported by our results. However, it is worth noting that the differences in health status and service utilization between rural and urban elderly populations were less pronounced than expected, which may be attributed to the higher premature mortality observed in rural areas. Our data indicate substantial rural–urban disparities in all-cause mortality and mortality from major conditions in the municipalities covered by this study. Rural residents, particularly males, exhibited higher premature mortality rates due to cardiovascular diseases, cancers, and diseases of the digestive system (particularly for alcoholic liver disease), while rural females experienced higher mortality rates due to COVID-19, falls, and external causes. These findings align with previous studies from other countries where rural areas demonstrated higher all-cause mortality, cardiovascular disease mortality and cancer mortality [49, 50], along with lower respiratory disease mortality [51]. However, these differences in mortality could be partly explained by the deprivation level of the area [46, 51]. Furthermore, similar to our findings, a shift from urban to rural excess mortality with age can be observed in several European countries [52]. It is important to note that the high premature mortality rate among rural residents may result in the exclusion of the most vulnerable population groups from our study, leading to a relatively healthier elderly rural population with higher levels of health literacy and positive attitudes towards health services. The presence of such marked rural–urban disparities in mortality patterns underscores the need to address health inequalities and implement interventions to prevent premature mortality through lifestyle changes and improved access to medical services.

Individuals' beliefs and attitudes toward aging can impact the utilization of health services among older adults. Positive self-perception of aging has been linked to better preventive health behaviour [53] and a higher likelihood of using various preventive services [54]. On the other hand, older adults who believe that health problems are inevitable in old age are less likely to have regular physician visits and use preventive services [55]. Factors such as cognitive impairment [56] also influence the utilization of health services among the elderly. Besides beliefs and attitude of older adults, health care system factors can also influence the use of different services. Common reasons reported by older adults for not obtaining the needed medical care include cost, long waiting time for an appointment and lack of transportation or distance [19]. Generally, the number of physicians per capita is lower in rural areas, resulting in the concentration of specialized services in urban areas [10]. In addition to the limited range of available services, there are longer travel distances and limited transport options, thus existing disabilities particularly in older ages may further limit access to services. In Hungary, the differences in the density of doctors between urban and rural areas are particularly large [10], and health workforce shortage is a major concern in the country [57]. Age itself is also considered as an important determinant of utilisation of health services [34]. In our study the probability of visiting a GP, and receiving mammography and cervical cancer screening significantly decreased with age, which underline that access to certain medical services may be limited due to age. Furthermore, the findings suggest that the importance of participation in screening program by women above the recommended age limit (over 65 years) should be better communicated to the older population.

Preventive services offer a cost-effective approach to prevent and reduce the burden of chronic diseases and associated disabilities among the elderly. Increasing the utilization of specific preventive services and addressing the underutilized services, such as colorectal cancer screening and influenza vaccinations, can contribute to population health improvement, extended healthy life years, and enhanced quality of life for older adults [58]. With healthy lifestyle and proper medical care it becomes possible even in older ages to prevent or postpone the occurrence and development of certain risk factors and conditions and to reduce disability and dependency due to chronic diseases, which may have a long-lasting impact on older adult's quality of life [59]. The demographic shift will require increased attention from health policy to health service provision for older people, since an increased focus on avoidable conditions and enhanced preventive health services is essential to achieve a healthy ageing population [60]. Health care systems have to address the needs of ageing populations, implement policies that promote lifelong health and emphasize preventive care to prevent or delay the onset of age-related disability and ensure the well-being [2].

Rurality does not inevitably lead to urban–rural disparities, although it may exacerbate the impact of certain determinants including poor access to health services (due to travel distances and limited transport), socioeconomic deprivation and personal risk factors on health disparities between rural and urban residents [61]. Therefore, a comprehensive health care policy is needed that includes interventions that target health literacy and health-seeking behaviour, as well as ensuring the availability of health services [61]. Since access to health services is an important determinant of health outcomes for both curative and preventive care, there is a need to improve the accessibility of services in terms of adequate transport, particularly for older people with activity limitations.

Several limitations of this study should be acknowledged. Firstly, the use of self-reported measures for health status and service utilization may be susceptible to recall bias, potentially leading to overreporting of service utilization and prevalence of chronic diseases. Secondly, although we adjusted for major socioeconomic and health-related factors in our multivariable models, there may be other independent variables (e.g., beliefs, attitudes) that could influence the results but were not included. Thirdly, the underlying reasons for medical care visits and the use of health services were not captured in our data, limiting our understanding of the motivations behind service utilization. Fourthly, our study focuses on a specific region of Hungary, which may limit the generalizability of the findings to the entire country or other CEE countries. Lastly, as our data collection took place during the COVID-19 pandemic, the pandemic's impact on the outcome variables cannot be ignored.

In conclusion, our study highlights that the utilization of health services among older adults is associated with their place of residence. Although utilization of services provided by specialists, particularly cancer screening, is more frequent among urban residents, a higher utilization of preventive services for cardiometabolic risk factors is observed among rural residents. However, the high premature mortality in rural areas may moderate the health differences between rural and urban elderly populations. These findings emphasize the importance of preventive measures in older age and the need to reduce inequalities in mortality between rural and urban areas. Addressing barriers to medical care among older adults has the potential to increase the utilization of preventive services, contributing to reduced mortality, increased healthy life expectancy, and improved quality of life. Our findings suggest that geographical regions may have different capacities to address the increasing health problems of older age groups; therefore, it would be beneficial to analyse urban–rural disparities in a more diverse range of regions and countries. Comprehensive studies are needed to further describe the health needs of older populations and implement policies that promote healthy aging in CEE countries.