Introduction
Population aging is occurring at an increasing pace due to increasing life expectancy and decreasing birth rates. Iran is among the countries experiencing an aging population. As people get older, their health and social care needs become increasingly complex, and they become more prone to chronic diseases, functional limitations, psychological disorders, and inadequate access to healthcare services, threatening their quality of life. Despite this demographic shift, the Iranian healthcare system has mainly focused on maternal and child health, with limited attention given to the health needs of older adults. Inadequate infrastructure, shortages of trained personnel in elderly care, poor inter-organizational coordination, and insufficient financial and social support constitute major barriers to the delivery of effective and equitable healthcare services for the elderly. This qualitative study aimed to explore the challenges experienced by Iranian older adults in accessing healthcare services to provide practical recommendations for improving the quality and accessibility of elderly care services.

Materials and Methods 
This qualitative study was conducted in 2024 using a conventional content analysis approach in comprehensive health service centers affiliated with Maragheh University of Medical Sciences in Maragheh County, East Azerbaijan, Iran. The study included 35 participants: 20 older adults who had visited the health centers and 15 key informants, including healthcare providers, health administrators, and experts in geriatric health. Participants were selected through purposeful sampling with maximum variation to capture diverse experiences and perspectives. For older adults, the inclusion criteria were willingness to participate in the study and the absence of dementia. For key informants, at least two years of relevant professional experience was required. Data were collected through individual semi-structured interviews using open-ended questions to allow for the free expression of viewpoints. Interviews were held in a quiet room, audio-recorded, supplemented with field notes, and subsequently transcribed verbatim. Data collection continued until conceptual data saturation was achieved. The average interview duration was about 50 minutes.
The data analysis process involved repeated reading of transcripts, identification of initial codes, clustering of similar codes into themes, and iterative review and refinement of themes. Data were analyzed in MAXQDA software, version 10. To enhance analytic rigor, two researchers independently coded the data, and discrepancies were resolved through discussion. Trustworthiness of the data was ensured based on Guba and Lincoln’s criteria. Credibility was strengthened through expert checking; confirmability through member checking; transferability through maximum variation sampling; and dependability through comprehensive documentation of all stages of the research process.

Results 
Analysis of the semi-structured interviews yielded 65 codes, which were organized into 11 subthemes and 4 main themes. The identified themes encompassed policy-related challenges (weaknesses in health system decision-making and behavioral and attitudinal barriers), structural/administrative challenges (financial/budget constraints, technological barriers, infrastructural and facility limitations, and shortage of medicines, equipment, and service delivery), human resource challenges (human resource allocation and empowerment, employee characteristics), and environmental/social challenges (social and individual factors).

Policy-related challenges
Participants emphasized the absence of clear and evidence-based policies addressing the health needs of older adults. Many expressed concerns about the limited attention given to population aging by health policymakers, the lack of long-term implementation strategies, and the absence of explicit performance indicators for evaluating elderly care services. Inadequate involvement of non-health sectors and weak intersectoral collaboration were also identified as significant barriers. Participants further highlighted the lack of community-based and intersectoral approaches in designing interventions for older adults as a major gap in current health policies.

Structural/administrative challenges
Inadequate physical infrastructure was one of the most frequently reported barriers to accessing healthcare services. Participants described inaccessible buildings, steep staircases, the absence of ramps and elevators, and even the lack of benches in health centers as major obstacles for older adults. Limited availability of essential equipment, including blood pressure monitors, blood glucose testing devices, accurate weighing scales, and screening services, further compromised the quality of elderly care. In addition, several healthcare professionals criticized the excessive emphasis on administrative reporting systems and documentation, arguing that these requirements reduce the time available for direct patient care.

Human resource challenges
A shortage of specialized personnel, including psychologists, nutritionists, social workers, and geriatric nurses, was consistently reported by participants. They also identified healthcare providers’ poor communication skills as a major source of dissatisfaction among older adults, with some feeling disrespected or ignored. Furthermore, insufficient education about the physical, psychological, and social needs of older adults was perceived to undermine the effectiveness and quality of elderly care services.

Environmental/social challenges
Many older adults suffered from social isolation, feelings of being a burden, and lack of emotional support. Financial hardship, limited health literacy, poor awareness of healthcare rights, and negative societal attitudes toward aging further limited their ability to benefit from available health services. Moreover, environmental barriers including lack of safe access routes, insecurity in crossing the street, and lack of public transportation suitable for the elderly were identified as other important obstacles limiting older adults’ access to healthcare facilities.

Conclusion
The study demonstrated the challenges of Iranian older adults in accessing healthcare services. To overcome these challenges, solutions such as strengthening health and medical infrastructure, increasing specialized human resources, allocating sufficient budgets, and improving employee motivation and job satisfaction are suggested. Also, success in providing services depends on reforming structures and implementing supportive policies, including increasing financial resources at the primary service level, making some medical services free, developing home visit services, increasing accessibility to medical centers, and educating families on caring for the elderly. In addition, the use of digital technologies, such as electronic health records and telemedicine, can facilitate the process of providing and following up on services. Financial and educational support for caregivers, raising awareness among older adults about available services, and strengthening private-sector participation will play an important role in reducing current barriers and promoting the health and well-being of older adults.

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Research Ethics Committee of Maragheh University of Medical Sciences (Code: IR.MARAGHEHPHC.REC.1403.038). Informed consent was obtained from all participants prior to data collection. Participant confidentiality was maintained, and all data were anonymized using coded identifiers during data analysis.

Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Authors' contributions
The authors contributed equally to the preparation of this article. All authors read and approved the final version of the manuscript.

Conflicts of interest
The authors declare no conflict of interest.

Acknowledgments
The authors would like to thank the personnel of the comprehensive health service centers in Maragheh County and all seniors who participated in this study.

References

1. Arabi H, Shahjamali M. [Studying the economics of aging and presenting lesson plans for education in Iranian universities (Persian)]. The Journal of Economic Studies and Policies. 2020; 7(1):203-32. [DOI:10.22096/esp.2020.43396]
2. World Health Organization. World Health Day 2012: Ageing and health. Geneva: World Health Organization; 2012. [Link]
3. Chatterji S BJ, Cutler D, Seeman T, Verdes E. Health, functioning, and disability in older adults-present status and future implications. The lancet. 2015; 385(9967):563-75. [DOI:10.1016/S0140-6736(14)61462-8] [PMID] [PMCID]
4. Heidari F, Mottaghi R. [The effectiveness of life skills training on cognitive flexibility and quality of life in elderly people with diabetes mellitus type-2: A quasi-experimental study (Persian)]. Journal of Rafsanjan University of Medical Sciences. 2023; 22(4):367-84. [DOI:10.61186/jrums.22.4.367]
5. Lotfalinezhad E, Abolfathi Momtaz Y, Nazaripanah NS, Honarvar MR, Arab Ameri F, Azimi MS. [Effectiveness of integrated and comprehensive geriatric care program of Ministry of Health on physical and mental health of older adults in Golestan province (Persian)]. Iranian Journal of Ageing. 2021; 16(3):438-51. [DOI:10.32598/sija.2020.16.3.2190.2]
6. Ogura S, Jakovljevic MM. Global population aging-health care, social and economic consequences. Frontiers in public health. 2018; 6:335. [DOI:10.3389/fpubh.2018.00335] [PMID] [PMCID]
7. UN. Population Division. World population ageing, 2013. New York: United Nations; 2013. [Link]
8. Segalin B, Kumar P, Micadei K, Fornaro A, Gonçalves FLT. Size-segregated particulate matter inside residences of elderly in the Metropolitan Area of São Paulo, Brazil. Atmospheric environment. 2017; 148:139-51. [DOI:10.1016/j.atmosenv.2016.10.004]
9. Taraghi Z, Ilali ES. [A comparison of older adults’ and managers’ attitudes towards age-Friendly City indexes (Persian)]. Iranian Journal of Ageing. 2018; 13(2):236-49. [DOI:10.32598/sija.13.2.236]
10. WHO, NIA, NIH. Global health and aging. Geneva: World Health Organization; 2011. [Link]
11. Yavari K, Basakha M, Sadeghi H, Naseri A. [Economic aspects of ageing (Persian)]. Iranian Journal of Ageing. 2015; 10(1):92-105. [Link]
12. Kinsella KG, Phillips DR. Global aging: The challenge of success. Washington, DC: Population Reference Bureau; 2005. [Link]
13. National Bureau of Statistics of China. New statistical yearbooks. Changsha: China Statistics Press; 2020. [Link]
14. Karar ME, Shehata HI, Reyad O. A survey of IoT-based fall detection for aiding elderly care: Sensors, methods, challenges and future trends. Applied Sciences. 2022; 12(7):3276. [DOI:10.3390/app12073276]
15. De Carvalho IA, Epping-Jordan J, Pot AM, Kelley E, Toro N, Thiyagarajan JA, et al. Organizing integrated health-care services to meet older people’s needs. Bulletin of the World Health Organization. 2017; 95(11):756-63. [DOI:10.2471/BLT.16.187617] [PMID] [PMCID]
16. Noroozian M. The elderly population in iran: an ever growing concern in the health system. Iranian journal of psychiatry and behavioral sciences. 2012; 6(2):1-6. [PMID]
17. Beard JR, Officer A, De Carvalho IA, Sadana R, Pot AM, Michel JP, et al. The World report on ageing and health: A policy framework for healthy ageing. The lancet. 2016; 387(10033):2145-54. [DOI:10.1016/S0140-6736(15)00516-4] [PMID] [PMCID]
18. Bloom DE, Chatterji S, Kowal P, Lloyd-Sherlock P, McKee M, Rechel B, et al. Macroeconomic implications of population ageing and selected policy responses. The Lancet. 2015; 385(9968):649-57. [DOI:10.1016/S0140-6736(14)61464-1] [PMID] [PMCID]
19. Tajvar M, Yaseri M, Karami B, Mohammadi M. [Pattern of outpatient health service utilization by older people in Iran (Persian)]. Iranian Journal of Ageing. 2021; 15(4):410-27. [DOI:10.32598/sija.15.4.2921.1]
20. De Biasi A, Wolfe M, Carmody J, Fulmer T, Auerbach J. Creating an age-friendly public health system. Innovation in Aging. 2020; 4(1):igz044. [DOI:10.1093/geroni/igz044] [PMID] [PMCID]
21. Vecchio N, Davies D, Rohde N. The effect of inadequate access to healthcare services on emergency room visits. A comparison between physical and mental health conditions. PloS one. 2018; 13(8):e0202559. [DOI:10.1371/journal.pone.0202559] [PMID] [PMCID]
22. Sukkird V, Shirahada K. Technology challenges to healthcare service innovation in aging Asia: Case of value co-creation in emergency medical support system. Technology in Society. 2015; 43:122-8. [DOI:10.1016/j.techsoc.2015.08.002]
23. Goharinezhad S, Maleki M, Baradaran HR, Ravaghi H. A qualitative study of the current situation of elderly care in Iran: what can we do for the future? Global Health Action. 2016; 9(1):32156. [DOI:10.3402/gha.v9.32156] [PMID] [PMCID]
24. Mostafavi Darani F, Abedi HA, Haliza Mohd. Riji HMR. Conditions affecting the elderly primary health care in urban health care centers of Iran. Research Journal of Medical Sciences. 200; 3(6):202-13. [Link]
25. Safdari R, Sadeghi F, Mohammadiazar M. [Aged care and services programs in Iran: Looking at the performance of relevant organizations (Persian)]. Payavard Salamat. 2016; 10(2):155-66. [Link]
26. Shaarbafchi Zadeh N, Akbari F, Khalili Khouzani P, Niaraees Zavare AS. [Comparative study of elderly care services among Iran, United States of America, and Sweden (Persian)]. Scientific Journal of Kurdistan University of Medical Sciences. 2020; 25(5):123-40. [DOI:10.52547/sjku.25.5.123]
27. Shoaei F, Nejati V. [Elderly-caring service pattern in USA comparing with Iran (Persian)]. Iranian Journal of Ageing. 2008; 3(1):68-77. [Link]
28. Young HM. Challenges and solutions for care of frail older adults. Online Journal of Issues in Nursing. 2003; 8(2):5. [DOI:10.3912/OJIN.Vol8No02Man04] [PMID]
29. Hsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qualitative Health Research. 2005; 15(9):1277-88. [DOI:10.1177/1049732305276687] [PMID]
30. Lincoln YS, Guba EG. Criteria for assessing naturalistic inquiries as reports. Paper presented: Annual Meeting of the American Educational Research Association. 5-9 April 1988; New Orleans, LA. [Link]
31. Bidarpoor F, Rahmani K, Akhavan B, Rahimzadeh A, Pourmoradi A. [Identifying reasons of non-attendance of urban households in the comprehensive centers of health services in Sanandaj: A combination of two quantitative and qualitative approaches (Persian)]. Iranian Journal of Epidemiology. 2019; 14(4):302-11. [Link]
32. Piroozi B, Abdullah FZ, Mohamadi-Bolbanabad A, Safari H, Amerzadeh M, Rezaei S, et al. Assessing unmet health-care needs of the elderly in west of Iran: A case study. International Journal of Human Rights in Healthcare. 2021; 14(5):452-64. [DOI:10.1108/IJHRH-09-2020-0083]
33. Goharinezhad S, Maleki M, Baradaran HR, Ravaghi H. Futures of elderly care in Iran: A protocol with scenario approach. Medical journal of the Islamic Republic of Iran. 2016; 30:416. [PMID]
34. Yahyavi Dizaj J, Emamgholipour S, Pourreza A, Nommani F, Molemi S. [Effect of aging on catastrophic health expenditure in Iran during the period 2007-2016 (Persian)]. Journal of School of Public Health and Institute of Public Health Research. 2018; 16(3):216-27. [Link]
35. Khodabandeh shahraki S, Dehghan Nayeri N, Abazari F,  Pouraboli B. Challenges in caring for the elderly in Iran: A systematic review. Ethiopian Medical Journal. 2018; 56(2):189-96. [Link]
36. Tkatch R, Musich S, MacLeod S, Alsgaard K, Hawkins K, Yeh CS. Population health management for older adults: Review of interventions for promoting successful aging across the health continuum. Gerontology and Geriatric Medicine. 2016; 2:2333721416667877. [DOI:10.1177/2333721416667877] [PMID] [PMCID]
37. Shati M, Mohamadi Bolbanabad A, Zokaei M, Mohamadi Bolbanabad S, Ghaderi E, Moradi G, et al. [Challenges in the elderly care system in Iran: A qualitative study (Persian)]. Scientific Journal of Kurdistan University of Medical Sciences. 2023; 28(3):101-14. [DOI:10.61186/sjku.28.3.101]
38. Adeyemo DO. Local government and health care delivery in Nigeria: A case study. Journal of Human Ecology. 2005; 18(2):149-60. [DOI:10.1080/09709274.2005.11905822]
39. Sule S, Ijadunola K, Onayade A, Fatusi A, Soetan R, Connell F. Utilization of primary health care facilities: lessons from a rural community in southwest Nigeria. Nigerian Journal of Medicine. 2008; 17(1):98-106. [DOI:10.4314/njm.v17i1.37366] [PMID]
40. Afilalo J, Marinovich A, Afilalo M, Colacone A, Leger R, Unger B, et al. Nonurgent emergency department patient characteristics and barriers to primary care. Academic Emergency Medicine. 2004; 11(12):1302-10. [DOI:10.1197/j.aem.2004.08.032] [PMID]
41. Rust G, Ye J, Baltrus P, Daniels E, Adesunloye B, Fryer GE. Practical barriers to timely primary care access: impact on adult use of emergency department services. Archives of Internal Medicine. 2008; 168(15):1705-10. [DOI:10.1001/archinte.168.15.1705] [PMID]
42. Feikin DR, Nguyen LM, Adazu K, Ombok M, Audi A, Slutsker L, et al. The impact of distance of residence from a peripheral health facility on pediatric health utilisation in rural western Kenya. Tropical Medicine & International Health. 2009; 14(1):54-61. [DOI:10.1111/j.1365-3156.2008.02193.x] [PMID]
43. Noor A, Zurovac D, Hay S, Ochola S, Snow R. Defining equity in physical access to clinical services using geographical information systems as part of malaria planning and monitoring in Kenya. Tropical Medicine & International Health. 2003; 8(10):917-26. [DOI:10.1046/j.1365-3156.2003.01112.x] [PMID] [PMCID]
44. Douthit N, Kiv S, Dwolatzky T, Biswas S. Exposing some important barriers to health care access in the rural USA. Public health. 2015; 129(6):611-20. [DOI:10.1016/j.puhe.2015.04.001] [PMID]
45. Amiri Delui M, Abedi H, Tahmasebi S, Ebrahimi N, Sadeghmoghadam L. [Improving the quality of services for the elderly referred to 22-Bahman hospital: An action research (Persian)]. Journal of Gerontology. 2018; 3(1):55-63. [DOI:10.29252/joge.2.4.55]
46. Ndikom CM, Ofi BA. Awareness, perception and factors affecting utilization of cervical cancer screening services among women in Ibadan, Nigeria: A qualitative study. Reproductive Health. 2012; 9:11. [DOI:10.1186/1742-4755-9-11] [PMID] [PMCID]
47. Yaya S, Bishwajit G, Ekholuenetale M, Shah V. Awareness and utilization of community clinic services among women in rural areas in Bangladesh: A cross-sectional study. PloS one. 2017; 12(10):e0187303. [DOI:10.1371/journal.pone.0187303] [PMID] [PMCID]