Introduction
With higher life expectancy and less death in women, Iran’s aging has become feminized, which is threatened by mismanagement of the health care system [1]. The difference in economic, social, demographic, and health indicators in elderly women shows that the health of elderly women is the result of individual biological, social, political, and cultural factors. Governmental and non-governmental policy makers and planners should use approaches such as life span, gender, age, and determinants of health and safety that should cover all periods of women’s lives [2].
The last decade of aging programs has often lacked an integrated inter-departmental strategic approach and a gender approach. The study aimed to prioritize “indicators affecting the health of aging Iranian women” [3, 4] so ​​that policymakers and planners at different levels can choose the best options for managing integrated, integrated, and continuous services and the necessary priority and appropriateness in allocating resources (financial, physical, equipment, human resources training, etc.).
Methods
This descriptive-analytical study with applied purpose was conducted in 2020. The analytical hierarchy process (AHP) ranked “indicators effective in the elderly woman’s health.” The hierarchical analysis method allows decision-makers and planners to make better choices by converting mental concepts into measurable quantities. Data collection was done in a consolidated manner (qualitative and quantitative), structured interview, targeted selection of experts, and data analysis with Excel software.
The AHP was carried out in 7 steps:
1. Hierarchical decision tree design at four levels: 1) aim (elderly women’s health), 2) effective factors (individual, family, social and religious, and spiritual factors), 3) decision factors (implementation and planning), 4) model Implementations: (case or integrated approach) - (public or private or collaborative approach) - (discrete planning or continuous planning with monitoring, continuous evaluation with feedback) (Figure 1).  2. Twenty experts completed a paired comparison matrices questionnaire of criteria and options with Likert rating, education in women’s health and geriatrics, and at least 5 years of service experience in decision-making, planning, etc. AHP method is performed with 5 to 20 experts.
3. Validity and reliability of questionnaires and answers by calculating the inconsistency rate (the inconsistency rate is less than 0.10).
4. Unweighting and normalizing:


Normalization


The relative weight of level k decision elements k=1,...,q 
5. Final weight calculation (every expert’s opinion):


6. Determining the final priority (combination of experts’ opinions): the most appropriate method is the geometric mean.


7. Determining ratios:


Results
Based on the final weight of the elements and options of the health model for elderly women, the decision priorities are as follows:
1. The level of decision factors: Among the four factors affecting the health of elderly women, individual factors include biological status, ability status, and lifestyle; it is the priority, and its ratio to other factors is 2. It means that in the requirements of planning and implementation (specialized composition of the decision-making team, allocation of financial resources, human resources, physical and programmatic infrastructure, number of programs and activities, etc.), the contribution of individual factors is twice as much as other factors.
2. The level of the decision elements: The implementation option, including preventive interventions, diagnosis and treatment, rehabilitation, and palliative medicine) is the priority and its importance ratio to research and development is 2 times. Prevention is the first priority among the implementation elements, and its ratio to other services is 3. In terms of decision-making and implementation requirements, preventive measures in life periods for individual, family, and social influencing factors, religion, and spirituality should be 3 times more than other diagnosis and treatment interventions and palliative medicine. In the component of the planning level, according to the experts, in the current situation, the government’s entry into the issue of aging has the priority, and it is necessary to take responsibility and play a role three times more than the organization (micro) and the service provider (meso, macro
3. The level of implementation models: this level of three implementation models: 1- a single-specialist approach means solving problems according to the case, as opposed to an integrated approach; 2- the state implementation method versus implementation by the private sector or as Participatory; 3- The planning method is formed in the form of n discrete steps in contrast to continuous (permanent) planning+IT along with feedback (analysis-correction).
The integrated approach is preferable to the case planning method in dealing with decision-level criteria (executive and planning interventions) and influencing factors in the health of elderly women. The joint participation of the public and private sectors in decision-making and implementation is preferred over the option of the monopoly of the public sector or complete handing over to the private sector. The method of continuous planning along with the information management system (IT), which continuously and regularly analyzes and evaluates the results, and if any errors and deviations are observed from the feedback received, the planning is corrected immediately; the first one is preferred.
Discussion
It is necessary to focus future programs on old age. Comprehensive and integrated management with a gender approach and attention to the difference in needs and effective factors in elderly women’s health is necessary. It is required for policymakers and planners at the decision-making levels (macro, meso, micro) to provide health and support services with the priority of prevention following the needs of life stages and not only in old age but in an integrated departmental and inter-departmental manner. Individual factors are the most critical factors in the health of elderly women; therefore, health interventions should focus on individual factors with a preventive approach. Active involvement of the government at all levels is necessary. It is essential to increase the participation of the private sector, the level of coverage, and the variety of old age services. The method of continuous planning, monitoring, analysis, permanent improvement, information system network, and targeted interventions, according to the weight and importance of the factors, accelerates the health goal in old age.

Ethical Considerations
Compliance with ethical guidelines
This research is a part of a doctoral dissertation with ethics code IR.IAU.TNB.REC.1398.002.

Funding
This article is taken from Soudabeh Tayiri's doctoral thesis in the Department of Healthcare Management, Faculty of Management, Islamic Azad University, North Tehran Branch.

Authors' contributions
All authors contributed equally in preparing all parts of the research.

Conflicts of interest
The authors declared no conflict of interest.

Acknowledgements
We are grateful to the respected faculty of Tehran University of Medical Sciences, Iran, Arak, West Azerbaijan, North Khorasan, Golestan and Shiraz.


References

1. Raymond SU, Greenberg HM, Leeder SR. Beyond reproduction: Women’s health in today’s developing world. International Journal of Epidemiology. 2005; 34(5):1144-8. [PMID]
2. World Health Organization. Facts on ageing. Geveva: World Health Organization; 2013. [Link]
3. Tehran Times. The National Document for the Elderly. Tehran: Tehran Times; 2020. [Link]
4. United Nation. World population prospects. New York: United Nation; 2020. [Link]
5. United Nation. World Population Prospects 2019: Highlights. New York :United Nation; 2019. [Link]
6. United Nation. World population ageing 2019. New York: United Nation; 2019. [Link]
7. Fathi E. [The Phenomenon of population aging in Iran (Persian)]. Iranian Journal of Official Statistics Studies. 2020; 30(2):387-413. [Link]
8. Statistical Centre of Iran. [Number and percentage of elderly people in each province, respectively, elderly population. Estimation of 2018 (Persian)]. Tehran: Statistical Centre of Iran; 2019. 
9. Lotfi R, Rajabi Naeeni M, Rezaei N, Farid M, Tizvir A. Desired numbers of children, fertility preferences and related factors among couples who referred to pre-marriage counseling in Alborz Province, Iran. International Journal of Fertility and Sterility. 2017; 11(3):211-9. [PMID]
10. Mmwr. Public health and aging: trends in aging. United States and worldwide. The Journal of the American Medical Association. 2003; 52(11). [DOI:10.1001/jama.289.11.1371]
11. Engel G. The need for a new medical model: A challenge for biomedicine. Science. 1977; 196(4286):129-36. [DOI:10.1126/science.847460] [PMID]
12. Eliopoulos C. Gerontological nursing. Philadelphia: Wolters Kluwer Health; 2014. [Link]
13. WHO. Global strategy and action plan on ageing and health. Geneva: WHO; 2017. [Link]
14. Grad FP. The preamble of the Constitution of the World Health Organization. Bulletin of the World Health Organization. 2002; 80(12):981-984. [PMID]
15. World Health Organization .Ottawa Charter for Health PromotionFirst International Conference on Health PromotionOttawa. Geneva: World Health Organization; 1986. [Link]
16. Golshiri P, Sadri G, Farajzadegan Z, Sahafi M, Najimi A. [Is there any association between family function self care in women? (Persian)]. Journal of Isfahan Medical School. 2012; 29(166). [Link]
17. Ahmadi B, Farzadi F, Dejman M, Vameghi M, Mohammadi F, Mohtashami B, et al. [Farmehr model: Iranian women’s health conceptual framework (Persian). Hakim Research Journal. 2014; 16(4):337-48. [Link]
18. Erfani Khanghahi M, Tayeri S. [Prioritizing factors affecting women’s health and ways to promote: Using the hierarchical analysis process (Persian)]. Journal of Hospital. 2019; 17(4):99-102. [Link]
19. World Health Organization, United Nations Population Fund. Women, ageing and health :A framework for action: Focus on gender. Geneva: World Health Organization; 2007. [Link]
20. World Health Organization. Active ageing: A policy framework. Geneva: World Health Organization; 2002. [Link]
21. Rashedi.V. [Analysis of inequality and modeling of factors affecting justice in th health of the elderly in Tehran (Persian)] [PhD dissertation]. Tehran: University of Social Welfare and Rehabilitation Science; 2017. [Link]
22. Shiri M, Rezaei Ghahroudy Z, Ali Akbari S, Safakish M, Rostami E . [The results of the study of economic, social, demographic characteristics and health of the elderly and the pattern of benefiting from elderly health service (Persian)]. Tehran: Statistics Center of Iran; 2018. [Link]
23. Mehrabi A, Gholipour H, Parisa T. [Statistical yearbook 2019 (Persian)]. Tehran: State Welfare Organization of Iran; 2020. [Link]
24. Abbasian M, Nakhodaeezah M, Namjoo S, Khalili Z, Jahangiry L, Fadayevatan R, et al. [Reasons for nursing home placement of older women in Tabriz, Iran: A content analysis (Persian)]. Salmand: Iranian Journal of Ageing. 2019; 13(4):406-17. [DOI:10.32598/SIJA.13.4.406]
25. Larijani M, Tajmazinani AA. [A study of factors influencing social exclusion of the elderly in Varamin City (Persian)]. Journal of Applied Sociology. 2015; 29(3):57-74. [Link]
26. World Health Organization. The global health obserervatory: Explore a world of health data. Geneva: World Health Organization; 2019.  [Link]
27. Zanjari N, Sadeghi R, Delbari A. [Analysis of gender differences in time use among Iranian older adults (Persian)]. Salmand: Iranian Journal of Ageing. 2019; 13(5):588-603. [DOI:10.32598/SIJA.13.Special-Issue.588]
28. Zanjari N. [Good old age; An overview of the concepts and dimensions of good agin (Persian)]. Tehran: Critique Plan; 2019. [Link].
29. Farzianpour F, Foroushani AR, Badakhshan A, Gholipour M, Hosseini M. Evaluation of quality of life and safety of seniors in Golestan Province, Iran. Gerontology and Geriatric Medicine. 2015; 1:2333721415599702. [DOI:10.1177/2333721415599702] [PMID] [PMCID]
30. Tayeri S, Jafri M, Ali Mohammadzadeh K, Hosseini SM, Shahanaghi K. [A conceptual model of Iranian older women’s health: Review paper (Persian)]. Salmand: Iranian Journal of Ageing. 2021; 16(3):304-29. [Link]
31. Akrami F. Requirement of considering the ethical issues in elderly health care policy. International Journal of Preventive Medicine. 2019; 10(2):10-25. [DOI:10.4103/ijpvm.IJPVM_149_18] [PMID] [PMCID]
32. Miri N, Maddah M, Raghfar H. [Aging and economic growth (Persian)]. Salmand: Iranian Journal of Ageing. 2019; 13(5):626-37.  [DOI:10.32598/SIJA.13.Special-Issue.626]
33. Yavari K, Basakha M, Sadeghi H, Naseri A. [Economic aspects of ageing (Persian)]. Salmand: Iranian Journal of Ageing. 2015; 10(1):92-105. [Link]
34. Kashanian Z, Raghfar H, Mousavi MH. [Simulation of macroeconomic effects of population ageing (application of general equilibrium overlapping generations model) (Persian)]. Tahghighate Eghtesadi. 2018; 53(122):93-115. [DOI:10.22059/JTE.2017.225321.1007461]
35. Shojaei A, Akbari Kamrani AA, Fadaye vatan R, Azimian M, Ghafari S, Jamali MR. [The health costs and diseases in Medical Services Insurance Organization, Tehran Province, 1386 (2008) (Persian)]. Salmand: Iranian Journal of Ageing. 2012; 6(4):65-74. [Link]
36. Yahyavi Dizaj J, Tajvar M, Mohammadzadeh Y. [The effect of the presence of an elderly member on health care costs of Iranian households (Persian)]. Salmand: Iranian Journal of Ageing. 2020; 14(4):462-77. [Link]
37. Karami Matin B, Rezaie S, Alinia S, Shaahmadi F, Kazemi A. [Ageing in Iran in 1410, a warning to health care system (Persian)]. Teb va Tazkiyeh. 2013; 22(2):9-18. [Link]
38. Soltani MH, Sahaf R, Mohammadi Shahbolaghi F, Ghaffari S, Khosravi A, Gohari MR. [Elderly, duration of hospitalization and hospital cost in milad hospital in Iran (Persian)]. Salmand: Iranian Journal of Ageing. 2012; 6 (S1):58-65. [Link]
39. Zeinalhajlu AA, Amini A, Tabrizi JS. [Consequences of population aging in Iran with emphasis on its increasing challenges on the health system (literature review) (Persian)]. Depiction of Health. 2015; 6(1):54-64. [Link]
40. Farajzadeh M, Ghanei Gheshlagh R, Sayehmiri K. Health related quality of life in Iranian elderly citizens: A systematic review and meta-analysis. International Journal of Community Based Nursing & Midwifery. 2017; 5(2):100-11. [PMID]
41. Abbasi-Ghahramanloo A, Safiri S, Torkamannezhad-Sabzevari J, Kogani M, Holakuie Naeini K, Hassanipour Azgomi S. Community assessment for identification and prioritization health problems in Navai Kola village, Babol, Iran. Journal of Research in Clinical Medicine. 2016; 4(1):47-52. [DOI:10.15171/jarcm.2016.008]
42. Asgarpor MJ. [Multiple criteria decision making (Persian)].Tehran: University of Tehran Publications; 1398. [Link]
43. Liberatore MJ, Nydick RL. The analytic hierarchy process in medical and health care decision making: A literature review. European Journal of Operational Research. 2008; 189(1):194-207.[DOI:10.1016/j.ejor.2007.05.001]
44. Melillo P, Pecchia L, editors. What is the appropriate sample size to run analytic hierarchy process in a survey-based research. Proceedings of the International Symposium of the Analytic Hierarchy Process, 4-7 August 2016, London, UK. [DOI:10.13033/isahp.y2016.130]
45. Shakeri A, Salimi F. [Effective Factors on investment absorption in Chabahar Free-zone and giving priority to them by using the mathematical technique of Ahp (Persian)]. Economic Research Review. 2006; 6(1):95-129. [Link]
46. Alsaeed D, Davies N, Gilmartin JF, Jamieson E, Kharicha K, Liljas AEM, et al. Older people’s priorities in health and social care research and practice: A public engagement workshop. Research Involvement and Engagement. 2016; 2:2. [PMID]
47. Mendis S, Puska P, Norrving B, World Health Organization, World Heart Federation. Global atlas on cardiovascular disease prevention and control. Geneva: World Health Organization; 2011. [Link]
48. 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 (London, England). 2016; 387(10033):2145-54. [DOI:10.1016/S0140-6736(15)00516-4]
49. Briggs AM, Valentijn PP, Thiyagarajan JA, Araujo de Carvalho I. Elements of integrated care approaches for older people: a review of reviews. BMJ Open. 2018; 8(4):e021194. [PMID] [PMCID]
50. Goh O. Successful ageing-A review of Singapore’s policy approaches. Ethos. 2014; 1:16-23. [LInk]
51. Sadoughi F, Shahi M, Ahmadi M, Davaridolatabadi N. Health information management system for elderly health sector: A qualitative study in Iran. Iranian Red Crescent Medical Journal. 2016; 18(2): e21520. [DOI:10.5812/ircmj.21520]
52. Boult C, Green AF, Boult LB, Pacala JT, Snyder C, Leff B. Successful models of comprehensive care for older adults with chronic conditions: evidence for the Institute of Medicine's "retooling for an aging America" report. Journal of the American Geriatrics Society. 2009; 57(12):2328-37. [ [PMID]
53. Alimohammadzadeh K, Bahadori M, Hassani F. Application of analytical hierarchy process approach for service quality evaluation in radiology departments: A cross-sectional study. Iranian Journal of Radiology. 13(1):e29424. [PMID]