Introduction
The increasing phenomenon of population aging and the problems of old age such as physical and mental disabilities and socio-economic issues [3, 4] have led to the emergence of the concept of age-friendly city [5]. It indicates the optimization of public services according to the needs and limitations of older adults [6]. Places providing healthcare services, including hospitals, should be created or improved to properly respond to the needs and expectations of the elderly that receive healthcare services [7]. Considering that the average age of people in Isfahan province is higher than the national average and Isfahan was selected as an age-friendly pilot city in Iran by the United Nations Population Fund (UNFPA) [20], this study aims to evaluate the hospitals of Isfahan city based on the criteria of age-friendly health systems and identify challenges and solutions in this field.

Methods
This cross-sequential study was conducted in 2020-2021 on 13 teaching hospitals of Isfahan city, 38% of which were single-specialty. First, by the checklist used in Ahmadi et al.’s study [16], the condition of the hospitals was evaluated based on the criteria of age-friendly health systems. This checklist was designed based on the World Health Organization’s (WHO) age-friendly primary health care centers toolkit [21] and Rashmi’s checklist [22], and has acceptable content and face validity for the use in the Iranian population. It contains 50 items and 9 subscales of accessibility (3 items), appointments (4 items), health promotion and medical care (11 items), information and education (6 items), physical environment (8 items), sanitary facilities (7 items), signboards (3 items), inpatient services (4 items) and admission and payments (4 items). The range of scores for each subscale is between 0 and 2 and for the entire checklist was between 0 and 100, where a higher score indicates a better condition in terms of being age-friendly. To complete the checklist, observations and experts’ opinions were used. Data analysis was done by SPSS software, version 26 and using descriptive statistics such as Mean±SD and analytical statistics including Pearson correlation test. The next stage was carried out to find challenges and solutions to deal with the deficiencies identified in the first stage. In this regard, 16 face-to-face interviews and 12 telephone interviews were conducted with relevant experts who were selected using a purposive sampling method with maximum diversity, and data analysis was done using the conventional content analysis.

Results
As can be seen in Table 1, Most of the hospitals were in good conditions in terms of physical environment, sanitary facilities and signboards.


The lowest scores were related to admission and payment, appointment, accessibility, inpatient services, health promotion and medical care, and information and education. In total, the mean score of the hospitals was 51.7 out of 100. No significant relationship was found between hospital characteristics (type of ownership, type of activity, specialty, number of beds, bed occupancy rate, degree of accreditation, manager’s field of study) and their age-friendly score. Challenges and solutions were presented in the form of 9 themes and 27 sub-themes. These challenges were: Lack of planning based on the needs of the elderly (lack of elderly-oriented programs and not having macro-policies with emphasis on elderly-oriented processes), limitation of financial resources (lack of sufficient financial resources for making hospitals suitable for the elderly, and lack of financial resources to reduce the expenses of the elderly), lack of focus on prevention and treatment policies (lack of written programs for consultation, examination, treatment and annual follow-up of the elderly, no screening of the elderly in the hospital, not providing health services for the elderly at home, and lack of dedicated inpatient services), weak inter-sectoral coordination and interactions (lack of cooperation between organizations in creating an age-friendly hospital), lack of specialized human resources (lack of geriatricians in the hospital, and lack of scholarships for geriatricians), poor management of the admission process (absence of a system for making and reminding of appointments for the elderly, absence of a special system for setting appointments for the elderly, absence of a system for prioritizing the elderly, and absence of recreational facilities), lack of staff empowerment (lack of teaching the basics of geriatric medicine and how to interact with the elderly to employees), poor facilities and infrastructures (lack of a separate entrance door for the elderly, lack of special facilities to guide the elderly in different departments, lack of necessary facilities in hospital clinics for the elderly, lack of communication facilities in all spaces, complexity of the indoor environment for the elderly, slippery floors, and no double-sided doors in toilets), challenges related to job position (lack of organizational chart for providing services to the elderly, lack of people coordinating health care services for the elderly, lack of caregivers for the elderly in inpatient departments, and appointing managers with unrelated education).

Conclusion
Experience of care in a hospital is one of the important factors that determine the health and well-being of the elderly. Older adults often have complex health and social needs due to multiple chronic conditions. In addition, due to biological, social and emotional factors and the burden on caregivers, it is necessary to optimize health services for the elderly. The studied hospitals in Isfahan have shortcomings in this field. Promoting the expertise of geriatric medicine and geriatric nursing, designing a special queuing system for the elderly, considering a special administrator for the elderly in different departments, reducing the costs of treatment for the elderly, promoting consultation/examination/treatment/follow-up programs for the elderly with an emphasis on upstream documents and cooperation between different departments, empowering employees, upgrading physical infrastructure can help solve existing challenges.

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Ethics Committee of Tehran University of Medical Sciences (Code: R.TUMS.SPH.REC.1399.062).

Funding
This study was extracted from a MSc thesis of Maryam Torabi in Health Care Service Management approved by Tehran University of Medical Sciences.

Authors' contributions
The authors contributed equally to preparing this article.

Conflicts of interest
The authors declared no conflict of interest.

Acknowledgements
The authors appreciate the participation of Isfahan University of Medical Sciences hospital officials in this study.

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