Priorities and challenges in social and healthcare policies for older people living in the Mediterranean basin: A Delphi panel study | BMC Geriatrics

Current health systems are facing the challenge of longevity and an inverted demographic pyramid, due to an increase in the global population aged 60 and older. In fact, by 2050, the proportion of this demographic is estimated to reach 22% of the worldwide population, almost a twofold increase from 2015, when the share was 12%. In this regard, many countries are facing significant challenges in preparing their respective social and healthcare systems for this shift [1].

This study is focused on five European and non-European countries that settle in the Mediterranean basin, the starting point of which is shown in Table 1. While Europe includes some of the oldest populations in the world with a range of 16.9–19.4.8% of the total population aged 65 and older, this proportion is quite lower in non-European countries, with a range of 4.63–9.1% [2] also lowering the life expectancy those countries [3]. In (Table 1). As for the average annual growth rate of the 70 + age group, it is currently 3.4% per year [4, 5]. Although all of the included countries have an old age pension system, those at non-European are quite recent and may not cover all the population (for instance, undeclared work) [6]. Differences in social protection systems can also affect health insurance schemes. In summary, this diversity among older people in these countries is not an accident, mainly due to the physical and social environments of people and the impact of these environments on their health opportunities and behaviors.

The relationship with these environments is significantly influenced by personal characteristics such as family history, gender social status, and ethnicity, resulting in health inequalities [1]. This is in line with the theoretical framework of Lalonde’s model of health determinants (later refined by Glouberman and Millar [7]) and the Whitehead and Dahlgren framework based on factors such as age, gender, and culture [8].

Interestingly, although longer life expectancy is an achievement of public health policies around the world, it has also generated a larger older population that is unevenly distributed among countries. However, it has not brought about a consistent quality of life, with high rates of frailty and dependency [9]. For example, care for dependent older people is either provided by formal caregivers, who receive specific training in social and healthcare services (and are paid for it), or by informal caregivers, i.e., untrained family members. In this regard, previous research has shown that formal care can improve the autonomy of beneficiaries and reduce the burden on the family and the need for hospital admissions [10, 11].

Conversely, there is a notable prevalence of older people at risk of social exclusion. This complex issue, which is related to poverty, lack of capabilities, or quality of life, is defined as a state of vulnerability linked to political, economic, and social dimensions [12]. Furthermore, people with social care needs have a higher risk of deteriorating physical and mental health, as seen during the COVID-19 pandemic [13].

This extraordinary social care challenge requires immediate and well-coordinated responses between different levels of government, non-governmental sectors, and the general public [14]. In this regard, the World Health Organization (WHO) defined integrated care as “services that are managed and delivered so that people receive a continuum of health promotion, disease prevention, rehabilitation, and palliative care services, coordinated between different levels and care sites within and beyond the health sector.” The integration of social and healthcare services can also be an effective way to improve person- and system-centered outcomes for the increasing number of older people with diverse (and sometimes complex) health needs or those at risk of social exclusion [15]. However, the strategies for achieving such integration in different European countries remain limited [16, 17].

Although Mediterranean basin countries share border proximity and cultural ties, they have been showing a common trend of declining social support for the older, especially regarding prevention strategies, innovative technologies, social services, and social health and ethical models of care [18]. Therefore, the Cross-Border Cooperation initiative, implemented under the European Neighbourhood Instrument (ENI CBC 2014–2020), included 14 countries in the Mediterranean basin (Algeria, Cyprus, Egypt, France, Greece, Italy, Israel, Jordan, Lebanon, Malta, Palestine, Portugal, Spain, and Tunisia) to promote the fair, equitable, and sustainable development of their respective populations [19].

One of the purposes of the ENI CBC 2014–2020 was social inclusion and poverty reduction. Within the framework of the Mediterranean basin, the project aimed to develop a person-centered model of transcultural and ethical social care for older people who are dependent or at risk of social exclusion ([20]. Among the 14 countries, the project eventually involved the European countries of Greece, Italy, and Spain (the Coordinating Team) and the non-European countries of Egypt, Lebanon, and Tunisia, all of whom agreed to participate in the project. As a prerequisite, several activities were planned, implemented, and evaluated through different work packages [21].

It is important to note that developing a social care model must include a review of the existing gaps between the current social and healthcare conditions and the desired situations [22, 23]. For example, previous research has analyzed such gaps when designing integrated approaches to support people with multimorbidity [24]. As a starting point for interventions, a gap analysis allows experts and stakeholders to identify and agree on key issues. It can also be used as a tool to support the production, analysis, and utilization of evidence for decision-making [25] by comparing actual performance with potential performance. In other words, it is a process that answers three main questions: (1) Where are we now?; (2) Where would we like to be?; and (3) How are we going to close the gaps [26]? . In order to answer these questions, this Delphi panel study analyzed the gaps in social and integrated care among the participating countries in this project.

Methods

Design

This three-round Delphi panel study focused on the European countries of Greece and Spain and the non-European countries of Egypt, Lebanon, and Tunisia. Since Italy joined the project in 2021, its participation in this initial activity was not possible. The Delphi method is a structured process that uses an iterative series (or rounds) of questionnaires to gather information until a consensus is reached. This widely used method allows the inclusion of many individuals (experts) in various geographic locations, but unlike face-to-face meetings, it prevents a specific expert from dominating the process [27]. In this project, the degree of consensus among the experts was measured by calculating the interquartile range (IQR) for each factor. Specifically, the IQR is a measurement of the variability of the median and consists of the middle 50% of the observations. In this sense, an IQR of < 1 indicates that more than 50% of all opinions fall within 1 point on the scale and serves as a method of determining consensus [28]. An IQR of 2 or less on a 10-unit scale and an IQR of 1 or less on a 4- or 5-unit scale can be considered a consensus but considering that the determination of an acceptable IQR may also depend on the aspiration level of the research object and the unit scale used in this study [29], an IQR < 2 was agreed as the cutoff point for consensus.

We also designed a graphical abstract based on the gap analysis and the Delphi consensus of what experts and stakeholders aimed to achieve in the future [30].

Delphi phases and panel selection

From May to July 2020, the Delphi technique was implemented through an online modality, due to the COVID-19 pandemic [31], while the design and consensus of the final graphical abstract were performed during the latter half of July 2020.

Each participating country implemented the Delphi phases internally and reported their final results to the project Coordinating Team in a new online meeting in June 2020.

The experts were selected from one of four groups (i.e., community and civil society; public administration, the business sector; and research and education), forming a quadruple helix model [32] (see Fig. 1). Meanwhile, each participating country conducted snowball sampling through key informants from universities, government agencies, and community associations.

Quadruple helix model (The number in each square is the absolute frequency and percentage of experts invited)

As for the panel selection, a total of 223 potential international experts received an email (with a link to the online questionnaire; see Supplementary Material 1) inviting them to participate in this Delphi study, after which 122 experts agreed to participate (response rate 55%). The official language of the three Delphi rounds was the language of each country, to use a common language and to minimize errors in linguistic comprehension. In addition, the coordinator of the project in each participating country was fully proficient in English to translate and provide the final results report to the Coordinating Team (See Fig 2).

Flow chart of the Delphi process

Instrument design and data collection

In this study, a four-item questionnaire was designed for data collection, based on the gap analysis method [26]. A gap analysis involves identifying the discrepancies between the desired and current states, determining the underlying causes, and devising strategies to bridge the gap [33]. Thus, based on the results obtained by the research team in a previous integrative review on current socio-healthcare for older people in the Mediterranean Basin [34] and the base protocol of the research project [21], the Coordinating Team and the participating countries designed by consensus via one online meeting in April 2020 the questionnaire. Specifically, there were three questions about social and healthcare models for older people in the countries of the Mediterranean basin. As a starting point for developing a new social healthcare model in this project, a fourth question was added about initiatives to bridge the identified gaps. In addition, an online tool for data collection was designed by using the Microsoft Forms© application, which consisted of five sections (see Supplementary Material 1). Section 1 asked for personal data (sex, social group, and relationship with care for dependent older people), while Sects. 2–5 asked the following questions: (a) Define the current situation by answering the question, Where are we? (Current state); (b) Set future goals, by answering the question, Where do we wish to go? (Desired state); (c) Locate the gaps between the current state and the final desired state by answering the question, How far are we from our goal?; and (d) Determine the action plans/initiatives required to achieve the final objective by answering the question, How do we reach the stated objective? (Initiatives).

Moreover, Table 2 presents the panel of experts participating in each of the three rounds. A qualitative analysis of the data obtained in the first round led to the configuration and prioritization of the items in the second round. Similarly, the third round proceeded until a consensus was reached.

Project vision: a graphical abstract

A graphical abstract of the main results, presented in Table 3, was designed to guide the identification of the project’s vision. In this regard, the Spanish team (as the project leader) designed the graphical abstract, which was shared with the rest of the countries by email in July 2020 in order for each expert to make any necessary improvements. Again, the Spanish team reviewed the final design and initiated a new round of emails requesting each country’s approval.

Ethical considerations

This study received ethical approval from the Research Ethics Committee of the Junta de Andalucía in Spain, given that the coordinating organization of the consortium was the University of Seville in Spain (Reference No.: 2412-N-19). Ethical approval was also obtained from the Ethics Committees in Greece (Reference No. 40640/30-5-22), Egypt (Reference No. HU.REC.H.6–22), Lebanon (Reference No. IRB-REC/Ol5l-2112321), and Tunisia (Reference No. 01/2022). The invited experts received an email containing the presentation of the study, the request to participate, and a link to the online questionnaire. They were also informed that their participation was voluntary and anonymous. All of the data in this study was treated confidentially and not shared with third parties (under any circumstances) until the conclusion of the project.