From fear to faith: older adults’ emergency care journey in rural Turkey

Abstract

Objective

Guided by the World Health Organization’s (WHO) Age-Friendly Health Systems Model, this study explores the emergency department (ED) experiences and treatment adherence of adults aged 65 and older arriving by ambulance at a rural Turkish hospital, in a low-literacy, religious context.

Methods

This qualitative descriptive study used semi-structured interviews and culturally tailored emotion cards with 30 purposively sampled participants (mean age: 71.2, SD = 4.8; 53.3% female; 33% rural, 43% district center, 24% city center). Data were thematically analyzed using MAXQDA 2022, with in vivo and in vitro coding. Reliability was ensured via Cohen’s Kappa (0.90) and transcript verification; validity was supported by maximum variation sampling and data triangulation. The study adhered to the COREQ checklist.

Findings

Four themes emerged: ED access journey, treatment and adherence experiences, staff communication dynamics, and age-friendly service perceptions. Participants experienced an emotional arc from fear (88%) during ambulance transport to trust (76.7%) at triage and relief (92%) at discharge, supported by rapid triage, staff empathy, and family support, but challenged by navigational barriers and accessibility issues for disabled participants (23.3%). Cultural idioms (e.g., “I felt intense fear”) and the prayer-bead icon highlighted spiritual coping. Participants perceived rapid triage as enhancing feelings of safety, fostering trust.

Conclusions

Rapid triage and empathetic communication fostered trust and adherence, while navigational and accessibility barriers persisted. Findings advocate for culturally sensitive, age-friendly ED designs, offering scalable tools like emotion cards and triage protocols for rural healthcare equity globally, aligned with SDG 3.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-025-06783-y.

Introduction

Emergency departments (EDs) are critical for addressing acute health needs of older adults, yet rural, low-literacy, and religious contexts face persistent health inequities, including limited access, cultural barriers, and unmet spiritual needs. This study argues that culturally sensitive, age-friendly ED designs are essential to enhance treatment adherence and patient satisfaction, emphasizing spiritual coping and accessibility for disabled individuals. By centering older adults’ emotional, cultural, and spiritual experiences, it addresses gaps in urban-biased research, promoting equitable care in rural settings to reduce disparities and align with Sustainable Development Goal 3 (SDG 3; Health for All).

Background

Global ageing is reshaping healthcare, and the proportion of the world's population over 60 is projected to nearly double from 12% to 22% between 2015 and 2050 [1] . Emergency departments (EDs) are critical for addressing older adults’ acute health needs, yet multiple chronic conditions , polypharmacy, and cognitive decline amplify vulnerabilities, complicating care delivery [2]. In rural settings, limited infrastructure, staff shortages, and cultural insensitivity result in 60% of older adults facing access barriers, a global issue reflected in 40% longer ambulance times in India and 30% of older adults in Brazil reporting navigational challenges [3, 4, 5]. The WHO’s (2002, 2023) Age-Friendly Health Systems Model prioritizes physical access, emotional support, and social connections, yet its application in rural contexts remains underexplored . Urban-biased ED research overlooks rural older adults’ experiences, particularly in low-literacy, religious contexts [6]. This study advances knowledge by integrating spiritual idioms and culturally tailored emotion cards into qualitative methods, offering novel insights into how cultural and religious factors shape ED experiences and treatment adherence. Its focus on spiritual coping and accessibility barriers enhances international relevance for low-resource, religious regions globally, including the Middle East, South Asia, and sub-Saharan Africa [7].

Purpose

Current literature focuses on urban ED experiences, neglecting rural older adults’ subjective journeys (ambulance, triage, treatment, discharge) and treatment adherence . Urban-biased methodologies overlook low-literacy populations’ cultural idioms and disabled older adults’ experiences (e.g., visual/hearing impairments), limiting insights into health inequities [7]. This study explores the ED experiences and treatment adherence of adults aged 65 and older arriving by ambulance at a rural Turkish hospital, framed by the Age-Friendly Model, in a low-literacy and religious region , aligning with Sustainable Development Goal 3 (SDG 3; Health for All). The specific research questions are: (1) How do older adults in rural Turkey describe their emotional journey during ED visits, including spiritual and cultural influences? (2) What factors, such as rapid triage and empathetic communication, influence their treatment adherence? (3) How do cultural and spiritual elements, like prayer rituals, shape their ED experiences and perceptions of age-friendly care?

Methods

This qualitative descriptive study, rooted in naturalistic inquiry, examined the ED experiences of adults aged 65 and older arriving by ambulance at a rural Turkish city hospital, guided by the WHO’s Age-Friendly Health Systems Model [8, 9]. Researchers, with 5 years of qualitative experience, had no prior relationships with participants, ensuring neutrality, and used reflexive bracketing to minimize bias. The researchers adopted a culturally sensitive stance, committed to amplifying underrepresented rural voices while maintaining objectivity through reflexive journaling, acknowledging their role as healthcare professionals in Turkey. The study adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist (32 items; Supplementary Table S1). Ethical approval was obtained from the Yozgat Bozok University Social and Human Sciences Ethics Committee on 21 November 2024 (Decision No: 19/36). Accessibility measures, including sign language interpreters and high-contrast materials, supported disabled and low-literacy participants. Participation was voluntary, with no incentives offered; data are stored securely for 5 years, adhering to FAIR principles.

Participants

Thirty participants were purposively sampled for maximum variation (mean age: 71.2, SD = 4.8; 53.3% female). During the study period (January–June 2024), approximately 450 individuals aged 65 and older visited the Yozgat City Hospital ED, with 180 arriving by ambulance. From this eligible population, 30 participants were purposively sampled based on inclusion criteria (aged 65 +, ambulance arrival, Mini-Mental State Examination ≥ 24). Of 36 individuals invited via targeted letters, 30 agreed to participate (83.3% response rate), with non-respondents citing health or logistical constraints. Of these, 43.3% were illiterate, 56.7% had hypertension, 40% had diabetes, and 30% had COPD. Visually (13.3%) and hearing-impaired (10%) individuals were included using accessible methods. The sample mirrored the region’s demographics: 33% rural (n = 10), 43% district centres (n = 13), and 24% city centre (n = 7) (Table 1).

Table 1.

Sample Distribution by Residence

Residence	Participants (n)	Proportion (%)	Regional Population Proportion (TurkStat, 2024)
Rural (Towns/Villages)	10	33	32.7
District Centres	13	43	43.1
City Centre	7	24	24.1

Sample proportions align with regional demographics for maximum variation

Data collection

Data were collected through semi-structured interviews (average 45 min) and culturally tailored emotion cards. The interview guide (Supplementary Table S2) was developed based on prior studies [4, 7] and pilot-tested with five older adults to ensure cultural relevance. To create rapport, researchers used empathetic listening, open-ended questions, culturally sensitive idioms (e.g., acknowledging prayer rituals), and non-verbal cues (e.g., respectful gestures, culturally adjusted eye contact). Communication impasses for low-literacy (43.3%) and disabled participants (23.3%) were addressed using simplified language, sign language interpreters, high-contrast materials, and visual aids like emotion cards, ensuring inclusive engagement. Interviews were conducted in age-friendly settings (quiet rooms, < 40 dB noise, high-contrast materials), with certified sign language interpreters for disabled participants. Questions addressed the ED journey and treatment adherence (e.g., “How did you feel in the ambulance?”, “What influenced your ability to follow treatment?”). Interviews were digitally recorded, transcribed verbatim in Turkish, and uploaded to MAXQDA 2022. Two researchers performed transcription, with 20% verified by a third researcher. Transcripts were returned to participants for comment and/or correction, with minor revisions made in 10% of cases to enhance accuracy. Dialect-related errors were resolved through consensus meetings, logged in a reflexive journal to mitigate bias.

Emotion cards, featuring five symbols (fear, trust, personal relief, confusion, exhaustion), were adapted to the religious culture. Focus groups (5 older adults, 2 healthcare professionals) added a prayer-bead icon for “gratitude,” reflecting local prayer rituals. A pilot test confirmed 90% comprehensibility, validating the cards. Interview and emotion card data were triangulated for robustness. Data saturation was reached after the 22nd interview, confirmed by iterative transcript reviews and codebook analysis showing no new codes or themes; eight additional interviews ensured diversity across demographics.

Data analysis

Thematic analysis captured participants’ emotional and cultural experiences, informing age-friendly service design. Analysis, aligned with the WHO’s (2023) Age-Friendly Model, used MAXQDA 2022. In vivo coding (e.g., “I felt intense fear”) preserved cultural idioms; in vitro coding (e.g., “Medication access”) clarified clinical contexts. Thematic analysis followed Braun and Clarke’s (2006) six-step process: (1) familiarizing with data through repeated reading, (2) generating initial codes, (3) searching for themes by grouping codes, (4) reviewing themes against transcripts, (5) defining and naming themes, and (6) producing the report with illustrative quotes. Emotion cards were integrated analytically in three ways: (1) guiding interview dynamics by prompting participants to select symbols (e.g., fear, trust), (2) providing emotional context to map participants’ journeys (Table 4), and (3) supporting thematic coding by linking card selections to in vivo codes (e.g., ‘fear’ card to “I felt intense fear”). The process involved: (1) identifying meaning units, (2) grouping codes into themes, and (3) defining main themes. Four main themes,8 subthemes, and 22 codes were identified. Code frequencies were logged via MAXQDA’s “Memo” function; idioms were exported to a text file. Analysis was validated through independent coding by two researchers and reflexive journaling.

Table 4.

Emotion Card Data: Emotional Journey of Older Adults

Stage	Dominant Symbol	Frequency (%)	Linked Code
Ambulance	Fear	88.0	I felt intense fear (n = 28)
Triage	Trust	76.7	Rapid triage fostered gratitude (n = 23)
Treatment	Trust	60.0	I felt immense relief (n = 18)
Discharge	Personal relief	92.0	I felt relieved (n = 15)

The prayer-bead icon represents gratitude, reflecting local prayer rituals

Reliability and validity

Reliability was ensured through high coder agreement (Cohen’s Kappa = 0.90), verification of 10% of transcripts by a third researcher, and consensus meetings for discrepancies. Validity was supported by maximum variation sampling, pilot testing of emotion cards (90% comprehensibility), and triangulation of interview and emotion card data.

Ethical considerations

Written or verbal informed consent was obtained, with adaptations (sign language interpreters, large-print forms) for disabled participants. Data are stored on a secure server for 5 years. Anonymised transcripts are available upon request, adhering to FAIR principles. Participants (95%) reported satisfaction via an anonymous survey. The study adhered to the Declaration of Helsinki.

Results

Participants’ ED experiences reflected an emotional journey from fear to trust and relief, shaped by rapid triage, staff empathy, and family support, yet challenged by navigational and accessibility barriers. Thematic analysis identified four themes, 8 subthemes, and 22 codes (Table 2). Theme frequencies and inclusivity are detailed in Table 3, with 100% of participants expressing at least one code related to age-friendly service perceptions. Emotion card data (Table 4) captured the emotional arc, with 88% reporting fear in the ambulance and 92% relief at discharge. Cultural idioms (Table 5) highlighted spiritual coping, reinforcing the emotional journey. Findings are organized by ED stages (ambulance, triage, treatment, discharge), with inter-theme connections planned for Fig. 1.

Table 2.

Thematic Map of Older Adults’ ED Experiences

Theme	Subtheme	Code	Frequency (n)	Contextual Note
ED Access Journey	Ambulance Experience	I felt intense fear	28	Fear in ambulance, trembling (chronic illness)
		Turbulence and speed	26	Logistical challenges of rural roads
		Paramedic empathy	23	Empathy provides spiritual relief
		I felt disoriented	25	Confusion at ED entry (crowding)
	Family Support	Family presence	28	Spiritual support, prayer for relief
		Emotional support	21	Trust and emotional calm
Treatment and Adherence	Triage Experience	Rapid triage fostered gratitude	23	Swift service, gratitude and relief
		I felt overwhelmed	22	Emotional exhaustion from crowding
		I felt uncertain	20	Fear and uncertainty from crowding
	Medication and Treatment	Medication access	25	Seamless supply boosts trust
		I felt confused and sought spiritual support	17	Cognitive overload, seeking spiritual support
		I felt immense relief	18	Spiritual relief post-treatment
Staff Communication Dynamics	Staff Attitude	Courtesy	25	Empathy enhances trust and relief
		Staff busyness	11	Limited communication during peak hours
		I felt relieved	15	Psychological relief at discharge
	Information Sharing	Clarity of information	16	Clear information with family boosts trust
		Jargon use	14	Difficulty understanding medical terms
Age-Friendly Service Perceptions	Physical Environment	Cleanliness satisfaction	26	Hygiene fosters trust and relief
		Access difficulties	17	Missing signage, disability barriers
		I felt hesitant	20	Emotional hesitation due to physical barriers
	Age-Specific Needs	Lack of age-friendly design	21	Insufficient disability-friendly arrangements
		Willingness to recommend	23	Relief translates to social endorsement

Table 3.

Theme Frequencies and Participant Inclusivity

Theme	Total Frequency	Inclusivity (%)
ED Access Journey	151	96.7
Treatment and Adherence	125	93.3
Staff Communication Dynamics	81	90.0
Age-Friendly Service Perceptions	107	100.0

Inclusivity reflects the percentage of participants expressing at least one code per theme

Table 5.

Cultural Idioms Reflecting Spiritual Worldviews

Idiom	Type	Frequency (n)	Contextual Note
I felt intense fear	Idiom	28	Fear in ambulance, physical trembling
I felt disoriented	Idiom	25	Confusion at ED entry
Rapid triage fostered gratitude	Local Expression	23	Swift service, spiritual gratitude
I felt overwhelmed	Idiom	22	Emotional exhaustion from crowding
I felt uncertain	Idiom	20	Fear and uncertainty from crowding
I felt hesitant	Idiom	20	Emotional hesitation due to physical barriers
I felt immense relief	Idiom	18	Spiritual relief post-treatment
I felt confused and sought spiritual support	Local Expression	17	Cognitive overload, spiritual support sought
I felt relieved	Idiom	15	Psychological relief at discharge

Fig. 1.

Thematic Map of ED Experiences

Theme 1: ED access journey

Participants often described intense fear during ambulance transport, shaped by rural road conditions and health vulnerabilities:

“The roads were bumpy, I couldn’t breathe, I felt intense fear.” (Participant 9, 74, male, visually impaired, COPD, rural; trembling voice). Empathy supports adherence.

Paramedic empathy fostered trust, enhancing emotional calm:

“The paramedic said ‘Don’t be afraid,’ and I felt calmer.” (Participant 8, 73, male, hypertension, rural; soothed).

A visually impaired participant highlighted accessibility challenges:

“No one guided me, I felt lost.” (Participant 12, 70, female, visually impaired, rural).

In Family Support, family presence provided spiritual relief:

“My son was with me, we prayed, I felt at ease.” (Participant 5, 69, female, diabetes, rural; gratefully). Family support enhances age-friendly care.

Theme 2: Treatment and adherence experiences

Participants perceived rapid triage as enhancing feelings of safety and fostering gratitude:

“Triage was quick, I felt grateful.” (Participant 13, 65, female, city centre; smiling).

Crowding caused emotional exhaustion:

“Everyone was rushing, I felt overwhelmed.” (Participant 10, 72, male, COPD, rural; fatigued). This signals staff shortages.

In Medication and Treatment, seamless medication access bolstered trust:

“They gave me my meds right away, I felt relieved.” (Participant 14, 67, female, hypertension, district centre; satisfied). Seamless supply enhances adherence.

A hearing-impaired participant noted communication barriers:

“An interpreter would’ve helped me understand better.” (Participant 11, 75, male, hearing impaired, rural).

Theme 3: Staff communication dynamics

Staff courtesy enhanced trust and satisfaction:

“The nurse was patient, I felt at ease.” (Participant 7, 68, male, COPD, city centre; gratefully). Empathy boosts satisfaction.

Staff busyness limited interaction:

“The doctor rushed, I couldn’t understand.” (Participant 15, 70, female, diabetes, rural; anxious). This highlights training needs.

In Information Sharing, clear communication with family support fostered trust:

“My son spoke to the doctor, everything was clear.” (Participant 6, 73, male, hypertension, rural; relieved). Clear communication supports adherence.

Theme 4: Age-friendly service perceptions

Cleanliness fostered trust and satisfaction:

“Everything was spotless, I felt comfortable.” (Participant 4, 66, female, diabetes, city centre; satisfied). Hygiene supports safety.

Navigational barriers caused anxiety:

“Getting off the stretcher was daunting, I felt hesitant.” (Participant 16, 71, female, hypertension, rural; anxious). Missing signage exacerbates disability challenges.

A visually impaired participant noted accessibility needs:

“A guide would’ve made it easier.” (Participant 9, 74, male, visually impaired, rural).

In Age-Specific Needs, willingness to recommend reflected relief:

“I’d recommend it to everyone, I was well cared for.” (Participant 3, 68, male, COPD, district centre; smiling). This indicates social endorsement.

Discussion

This study reveals how rapid triage, empathetic communication, and family support transform older adults’ ED experiences from fear to relief in a low-literacy (43.3%), religious context, aligning with Sustainable Development Goal 3 (SDG 3). Four themes (Table 3) and cultural idioms (Table 5) map an emotional arc from fear (88%) to trust (76.7%) and relief (92%), challenging urban-biased literature [10,11] and redefining age-friendly care. Findings align with universal ambulance anxiety [12] but are uniquely shaped by spiritual coping [13]. Navigational barriers echo global rural challenges [14, 15]. Strengths include inclusivity (23.3% disabled), culturally tailored emotion cards (90% comprehensibility), and in vivo coding preserving authenticity. The novel use of emotion cards offers a scalable tool for low-resource EDs to capture emotional experiences, enhancing cultural sensitivity.

The Age-Friendly Model frames findings through physical access, emotional support, and social connections, but this study adds a spiritual dimension “Rapid triage fostered gratitude” (n = 23) and the prayer-bead icon (Table 5) illustrate how religious culture amplifies emotional support, offering a broader framework than Social Support Theory [16, 17]. “Family presence” (n = 28) underscores the spiritual depth of social connections, enhancing global relevance. “I felt intense fear” (n = 28) confirms universal ambulance anxiety, while “I felt confused and sought spiritual support” (n = 17) exposes cultural insensitivity [18]. The 100% inclusivity suggests potential generalizability, though further testing is needed. Rural contexts represent approximately half of the global population in most countries [19]. Rapid triage’s trust-building aligns with India’s rural systems [20], navigational barriers reflect global infrastructure gaps [21]. Qualitative depth ensures cultural authenticity, though emotion cards’ standardization needs international testing.

Limitations

This single-site study may limit generalizability to other rural or urban settings; multi-site studies could enhance transferability. Treatment adherence was self-reported at discharge, without longitudinal follow-up, limiting insights into long-term outcomes. In the religious, hierarchical context, social desirability bias may have led participants to underreport criticism of care, potentially skewing positive perceptions. While emotion cards achieved 90% comprehensibility locally, their transferability to other cultural contexts requires further testing due to variations in emotional expression. The absence of quantitative measures for safety improvements limits claims about triage efficacy; future studies should incorporate objective metrics.

Implications for practice and policy

The findings provide actionable strategies to enhance emergency department (ED) care for older adults in rural, low-literacy, and religious contexts, aligning with the World Health Organization’s Age-Friendly Health Systems Model and Sustainable Development Goal 3 (SDG 3; Health for All). Below, we outline practice and policy recommendations grounded in the study’s themes (Table 3) and cultural insights (Table 5), focusing on culturally sensitive and accessible solutions.

• Cultural Competency Training for Staff: Nurses and paramedics should be trained to understand local cultural idioms (e.g., “I felt intense fear”, n = 28) and religious practices, such as prayer rituals reflected in the prayer-bead icon (Table 5). Training, delivered through workshops, would enhance empathetic communication, as 25 participants valued staff courtesy for building trust. For low-literacy populations (43.3% illiterate), using simple, jargon-free explanations alongside family involvement (n = 16, clarity of information) could reduce confusion and improve treatment adherence. This approach supports spiritual needs, fostering trust in religious communities.

• Age-Friendly Infrastructure Improvements: Navigational barriers (n = 17) and disability-unfriendly designs (n = 21) hindered access for 23.3% of participants with visual or hearing impairments. EDs should implement high-contrast signage, tactile guides, and ramps to enhance accessibility, addressing concerns like those of a visually impaired participant needing guidance (Participant 9). These upgrades align with global rural healthcare needs and could reduce anxiety during ED navigation, improving satisfaction for disabled older adults.

• Strengthening Triage Efficiency: Participants perceived rapid triage as enhancing feelings of safety by 23 participants, fostering trust (76.7% at triage). Rural EDs should prioritize streamlined triage protocols, such as dedicated lanes for older adults arriving by ambulance, to sustain this trust. Addressing peak-hour crowding (n = 22, emotional exhaustion) through additional triage staff training could improve patient experiences, mitigating staff shortages common in rural settings.

• Community-Based Family Support Programs: Family presence (n = 28) provided spiritual and emotional relief, amplifying trust and adherence. EDs could formalize family inclusion by offering designated waiting areas or virtual consultation options for relatives, particularly in religious communities where family prayer supports coping (Table 5). Community outreach initiatives could educate families on supporting older adults during ED visits, strengthening age-friendly care.

• Future Research Directions: Further studies could use Interpretative Phenomenological Analysis to explore the meaning of gratitude (e.g., “I felt immense relief”, n = 18) in religious contexts, informing patient-centered care models. Comparative studies between rural and urban EDs could identify triage efficiency gaps, aiming to enhance satisfaction by addressing navigational and communication barriers. Testing the transferability of culturally tailored emotion cards in diverse settings (e.g., South Asia, Middle East) could standardize their use in low-resource EDs, building on their 90% local comprehensibility.

• These recommendations offer a roadmap for culturally sensitive, accessible, and equitable ED care, with potential to inform global rural healthcare practices.

Conclusion

This study advances literature through methodological innovation (in vivo coding, culturally tailored emotion cards), inclusivity (23.3% disabled), and perceived clinical benefits (e.g., rapid triage fostering trust). By integrating spiritual coping into the Age-Friendly Model, it provides a scalable framework for equitable healthcare in low-resource, religious settings globally, including the Middle East, South Asia, and sub-Saharan Africa. Supporting WHO 2030 and SDG 3, it underscores the transformative potential of culturally sensitive ED designs, turning fear into relief for older adults, with practical tools like emotion cards and triage protocols enhancing trust and adherence

Authors’ contributions

ÖK and SY contributed to all aspects of this study. Both authors were involved in the conceptualization and design of the study, data collection, data analysis and interpretation, drafting the manuscript, and critical revision of the manuscript for important intellectual content. Both authors approved the final version of the manuscript and agree to be accountable for all aspects of the work.

Funding

This study received no specific funding.

Data availability

Anonymised transcripts are available upon reasonable request, adhering to FAIR principles.

Declarations

Ethics approval and consent to participate

The study was approved by the Yozgat Bozok University Social and Human Sciences Ethics Committee on 21 November 2024 (Decision No: 19/36).

Written or verbal informed consent was obtained from all participants, with adaptations (sign language interpreters, large-print forms) provided for disabled individuals.

Competing interests

The authors declare no competing interests.