Research Synopsis for Ph.

D in Hospital Administration

Topic The Role of Primary Health Care Centers in Providing Comprehensive Care for the Elderly in Kingdom of Saudi Arabia

by Mohammed Saeed Aowda

Under the supervision of Dr. Varanasi Madhusudan Prasad

Synopsis Checklist Introduction 1.0 2.0 3.0 4.0 5.0 6.0 7.0 8.0 The Backdrop Review of Literature Gaps in the existing literature Research questions The Problem Objectives Hypotheses Research Methodology 8.1 8.2 8.3 8.4 8.4.2 8.5 9.0 Scope of The Study Sample The Period of the Study Collection of Data 8.4.1 Primary Data Secondary Data

Limitations of the Study Chapter I : Introduction Chapter II: Literature Survey Chapter III: Research Methodology Chapter IV: Statistical Analysis Chapter V: Discussion of Results Chapter VI: Conclusion and Recommendations

Chapterization

Appendix I: Questionnaire or Research Instrument Appendix II: Theoretical Nuances, Models, Formulas etc. Appendix III: Business Environment - Industry Forces, Laws, Rules, Procedures... References (Author, Title, Publisher, Edition, Year)

Introduction It is a well known fact that the structure of the population in the world has changed very drastically during this century. Perhaps the most important change has occurred in mortality rate, particularly among the elderly population. It is estimated that, currently, people live about 20 years longer-on average- than they did at the beginning of this century. This is due to the fact that advances in the field of medicine have achieved great improvements to the treatment of many diseases associated with old age. For this reason, a great deal of attention has been given to health care for the elderly in health care planning and delivery all over the world. For instance, elderly persons receive a large share of health services expenditures that do younger individuals in the USA. The health care system should respond to social change in order to meet people's expectations as well as to set and implement efficient health care plans, both in terms of the types of services needed, their mode of delivery, and the staff required to deliver them. Aging is a natural process that leads to a gradual deterioration of body functions. The elderly person is more susceptible to diseases such as bronchitis, heart disease, diabetes, tumors etc. In addition to that, the senses and mental abilities get weaker, and a drastic change in personality takes place. The elderly person grows more suspicious, introverted, and more concerned about his health. Also, the elderly are more likely to experience episodes of depression and melancholy. Elderly persons usually fear the loss of the ability to walk, dress, bathe or perform any of the other activities essential for independent living declining physical and mental capacities signal marked deterioration in the quality of life. The elderly are not a homogeneous group, but represent a spectrum of individuals ranging from those who are fit and able to lead an independent life to those with multiple medical, functional and social problems. The needs of the elderly who become unwell and require hospital admission, therefore, will vary greatly and depend both on the nature of their illness and on their previous state of health. This fact has very important implications for the type of services needed by the elderly and the appropriate means of delivering such services. 1.0 The Backdrop:

The proportion of older persons in the world is increasing and the Kingdom of Saudi Arabia is not exception from this scenario. In 1982 the proportion of older persons was 2,7% of the total population while it rose in 1990 to become a 4% (World Bank report in 1993, p. 201). This increase in this age group which is established by some experts as "Risk Group" need special attention in the quality and dispensing method of health services provided to them. It is remarkable that this age group (the elderly) and other groups tend to receive health services to the advanced health facilities (specialized hospitals) or the second row of health services (public hospitals). They rarely go to the services of the first row (primary health care centers), although in practice they do not need more than services of primary health care centers, which causes wasting of more health resources at the time the countries are suffering from high cost of health services. As far as the religious and social aspect is concerned, our religion urged the need to care for the elderly whether from the Muslim family or non- Muslims. This is commensurate

with the social aspects. The majority in the Islamic and Arab societies prefer this group leave with them at home or in vicinity so they look after them almost every day. Therefore, to preserve the optimal use of resources, the establishment of primary health care centers in all villages and towns can play this role. Although many facts about the elderly are more or less universal, countries differ in varying degrees regarding their health policies towards the elderly. These differences could be attributed to economic, social or cultured factors. In the Kingdom of Saudi Arabia, which is the focus of the present research, the type of cultural setting and the type of family relations, as well as the economic stability make the Saudi society rather unique, particularly regarding the issue of care for the elderly. None of the models or policies adopted abroad can be applied completely in the Saudi setting. The socio-cultural factors unique to the Saudi society have to be taken into consideration. The field of health services in the Kingdome of Saudi Arabia has witnessed a tremendous development both in terms of quality and quantity. Health care for the elderly has been part and parcel of the health care plans in the Kingdom, but in practical terms, this category of the population does not receive any special attention in the sense that there are no special programs for the care of the elderly. Even in the census and other population statistics, the elderly are often placed under the age group '45 or more'. Thus, despite the great deal of attention that has been given to health care in the Kingdom of Saudi Arabia. There is much left to be done regarding the channeling of such services and the coordination of efforts among the various sectors and levels of health care within the health care system. The present study is concerned with the role that is being played and that can be played by Primary Health Care centers (PHCCs) in the delivery of comprehensive care for the elderly in the Kingdom of Saudi Arabia. 2.0 Review of Literature

This literature review falls into two major parts. The first part addresses some issues of the elderly, their needs and the types of health care that can be given to them, in the light of the current trends in the care for the elderly in various parts of the world. The second part addresses the topic of primary health care centers, the regulations that govern their performance, and the role they play in the care for the elderly. There isn't a consensus of opinion regarding the definition of the aged person, and the time at which old age begins. Many studies indicate that the symptoms of old age, whether physical, mental or psychological can appear in any stage of life. For instance, mental capacities begin to change at the age of twenty. It is also known that the age of a person not necessarily coincide with his physical functions. On this basis, many researchers agree that old age is the stage of life at which physical and mental functions begin to deteriorate more clearly than in any other previous stage. (Abdel Mohsen, 1992, p. 15). The elderly population lacks homogeneity. While it is clear that the 88-year-old person, the ways in which they differ cause much confusion. Are the two differentiated only by chronological age, or do more specific differences exist by which they might be categorized? One of thought (Klinman et al. `1992, p. 206) divides the elderly into groups solely by age. There is difficulty in determining where to draw the line, however, some authors describe the 'young old' as those younger than 75 years of age and the 'old old' as those 75 years of age or elder, while others draw the line at 80 or 85 years of age.

It should be noted that no line of division could be generalized across cultures. This categorization is study different from the categorization in Saudi Arabia for instance. There are various factors that should be considered in this regard such as life expectancy and general patterns of health conditions in the whole population, in addition to other cultural and religious factors. In this research, the elderly group is taken to refer to male and female individuals beyond 60 years of age. Because of the lack of agreement about the categorization of the elderly persons, the medical community has not yet agreed on the appropriate definition of health in the elderly. The definition chosen is very important, because it establishes the boundaries for the discussion of appropriate health outcomes by which we can measure the value of health services. If we look at health as the presence or absence of disease, our analysis of the benefits of preventive services will be limited to measuring differences in diseaserelated morbidity or mortality, and the potential benefits from preventive services for the elderly would be inherently be much smaller in magnitude than the potential benefits for younger persons. It should be noted here that the World Health Organization (WHO) defines health as a state of complete physical, mental and social well being and not merely the absence of disease of infirmity. Some experts (Klinkman et al. 1992, p. 207) describe health in old age as consisting of three related factors: 1 The absence of disease. 2 The maintenance of optimal function. 3 The presence of an adequate support system. The second and third factors allow the inclusion of quality of life, satisfaction with life, and productivity. This expanded definition of health may indicate that the major goal of preventive care in the elderly is compression of morbidity rather than prevention of disease. Thus the goal of preventive health care in the elderly should be to maintain optimal function as well as to prevent biomedical diseases. Abrahams and Lamb (1988, p. 179) point out that the elderly group comprises not only high users of medical and hospital services, but also those most vulnerable to chronic disease and functional impairment and most at risk for long term care. They conclude that there will, therefore, be a growing need for programs that combine both health care and social support services designed to maintain the physical, mental and social functioning of the chronically disabled elderly in the least restrictive environment and at the best functioning level attainable by the individual. Kramer et al. (1991, pp. 53-54) report on the conclusions and recommendations of a conference on geriatric evaluation and management. They point out that the geriatric assessment includes a multidimensional interdisciplinary patient evaluation that leads to identification of patient problems and the development of a plan for resolving these problems. They also propose that patient eligibility to high cost management should be limited to those who are most likely to benefit from this comprehensive and expensive form of care. They also point out that outpatient clinics in their setting require further development and evaluation. It should be noted here that outpatient clinics are similar to primary health care centers found in Saudi Arabia.

They suggest that the most important outcomes to assess in any program for geriatric care are mortality, patient function, satisfaction, caregiver burden and costs. Other outcomes, such as numbers of diagnoses, number of medications and level of care placement may be important to assess but are process measures which presumably mediate the desired final outcomes of reduced mortality, improved function and lower costs. We shall come back to this point when we discuss the current techniques for evaluating PHC centers in the Kingdom of Saudi Arabia. Hengstler (1986, pp. 1516) believes that care of the elderly should be oriented towards early identification of high risk groups and reversal or arrest of disease and functional decline. Hedrick et al. (1991, pp. 48-52) present a working group recommendations regarding the measuring of outcomes of care in geriatric evaluation and management units. That group suggested measures for physical health included survival, restricted actively days, general health perceptions and comprehensive physical function. They also suggest measuring cognitive function, affect/life satisfaction, social function and satisfaction with care. Oktay et al. (1992, p. 291) present an evaluation of social work discharge planning services for elderly people. They discuss three aspects of social work; access, complexity and outcome. Specifically, their article examines the extent to which elderly people most in need receive social services, the extent to which the discharge planning performed is a professional task, and the effectiveness of discharge planning for those who return to their homes after hospitalization. They view planning as a complex and highly skilled task involving screening, through psychosocial assessment, provision of counseling and education, and coordination of an interdisciplinary team of providers. 3.0 Gaps in existing literature:

The present literature is merely based on experiments carried out in few countries. This study will focus on various countries of Middle East, south and east Asia, Europe, and gulf countries. The main significance of the present study lies in the fact that it tries to utilize already existing health facilities to provide better services instead of establishing new facilities. The fact that PHCCs are wide-spread and can reach and be reached easily by citizens makes them suitable locations for the provision of comprehensive care to the elderly. The direct result of this proposition would be not only the care for the elderly, but also the better management of health services in general, and the better coordination of primary, secondary and tertiary health services in the Kingdom. 4.0 Research Questions: The present research is set to answer the following questions: 1 What is the type and quality of services currently provided by the PHCCs to the elderly? 2 To what extent can PHCCs be utilized to provide comprehensive care for the elderly?. Particularly the following: Physical services.

Psychiatric services. Social services. Preventive medical services. Diagnostic services. Prognostic services.

3 What are the facilities required by PHCCs in order to provide comprehensive care to the elderly? 4 What is the staff requirement of PHCCs in order to provide comprehensive care to the elderly (physicians, psychiatrists, multidisciplinary paramedical personnel, social workers, home nurses etc.) 5 Does the opinion of the PHCCs physicians regarding care for the elderly vary according to their age, experience and position? 5.0 The Problem:

Health care service is expanding very rapidly in Saudi Arabia. One of the criteria of evaluating any health care system in making available the suitable and comprehensive health care in a convenient way on equitable basis to the various geographical locations and the various age groups. The number of the elderly in the Kingdom of Saudi Arabia, as it is generally the case all over the world, is increasing due to the development in health care. In 1982 the elderly were 2.7% of the population. In 1990 the elderly become 4% of the population (World Bank, 1993, p. 201). This expanding age group requires special attention in terms of the type of health care and their mode of delivery. One can easily notice that elderly people utilize tertiary and secondary health care services more that primary health care. The reason for this could lie in the type of health service provided by primary health care centers which may not be suitable to the needs of the elderly. It also lie in socio-cultural factors, particularly the attention given to the elderly by their family members. Every elderly person has one way or the other of utilizing tertiary health care directly even if his ailment can be handled in secondary or even primary levels. This, of course is a great waste in resources and a clear mismanagement of health care. The fact remains that primary health care can play a major role in providing health care to the elderly particularly at the preventive level. Although the PHCCs are considered convenient and readily available sources of health care, their services to the elderly population are less than satisfactory. In fact, those centers do not adopt any special policy or programs directed towards the elderly. Elderly people are not only treated like other individuals who use PHC services, but also they are viewed from a somatic aspect with their psychological, psychiatric and social problems disregarded. Thus, the problem of the present study is the inadequacy of the services provided by PHCCs to the elderly population in the Kingdom of Saudi Arabia. 6.0 The Objectives:

The goal of the study is to improve the health care services of the elderly population in Saudi Arabia. Under this broad goal, the objectives of the present research

are defining the role currently played by PHCCs in the delivery of comprehensive care to the elderly, and the ways it can be improved. 7.0 Hypotheses: This study will be carried out on the basis of few assumptions given below: 1 - The actual needs of the elderly are not fulfilled in primary health care centers 2 The primary health care centers can provide additional services apart from the materials that they have. 3 The primary health care centers can provide comprehensive services for the elderly by adding some privileges and resources 8.0 Research Methodology: This study will be conducted in the Kingdom of Saudi Arabia which lies in west Asia. It is a significant country among the gulf countries. It has a large number of primary health care centers, hospitals and specialty hospitals. Its population of Saudi Arabia as of the April 2010 Census was 18707576 Saudi nationals and 8429401 non-nationals. This country is also distinguished by its urban as well as nomadic and rural life which includes various sects of the society. Moreover it has terrain elevations, deserts and plains. The community of study includes all doctors working in primary health care centers in the Kingdom. 8.1 Scope of Study:

The study is conducted on Primary Health Care Centers in Kingdom of Saudi Arabia. It involves an opinion survey of the physicians currently working in the PHCCs, and focuses on the role PHCCs currently play in the care for the elderly, and the way they can be improved in order to provide an efficient and comprehensive care for such group. The survey covers physicians in the PHCCs in Saudi Arabia. Following are operational definitions of the key terms of the study: Primary Health Care: The type of health services provided through PHCCs as regulated and described by the Ministry of Health in the Kingdom of Saudi Arabia. Comprehensive Care: The type of care that would include not only the somatic aspect of the individual, but the psychological, mental and social aspects as well. The Elderly Group: Male and female individuals 60 years of age and above. 8.2 Sample : The study samples include all the study community i.e. the number of doctors working in primary health care centers in Kingdom of Saudi Arabia. 8.3 The Period of Study: This study will focus on health care services for elderly in Kingdom of Saudi Arabia during last two decades.

8.4

Collection of Data: 8.4.1 Primary Data: Information will be collected through the questionnaire distributed to doctors working in primary health care centers in Saudi Arabia. This will cover the following aspects:

a - Services provided to the elderly in the present time and the importance and the extent to which they are used. b - The actual services that can be provided for the elderly and the degree of its relevance. c The additional services that can be provided for the elderly by the current equipment in primary health centers. d The needs that can be provided to primary health care centers for providing quality services for older people 8.4.2 - Secondary Data: This information will be collected from books, magazines and publications of the Ministry of Health related with topic the research. 8.5 Limitations of the Study:

The community of study includes the working manpower Saudis and non-Saudis to improve the health care services of the elderly population in Saudi Arabia. The study will focus the following: 1 - Services provided to the elderly in the present time and the importance and the extent to which they are used. 2 - The actual services that can be provided for the elderly and the degree of its relevance 3 The additional services that can be provided for the elderly by the current equipment in primary health centers 4 The needs that can be provided to primary health care centers for providing quality services for older people 9.0 Chapterization

The Chapterization will be as under: Chapter I : Introduction The proportion of older persons in the world is increasing and the Kingdom of Saudi Arabia is not exception from this scenario. In 1982 the proportion of older persons was 2,7% of the total population while it rose in 1990 to become a 4% (World Bank report in 1993, p. 201). This increase in this age group which is established by some experts as "Risk Group" need special attention in the quality and dispensing method of health services provided to them. It is remarkable that this age group (the elderly) and other groups tend to receive health services to the advanced health facilities (specialized

hospitals) or the second row of health services (public hospitals). They rarely go to the services of the first row (primary health care centers), although in practice they do not need more than services of primary health care centers, which causes wasting of more health resources at the time the countries are suffering from high cost of health services. As far as the religious and social aspect is concerned, our religion urged need to care for the elderly whether from the Muslim family or non- Muslims. This is commensurate with the social aspects. The majority in the Islamic and Arab societies prefer this group leave with them at home or in vicinity so they look after them almost every day. Therefore, to preserve the optimal use of resources, the establishment of primary health care centers in all villages and towns can play this Chapter II: Literature Survey The literature available on the subject will be reviewed. It falls into two major parts. The first part addresses some issues of the elderly, their needs and the types of health care that can be given to them, in the light of the current trends in the care for the elderly in various parts of the world. The second part addresses the topic of primary health care centers, the regulations that govern their performance, and the role they play in the care for the elderly. Chapter III: Research Methodology This study will be conducted in the Kingdom of Saudi Arabia which lies in west Asia. It is a significant country among the gulf countries. Its population of Saudi Arabia as of the April 2010 Census was 27136977: 18707576 Saudi nationals and 8429401 non-nationals. It has a large number of primary health care centers, hospitals and specialty hospitals. This country is also distinguished by its urban as well as nomadic and rural life which includes various sects of the society. Moreover it has terrain elevations, deserts and plains. The study is conducted on Primary Health Care Centers in Kingdom of Saudi Arabia. It involves an opinion survey of the physicians currently working in the PHCCs, and focuses on the role PHCCs currently play in the care for the elderly, and the way they can be improved in order to provide an efficient and comprehensive care for such group. The survey covers physicians in the PHCCs in Saudi Arabia. Chapter IV: Statistical Analysis The two methods that will be used to analyze the data are as follows: A - Descriptive Statistics These descriptive statistics are used for information that is collected B - Kay Square "2" This method is used to determine the importance of the impact of some personal characteristics of the building such as age, experience and position on their replies. Chapter V: Discussion of Results The results of complete data analyzed by the descriptive and method Kay square 2 will be laid down after having discussed the pros and cons of various forms and trends of

health care for the elderly in some eastern and western societies along with the problems tackled and the services rendered to the elderly group in each of those societies such as: The Elderly in the British Society: The British society gives a great deal of attention to the elderly group. Some new trends suitable to the British society are adopted. These include the following programs: 1 The Heat Support Project: This project has been in effect for a long time. Its main aim is ensuring that the elderly receive adequate heat during the cold months of winter. The program subsidizes the heat and electric bills of the elderly. During the two years 1976 and 1977, this program served more than half a million elderly persons. 2 The Unemployment Program: This program helps the elderly people by helping them find suitable jobs to spend their time and meet the necessities of life. 3 Insurance for the Elderly: This program regularized the insurance benefits of the elderly and follows up on the paper work and other insurance procedures on behalf of the elderly. 4 Mass Media Services: This program works for the production of media materials and programs to educate the society about the need of the elderly, and instruct the elderly on how to take care of themselves. 5 The Good Neighbor Program: This program works for the establishment of active groups that disseminate information regarding the elderly and urges the society and the various organizations to extend help and support to them. 6 Neighborhood Care: This program provides financial support to families that undertake care for the elderly neighbor. Each family is given 30 pounds a week. 7 Transportation Services: This program provides free transportation to the elderly. Bus service for the elderly are usually provided by local companies and it usually employs elderly drivers. 8 Meals on Wheels: This program provides free meals for the elderly at their homes. It is usually financed by the local authorities. The Elderly in the Italian Society: The elderly in the Italian society have various needs and problems. These include housing, health care. People above 60 years of age in the Italian hospitals are 17%. Also, 50% of the inpatients are elderly persons. Some of the programs designed for the elderly include housing, comprehensive home care, financial assistance, day-care centers, and day care hospitals.

The Elderly in Denmark: The elderly in Denmark enjoy a comprehensive care program based on the application of new techniques. It includes social services, home care, financial assistance, day care in addition to other forms of care. Only those elderly persons who are not independent that is, they need the help of others around the house, are accepted in the day are centers. Other elderly persons are kept in their families as much as possible and financial as well as technical assistance are extended to them free of charge. Day care centers extend their services to those elderly who do not have someone to help them at home. They offer educational activities as well as professional and sports functions. The day care centers are financial by the local authorities in collaboration with local private establishments. The Elderly in the U.S.A: The new trends for elderly care in America reflect the nature of the American society itself. That society is characterized by economic power and advanced technology. Some of the forms of care for the elderly in the American society include the following: 1- Involving the elderly in voluntary services to spend their time and to help them feel their importance to society. 2- Employment projects : There are establishment that work towards employment of the persons above 50 years of age. 3- Medical services which include: - health care and rehabilitation. - health care through day care centers. - health care through public health centers. 4- Social programs which include: - telephone contacts with the elderly by volunteers. - social services and social welfare. - preventive care through the social services section. The Elderly in France: Care for the elderly in the French society is based on integrating the elderly with those who are younger. In order to encourage the elderly to remain in their families, some services are provided for them. These include financial assistance, home care, and medical treatment. The elderly in France are classified into healthy, semi healthy, ill and disabled. Depending on their health status they are provided discounted health completely free health care. Elderly persons who choose to stay with their families are provided with opportunities to participate in social functions. There are three types of care for the elderly according to the French plan: home care, third age clubs and restaurants, and day care centers. 270,000 elderly persons are provided with health services at home so whey don't have to go the hospital. The Elderly in Hungary:

In Hungary, the state takes full responsibility for the welfare of the elderly. The family also plays an important role in that regard. Care is extended to the elderly through a department affiliated to the Ministry of Health. Some of the forms of care for the elderly in Hungary include the following: 1 Home social care: This service is extended to the elderly who wish to stay at home. It includes visits by nurses, social workers, physicians and healthy elderly people. 2 Day care centers: This service is provided to the elderly with the aim of monitoring their health conditions, and to help them follow the mass media and practice their favorite sports. 3 Elderly homes: This service is provided to the elderly who choose to leave their families. Such persons are employed also in visiting other elderly in their homes. 4 Home-for-the old: This service is provided to elderly couples who wish to lead an independent life but cannot afford it. The Elderly in Kuwait: The Kuwaiti law provided for extending assistance to elderly citizens. They are provided with social insurance, health care, and other daily needs by the state, free of charge. Some forms of care for the elderly in Kuwait include: 1 Home care, which include the visiting social worker, and the visiting psychiatrist, the visiting physical therapist, and the visiting physician. 2 Day care, which allows the elderly to spend the day in the center where he indulges in social activities and receives recreational and therapeutic services. 3 Complete housing for disabled elderly citizens, where they receive complete care and are visited by their families and friends. The Swiss Experience: Junod and Levy (1981, pp. 438-441) report on the Geriatric Institutions of Geneva. They state that these institutions constitute a 275-bed hospital, and 80-bed extended care facility, and a large consultation service for ambulatory patients. The staff comprises over 50 physicians and psychiatrists, multidisciplinary paramedical personnel, and a large complement of social workers. These institutions have the following three goals: 1 To address the complex medical needs of the older patient. 2 To motivate the staff about the specific problems of the elderly and how to deal with them. 3 To promote awareness in the community of the complexity of problems associated with geriatric patients.

Junod and Levy describe the model of geriatric health-care delivery developed and practiced in Geneva as "Integrated Medicine". This is not simply a multidisciplinary approach to the multiple disorders of the elderly patients, but also a particular philosophy of management with objectives specifically adapted to their unique path physiologic, psychiatric and social needs. The model comprises preventive medicine, diagnosis, therapeutics, and prognosis. It constitutes a step toward developing a health-care delivery system specifically adapted to the geriatric patient. Chapter VI: Conclusion and Recommendations: As the correct results will be accumulated to analyze the study and the opinion of previous studies on the topic of this research including the opinion of the researcher, the recommendations will be presented.

Appendix I: Questionnaire or Research Instrument

A QUESTIONNAIRE TO PHCC DIRECTORS ON THE ROLE OF PRIMARY HEALTH CARE CENTERS IN COMPREHENSIVE CARE FOR THE ELDERLY IN THE KINGDOM OF SAUDI ARABIA

(A Research Project Proposal) By: MOHAMMED SAEED AOWDA Research Advisor: Dr. Varanasi Madhusudan Prasad Dear PHCC Physician, I am currently conducting a research project in partial fulfillment of the requirements of Ph. D degree in health administration. The topic of my research is "The Role of Primary Health Care Centers in Providing Comprehensive Care for the Elderly". A major aim of this research is to propose ways and means for improving the type and quality of service provided to the elderly by primary health care centers. To achieve this aim the questionnaire in your hands has been designed to obtain your opinion regarding the current practices in primary health care centers and the means to improve them. You are kindly requested to read the statements of the questionnaire very carefully and then "tick" the answers that represent your viewpoint. The information collected in this questionnaire will be used only for the research purposes and will be kept confidential. Please note that an elderly person is taken to refer to a man or woman beyond 60 years of age. Thank you for your cooperation.

1 Age: less than 30 30-39 40-50 more than 50

2 What is your position in PHCC? (check one) Physician Medical director Other (specify ----------------------3 How long have you been in this post: less than 3 years 3-5 years more than 5 years

4 Do you keep any special records for elderly citizens in your service area? Yea No

5 Approximately, what is the percentage of elderly patients to other patients that actually use the services in your center? [ % ] 6 Is there any program in your Health Center especially designed to meet the needs of the elderly? Yea No

7 In your opinion, do you think old patients reporting to your center complain about some special problems? Yea No

8 Indicate the following health problems for which elderly people may visit your center according to their level of frequency. Health problems Mental problems Physical problems Psychological problems Social problems Frequent Sometimes Rare Never

9 Indicate the following health problems for which elderly people may visit your center, according to the service provided (please check more than one service if applicable). Health problems treatment diagnosis referral Follow up no service

Mental problems Physical problems Psychological problems Social problems 10 Indicate the degree of importance of each of the following services for the elderly. Service Mental services Physical services Psychological services Social services Others (specify) very important important unimportant

11 Are all services indicated above in question 10 available at your center? All of them Some of them Non of them

12 Specify the reasons (and their degree of importance) for the unavailability of such services at your PHCC Reason lack of trained staff irrelevance of such services to the elderly lack of necessary equipment lack of building facilities lack of cooperation of the part of elderly lack of cooperation on the part of family Others (specify) very important important Unimportant

13 To what extent can your PHCC provide the following services depending on its current facilities and resources? Service 1- physical health service 2 mental health service 3 - psychological service 4 social service fully only partially not at all

14 To what extent can your PHCC incorporate the following new services with its current facilities and resources, and if provided with new facilities and resources? (Choose 1, 2 or 3) 1 fully 2 only partially 3 not at all

New Service visiting nurse doctor-on-call emergency home service routine home service on-phone prognostic service physical therapy at PHCC home physical therapy psychiatric service social gatherings spare time activities social consultation health awareness lectures public seminars family consultation

With existing facilities and resources

With new facilities and resources

15 Determine the degree of importance of each of the following items in providing comprehensive service (including new services) to the elderly at your PHCC. 1 very important 3- important to some extent 2- important 4- unimportant Degree of importance

Service 1- visiting specialists 2- additional technical staff 3- social workers 4- sports and social activities supervisor 5- additional building facilities and equipment 6- hospital-PHCC service coordinator 7- citizen-PHCC relations committee Others (specify) ********** References

Abrahams, R., and S. Lamb; Developing Reliable Assessment in Case-Managed Geriatric Long Term Care programs QRB-June 1988. Cole, M. G. (1991), Effectiveness of three types of geriatric medical services: Lessons for geriatric psychiatric services, Canadian Medical Association Journal, 144(10). Gill, W. and Patrick Vaughan, An introduction to primary health care approaches in developing countries. London: Ross Institute Publication, No 13, 1981. Graber A.; Cost-containment and Financing the Long-term Care of the Elderly, JAGSAPRIL 1988-VOL.36, No. 4

Hedrick S., Nancy Barrand, Richard Deyo, Paul Haber, Kenneth James, Jeffery Metter, Vincent Mor, William Scanlon, William Wissert, and Mark Williams. Working Group Recommendations: Measuring and Management Units, The American Geriatric Society (JAGS-Sup) 39: 48S-52S, 1991. Hengstler, L.; Medicare 1986: Can Society afford quality physician care? Part 11, Geriatrics, Vol. 41 No. 10, October 1986. Junod, J., and M. Levy; What is Geriatrics? The Swiss Experience. Journal of the American Geriatrics Society, Vol. 24, No. 10, October 1981. Klinkman P., P. Zazove, D. Mehr, and M. Ruffin, A Criterion-Based Review of Preventive Health Care in The Elderly: Part 1. Journal of Family Practice, Vol. 34, No. 2, 1992 Kramer A., R. Eeyo, W. Applegate, and S. Meehan: Research Strategies for Geriatric Evaluation and Management: Conference Summary and Recommendations. JAGS-SUP, Vol. 39, 1991 Moxley, D., L. Buzas; Perceptions of Case Management Services for Elderly People. Health and Social Work, August 1989. Oktay, J. S., D. Steinwachs, J. Mamon, L. Bone, and M. Fahey; (1992) Evaluating social work discharge planning services for elderly people: Access, complexity, and outcome, Health & Social Work, Vol.17, No.4. Rabins, P.V. ; Prevention of Mental Disorder in the Elderly: Current Perspectives and Future Prospects. JAGS, July 1992, Vol. 40, No. 7. Rubenstein L., Targeting Health Advocacy Efforts Toward the Older Population, Cancer, December 1 Supplement Vol. 68, 1991. Salloway J., M. Counte, and G. Clandon; Constructing Gerontological Curricula for Health Administration, The Journal of Administration Education 11:1, Winter 1993. Steel, K. Home Care for the Elderly: Arch Intern Med- Vol. 151, March 1991. Stewart D., J. Burns, K. Beard, J. Dall, I. Lennox, M. Roberts, and G. Macfarlane. The Roles of General and Geriatric Medicine in the Provision of Acute Medical Care for Elderly Patients. Health Bulletin, 50/3 May 1992. World Bank, World Development Report, Oxford University Press, 1993.

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