Introduction
The ageing of the world’s populations is a global concern [1, 2]. The problems of the elderly population have direct effect on the socio-economic structure of countries, such as disruption of financial balance, lack of labor force, and possible reduction of productivity and economic growth [3, 4]. Therefore, important issues related to the promotion of the health of the elderly are preventive care and its management, as well as a detailed examination of the phenomenon of population aging to pay more attention to the process and its positive and negative consequences [5]. Since no comprehensive research has been done in the field of identifying the factors affecting the management of elderly health services, the present study aims to identify the most important factors of providing primary preventive care services to the elderly in Iran.
Methods
This is a descriptive-survey study that was conducted in four stages in 2020. First, with a systematic review, factors affecting the provision of primary preventive care for the elderly in 14 countries (Iran, Germany, England, the United States of America, Italy, Turkey, Sweden, Norway, Canada, South Korea, Japan, Singapore, Australia and Cuba) were identified. The reason for choosing each of the mentioned countries was the difference in their health system and their location in the continent. The countries were compared in terms of planning, organization, supply of resources, and monitoring of service provision, and the main factors affecting the provision of primary preventive care were extracted. Then, using the experiences of a panel of experts (n=12) selected using a non-probability sampling method, an initial questionnaire with 19 closed questions and 4 open questions was designed. To obtain consensus from the panel of experts, a Delphi process was carried out in 3 rounds. All the experts reached an agreement with a questionnaire with 6 subscales and 63 items (mean difference < 0.2) and no changes were suggested in the questionnaire in the third round. To determine the face and content validity of the questionnaire, the opinions of 12 faculty staff who were expert in health care management were used to calculate the content validity ratio and the content validity index. Next, the reliability of the questionnaire was measured by calculating Cronbach’s alpha coefficient. In the fourth step, structural equation modeling (SEM) was used to design the model. To determine the construct validity, exploratory and confirmatory factor analyses were performed. A valid and reliable questionnaire was distributed among the participants who were 176 experts in health care management, economics and health policy from selected medical universities with first, second and third rankings in Iran. the collected data was then analyzed in LISREL software.
Results
Among the reviewed countries, the provision of primary preventive care services to the elderly had received more attention in Singapore. Management and organization at the national level and monitoring were mostly done by the Ministry of Health. After collecting the data, the Kolmogorov-Smirnov test was used to test the normality of the data. The test statistic for the variable of planning was 0.847 (P=0.183); for organization, 0.968 (P=0.345); for resource supply, 0.857 (P=0.245); for monitoring, 0.91 (P=0.117); for leadership, 1.108 (P=0.098); and for preventive care, 1.91 (P=0.068). The observed factor load of each of the variables was greater than 0.3, indicating that the correlation between the latent and observed variables was acceptable. Normalized fit index, relative fit index, incremental fit index, comparative fit index, and chi-squared were used to examine the model’s goodness of fit, whose results showed that the model had good fit to the data. After confirming the factorial structure of the model, SEM was used to examine the relationships between variables and to test hypotheses. Five indicators were removed from the planning dimension, five indicators from the organization dimension, seven indicators from the resource supply dimension, four indicators from the monitoring dimension, one indicator from the leadership dimension, and five indicators from the preventive care dimension. Finally, by using the remaining items for each dimension, the model was designed using SEM. The factor load for the variable of planning was 0.680 (t=5.22); for organization, 0.560 (t=4.54); for resource supply, 0.470 (t=3.65); for monitoring, 0.590 (t=2.67); for leadership, 0440 (t=3.05); and for preventive care, 0.650 (t= 3.85). Since all the obtained coefficients were greater than 0.3 and the t values were greater than 1.96, it can be concluded that the identified factors of the model affect each other.
Discussion
The most important factors affecting the provision of primary preventive care services to the elderly are planning, organization, resource supply, monitoring, leadership, and preventive care. In planning for providing primary preventive care, the greatest effects were related to the process improvement, needs assessment, participation of senior managers, policy making, setting goals, long-term planning, and centralized planning. In organizing services, the greatest effects were related to authority limits, responsibility limits, delegation of authority, intra-organizational relations, being a formal organization, and allocation of organizational positions for elderly care. In supplying resources, the highest effects were related to the Ministry of Health, social security organization, insurance and pension organizations, welfare organization, national tax admission organization, private sector, and charity organizations. In monitoring the provision of services, the greatest effects were related to continuous monitoring, periodic evaluation, comprehensive monitoring, monitoring by non-governmental organizations, monitoring by the Ministry of Health, and final evaluation. In the leadership dimension, the greatest effects were related to human resource management (organizational behavior), employee motivation, and communication (facilitating group relations). Finally, in the dimension of preventive care, the highest effects were related to nutritional interventions, referral system, screening, immunization, pharmacological prophylaxis, and health assessment.

Ethical Considerations
Compliance with ethical guidelines
All ethical principles were considered in this study. The study was approved by the ethics committee of Islamic Azad University, South Tehran Branch (Code: 164100).

Funding
This study was extracted from a PhD thesis in health care management approved by Islamic Azad University, South Tehran Branch.

Authors' contributions
The authors had equal contribution to the preparation of this article.

Conflicts of interest
The authors declare no conflict of interest.

Acknowledgements
The authors would like to thank all experts for their opinions in improving the study model.


References

1. Asadzadeh M, Maher A, Jafari M, Alimohammadzadeh K, Hosseini S. [Review health care service patterns for older adults-a narrative review (2015 to 2020) (Persian)]. Journal of Gerontology (JOGE). 2020; 5(2):1-13. [Link]
2. Farhadi A, Foroughan M, Mohammadi F, Rassouli M, Sadegh Moghadam L, Nazari S, et al. [Caregiving appraisal in family caregivers of older adults (Persian)]. Iranian Journal of Ageing. 2016; 11(1):8-19. [DOI:10.21859/sija-110108]
3. Darabi S, Torabi F. [Analysis and comparison of aging population in Europe and Asia during 1950 to 2015 (Persian)]. Iranian Journal of Ageing. 2017; 12(1):30-43. [DOI:10.21859/sija-120128]
4. Noroozian M. The elderly population in iran: An ever growing concern in the health system. Iranian Journal of Psychiatry and Behavioral Sciences. 2012; 6(2):1-6. [Link]
5. Ghasemi S, Keshavarz Mohammadi N, Mohammadi Shahboulaghi F, Ramezankhani A, Mehrabi Y. [Physical health status and frailty index in community dwelling older adults in Tehran (Persian)]. Iranian Journal of Ageing. 2019; 13(5):652-65. [DOI:10.32598/SIJA.13.Special-Issue.652]
6. Walston J, Hadley EC, Ferrucci L, Guralnik JM, Newman AB, Studenski SA, et al. Research agenda for frailty in older adults: toward a better understanding of physiology and etiology: Summary from the American Geriatrics Society/National Institute on Aging Research Conference on Frailty in Older Adults. Journal of the American Geriatrics Society. 2006; 54(6):991-1001.[DOI:10.1111/j.1532-5415.2006.00745.x] [PMID]
7. Crimmins EM. Trends in the health of the elderly. Annual Review of Public Health. 2004; 25:79-98. [DOI:10.1146/annurev.publhealth.25.102802.124401] [PMID]
8. Caffrey C, Harris-Kojetin LD, Moss AJ, Sengupta M, Valverde R. Home health care and discharged hospice care patients; United States, 2000 and 2007. National Health Statistics Reports. 2011; (38):1-27. [PMID]
9. Safdari R, Shams Abadi AR, Pahlevany Nejad S. [Improve health of the elderly people with M-health and technology (Persian)]. Iranian Journal of Ageing. 2018; 13(3):288-99. [DOI:10.32598/sija.13.3.288]
10. Iqbal N, Ahmad S, Kim DH. Health monitoring system for elderly patients using intelligent task mapping mechanism in closed loop healthcare environment. Symmetry. 2021; 13(2):357. [DOI:10.3390/sym13020357]
11. Rahimi A, Anosheh M, Ahmadi F, Foroughan M. [Exploring the nature of the elderly people life style: A grounded theory (Persian)]. Iranian Journal of Ageing. 2016; 10(4):112-31. [Link]
12. Tayeri S, Jafari M, Alimohammadzadeh K, Hosseini SM, Shahanaghi K. [A conceptual model for Iranian older women’s health: A review study (Persian)]. Iranian Journal of Ageing. 2021; 16(3):304-29. [DOI:10.32598/sija.2021.16.3.3090.1]
13. Cristea M, Noja GG, Stefea P, Sala AL. The impact of population aging and public health support on EU labor markets. International Journal of Environmental Research and Public Health. 2020; 17(4):1439.[DOI:10.3390/ijerph17041439] [PMID] [PMCID]
14. Khayat P. [The study of elderly health care services in the world (Persian)]. Social Security Journal. 2008; 9(4):99-144. [Link]
15. Tomita N, Yoshimura K, Ikegami N. Impact of home and community-based services on hospitalisation and institutionalisation among individuals eligible for long-term care insurance in Japan. BMC Health Services Research. 2010; 10:345. [DOI:10.1186/1472-6963-10-345] [PMID] [PMCID]
16. Imani A, Dastgiri S, Zeinalhajlu AA. [Population aging and burden of diseases (a review) (Persian)]. Depiction of Health. 2015; 6(2):54-61. https://doh.tbzmed.ac.ir/Article/doh-125
17. Mahfoozpour S, Iranfar M, Ainy E. Determinant factors and elderly perspectives of user friendly transportation. Safety Promotion and Injury Prevention (Tehran). 2017; 5(1):9-14. [Link]
18. rafiefar S. [From health education to health (Persian)]. Tehran: Tandis; 2004. [Link]
19. Aseyedali M, Sadeghi Mahalli N, Norouzi Tabrizi K. [A review on adult daycare centers in the world (Persian)]. Salmand: Iranian Journal of Ageing. 2019; 13(4):518-29 [DOI:10.32598/SIJA.13.4.518]
20. Bahador F, Mahfoozpour S, Masoudiasl I, Vahdat S. [A systematic review of management of preventive healthcare for the elderly in the world (Persian)]. Salmand: Iranian Journal of Ageing. 2022; 16(4):592-607. [DOI:10.32598/sija.2021.3180.2]
21. Safdari R, Sadeghi F, Mohammadiazar M. [Aged care and services programs in Iran: Looking at the performance of relevant organizations (Persian)]. Payavard Salamat. 2016; 10(2):155-66. [Link]
22. Jiang M, Hughes DR, Wang W. [The effect of Medicare's Annual Wellness Visit on preventive care for the elderly (Persian)]. Preventive Medicine. 2018; 116:126-33. [DOI:10.1016/j.ypmed.2018.08.035] [PMID]
23. Sudo K, Kobayashi J, Noda S, Fukuda Y, Takahashi K. Japan's healthcare policy for the elderly through the concepts of self-help (Ji-jo), mutual aid (Go-jo), social solidarity care (Kyo-jo), and governmental care (Ko-jo). Bioscience Trends. 2018; 12(1):7-11. [DOI:10.5582/bst.2017.01271] [PMID]
24. Majumder S, Aghayi E, Noferesti M, Memarzadeh-Tehran H, Mondal T, Pang Z, et al. Smart homes for elderly healthcare—Recent advances and research challenges. Sensors. 2017; 17(11):2496. [DOI:10.3390/s17112496] [PMID] [PMCID]
25. Faqih A, Afsharnejad A. [Performance management model in the oil industry; Research in the National Iranian Petroleum Products Distribution Company (Persian)]. Journal of Industrial Strategic Management. 2012; 9:47-64. https://www.sid.ir/paper/151388/en
26. Babaee Zakliki MA, Hasanzadeh HR, Alvani SM, Zaraei Matin H, Rastegar A. [Designing an efficient implementation model of performance management system in service organizations (Persian)]. Public Management Researches. 2015; 8(28):5-31. [Link]
27. Rafizadeh A, Mirsepasi N, Azar A. [Design model of performance management at the state level (Persian)]. Quarterly Journal of Public Organizations Management. 2016; 4(4):81-100. [Link]
28. Yavari V, Zahedi SS. [Designing a conceptual model of organizational performance management for governmental and non-profit organizations (Persian)]. Strategic Management Thought. 2013. 7(1):79-122. [Link]

29. Vahedi h, Hajalyan F, Jahangirfard M, Mojibi T. [Designing a health system performance management model for Iran (Persian)]. Quarterly Journal of Nersing Management, 2020. 9(3):87-100. [Link]
30. Mukherjee SB. Elderly health care: Diverse cultural implication. Asian Ethnicity. 2019; 20(4):555-70. [DOI:10.1080/14631369.2019.1622406]
31. Sheikhzadeh R. [Designing a model for evaluating and managing the performance of the country's health system (Persian)]. Management Research. 2010; 10(3):83-108. http://ensani.ir/fa/article/301140/
32. Sundel S, Sundel D. Chronic care management. In: Chun A, editor. geriatric practice. New York: Springer; 2020. [DOI:10.1007/978-3-030-19625-7_40]
33. Mohammadi M, Zadeh FS, Hoseinpour D, Manesh BR. [Designing a government performance model based on the roles of each of the effective actors (Persian)]. Quarterly Journal of Public Organzations Management. 2018; 6(1):83-100. [Link]
34. Dadkhah A. [Special aging services system in the US and Japan and indicators for developing an aging services strategic plan in Iran (Persian)]. Salmand: Iranian Journal of Ageing. 2007; 2(1):166-76. [Link]
35. Khodamoradi A, Hassanipour S, Daryabeigi Khotbesara R, Ahmadi B. [The trend of population aging and planning of health services for the elderly: A review study (Persian)]. Journal of Torbat Heydariyeh University of Medical Sciences. 2018; 6(3):81-95. [Link]
36. Rasel M, Ardalan A. [The future of ageing and its health care costs: A warning for health system (Persian)]. Salmand: Iranian Journal of Ageing, 2007. 2(2):300-5. [Link]
37. Morowatisharifabad MA, Pakdaman M, Emadi P. [The utilization of outpatient health services among the elderlies in yazd in 2018 (Persian)]. Management Strategies in Health System. 2019; 3(4):276-89. [DOI:10.18502/mshsj.v3i4.511]
38. Ajami S, Chavongar K. [Information and communication technology in home care services for the elderly (Persian)]. Journal of Health Administration. 2019; 22(4):9-11. [Link]