Author: potanina
Company: СВИННОЕ САЛО

APPLICATION OF COMPUTER TECHNOLOGY EDIFAR FOR THE DEVELOPMENT OF LOCAL SOCIAL POLICIES FOR THE ELDERLY
Yulia Potanina,

Researcher, Moscow State Lomonosov University, Moscow, Russia

 Inessa Frolova

Policy Analyst, Public Health Institute, Moscow, Russia

Chapter 1.  Concept of Targeting Nature of Social Programs for the Elderly  
One of the problems, which is mentioned in connection with the social protection reforming for the elderly population, is concerned with targeting nature of social assistance. Assistance programs in socially oriented model of the mixed economy imply the formation of the social responsibility of the state and citizens. This is long-term process requiring the systematized measures within the framework of Russian type of socio-economic model.
The social responsibility takes place in public and private sectors of economy. Conducting economic reforms, socially oriented state pays close attention to forecast and alleviate their consequences for the citizens. As to the elderly population, it is especially vulnerable to the changes in economic life in legal, medical, and social sense. For example, under the law on private pension funds of Russian Federation, the latter have the right to purchase the real estate (practically, it is a possibility especially for lonely elderly to afford the additional pension income in exchange for an apartment in the future). The elderly people are not informed about their rights appropriately, and frequently abuses happen in this field. 

Alyoshina, Irina. Elderly People – Hostages of the Housing Problem. Psychology of Adult Ages and Aging (Summer, 1998) : 98-102

The economists usually link the necessity of targeting measures with low efficiency of budget funds use allocated for social support, and sharp growth of these expenses. In the conditions of shortage of the funds and facilities, it is appropriately to mention that the private charity could complement state social assistance. In Russia before the Bolsheviks revolution the private contributions were widely used for social purposes. For example only in Tver region about one third of all nursing homes for the elderly people were constructed on the private donations (Davidova 1998). After the revolution the system of the private investments, directed to satisfy social needs, was abolished. Only state-organized social protection was allowed, and as researchers state, the quality and ranges of services has decreased compared to the pre-revolutionary level (Davidova 1998).

Davidova V.N. " The Socio - Demographic Characteristics of the Persons of Old Age, Medical, Social and Economic Aspects of the Improvement of Organization and Activities of Nursing Homes of General Type in the Tver Area ". The printed abstract of the Candidate dissertation. ( Moscow, 1998).

See Ibidem

The state should promote such socially responsible ideas, way of thinking in the society, as many researchers state (S.Zimmermann, R.Goodin). The population surveys demonstrate the loss of stable spiritual orientation after the socialist system collapse in Russia. Spiritual and moral values promote the ideas and behavior, which can support the results of the state programs more safely, than material inducements.
Targeting nature of the programs implies the existence of the ramified system of the social policies satisfying various needs, and also dictates the necessity of the training for specialists, social workers, which could take the decision in each case, recommend and provide a kind of support. 
Some researchers point to the problem of socio-psychological competence of social workers. Social workers, which work with the elderly, have own psychological problems. They do not know how to communicate with elderly patients. It is shown that increasing service length leads to the growth of aggression and enmity. Social workers learn to manipulate, so their skill becomes “manipulative competence”. Therefore it is necessary to pay more attention to psychological training for communication with elderly and social workers have to test their professional suitability.

Krasnova O.V. “Problems of Social and Psychological Competence in the Social Work with Elderly.” Psychology of adult ages and aging, (May 1999) : 62.

Targeting nature of the elderly support programs is a wide concept, encompassing the creation of the mechanisms for better management of the available programs. As the Russian public managers surveys demonstrate, there exists a large potential for improvement of the work conditions and style for the public employees. It concerns both the implementation of new technologies, increase in educational level, and improvement of work of different levels of bureaucrats. 
The creation of the bureaucratic structures responsive to the citizens needs is one of the tasks of reforming the system of social protection. The experts occupied in the reform of the local authority, argue, that the additional difficulties in the public management are created due to the absence of straight links and feedback with the population. The local authority is obliged to have population support of its policies, to care about of social and political base creation. Among other democratic methods of dialogue with the population it is proposed to conduct surveys and monitorings investigating population socio-economic status. 
Social sphere that includes the system of public health services, social security, education, culture and science is often unfortunately considered to be unproductive, but it is here where the reproduction, self-keeping and sustainable development of the person takes place. Thus it becomes more important and priorital for the tasks of public security provision. Taking into consideration the importance of the population health, as effectiveness criterion of all spheres of country economy and population development, the WHO states that the responsibility for people’s health should be assigned not to the bodies of public health services, but to the government as a whole. The large state programs such as charge-free primary medical assistance are supplemented by the targeting social assistance, which is impossible to render without direct involvement of the population. Performance evaluation, improving the available state programs, forecasting the situation and prevention of negative events requires constant local collection of information from population. 

Chapter 2. Description of Computer Technology EDIFAR 
Already for some years the monitoring of medico-social status of the population has been conducted in Moscow by the Institute of Control Sciences of the Russian Academy of Science, Public Health Institute of the Ministry of Health of the Russian Federation and management of polyclinic # 111 of North-Eastern District of Moscow (Chief medical officer – Osipenko A.P.) This survey features the application of computer technology EDIFAR (abbreviation – Expert Dialogue and Investigation of FActors of Risk) which is installed on the computers located in pretreatment room of the health center. In the regime of dialogue with computer the patients answer the questions of the questionnaire (about 200) covering socio-economic, family and health status (among others the symptoms of cancer, status of cardio-vascular and nervous system, and  other diseases are considered), life style and functional capabilities. The questions are differentiated by age and sex and new questions can be added at any time in the system. A large massif of data has been accumulated already. Further we will discuss the results of the monitoring considering only questions related to elderly. 
The operation of the EDIFAR occurs to be most efficient during regular preventive health checks, which are now obligatory for school and college students and war veterans. The questions composed together with doctors seem to supplement the medical examinations and tests. When there is a large inflow the patients (as during health checks), one operator can interview up to 30 persons per day. In usual days EDIFAR  is exploited at a reduced capacity. 5-10 persons attracted by the advertisements in the health center are surveyed per day. 
There was an attempt to provide a constant inflow of patients by issuing special coupons, which were attached to the medical records of the patients, scheduled to attend therapist. But still the inflow was not as high, as in the time of the health checks. Certainly, effective operation of EDIFAR need support and understanding from the polyclinic management and doctors, and not all of them understand usefulness of the patients survey in pre-treatment rooms. 
Many computerized diagnostic centers have recently appeared and people mistakenly think that EDIFAR is one of such diagnostic method. The EDIFAR is operated with another purposes. Preventive regular health checks, when the doctor has to serve a large inflow of the patients and there is no time for detailed examination, frequently are carried out formally (for example, during our survey the doctors did not pay attention in time to the girl with very high blood pressure, mechanically having examined her, and we had to return her for an injection). The detailed survey questionnaire, if questions are formulated together with a doctor, can complement  medical examination, and also serve for the preventive and information purposes. And this is important as  in Russia the plans of sanitary - preventive measures are executed only on 75-80% (Nazarova 1999). 

Nazarova I.B. “Pensioners and workers people: labor, health and treatment.” Psychology of adult ages and aging, (May 1999) : 66

The survey is conducted in the pre-treatment room. Two or more personal computers of small capacity are installed. The questionnaire is arranged in such a manner, that answering the question one uses only two keys of the keyboard – arrows “up” and “down” for a choice of the answer, and “enter” to pass to the following question. The operator consults the patients during the interview. The answer to the questionnaire on the average occupies 10-20 minutes. At the end of the interview the operator prints out a record of a patient, with key points about his health status. The record of the patient with the date of the survey is attached to the regular medical record. After the survey the patients are asked to come again in a year. 
Surveys in Russia show that people passively relate to their health, and its value is realized with the years. The concerns with the population health status, low efficiency and insufficient amount of preventive measures to reduce sickness rate at limited financial resources force to implement new measures (like EDIFAR technology), in which the population is involved  in greater extent. 

Chapter 3. Problems of the Application of the Computer Technology EDIFAR
Computer technologies are not widely used in Russian polyclinics. The reasons for that are limited budget financing of polyclinics, the absence of uniform regional policies on computerization, management orientation towards paper form of information processing and to the definite extent hostile or indifferent attitude to computer technologies from the part of medical workers. The latter can take place because of specificity of medical activities, and for bureaucratic and social - psychological reasons. 
Information about computer technologies can be obtained only from specialized journals, which are insufficiently utilized by the government officials, as their language is very specific. Meanwhile currently these aspects knowledge is necessary.
In polyclinics the computer technologies may be used for: 
•	Εvaluation  of their  operation;  
•	Informational support of separate structural elements of polyclinic - registry operation, sick leaves record-keeping;
•	Management of separate programs (for example, program of the free medicines, paid medical services).
Because of impossibility to obtain expensive computerized complexes, computerized systems are implemented only experimentally or partly in the budget-financed polyclinics. The systems including client – server element for optimal data support for polyclinics are created only at the final stage of the system implementation. 
Computerized technology positively influences administrative and managerial operation in polyclinic. But the standardizing should not encompass processes of diagnostic and treatment of the particular patient. It is not an excessive attention to gathering statistical data in the operation of polyclinic that is the goal, but health status of a particular patient.
The computer technology EDIFAR collects data in the regime of a patient and computer dialogue and ensures the immediate acquisition of the data from the population. Its installation is not expensive (the computers of small capacity are required, and the software), operating expenses are small, and the data collection can be carried out permanently. It can support the informational systems of polyclinic management.
In the past the planned measures of health control in Russia were carried out for able-bodied people partly at the enterprises, for elderly and college and school students in local health centers. The transfer to the market economy in Russia has coincided with the processes of financial and economical activity globalization, one of the principles of which is the growth of the privatized sector of the economy. As a result of privatization, as its by-product, those social services at the enterprises were cut or totally eliminated. This niche was filled by the paid services, which can not automatically decide all social problems. Therefore physical and mental health, life style  (availability of harmful habits, like smoking or drinking, healthy nutrition, fitness) in transitional market economy are not controlled in any way by the state. At an increasing share of the population working in small and medium businesses (large companies usually have a possibility to provide the workers with a sufficient range of social services) the priority should be given to the provision of targeting support and protection of the given population category. 
The appearance of many unregistered computer network systems has lead to the fact that the information, contained in them and falling into the category of “medical secret” has become accessible not only to medical workers. Russian legislation provides protection of several kinds of information, including the personal information (medical data are protected by the Article 30 of Fundamentals of Legislation of Russian Federation. In modern economic conditions this information can be used by the businessmen, which are interested in the health status of potential workers. All this results in necessary licensing of the services rendered by means of data collection with computerized systems. Such license was obtained for the application of EDIFAR system. 
All items of information about population were obtained by means of anonymous survey using EDIFAR. The name of a patient is simply not loaded into the computer. As the survey questionnaire contains personal intimate information, the anonymity of the survey is an additional protection against the utilization of database by interested organizations or people and thus the study of health status does not violate privacy law.

Chapter 4. Research Opportunities of EDIFAR System 
The idea of EDIFAR technology application for estimating physical and social health has arisen after the discovery of objective processes of measured indexes stabilization and possibility of their repeated check in a short time. In other words, the data about local medico-social situation can be considered to be representative and utilized by the management for the purposes of control and analysis of  programs results.
 The application of EDIFAR technology allows avoiding the effect of influence of moderator or interviewer on the surveyed person. The operator just assists the latter to work with the computer, which originates questions in the questionnaire. The operator does not influence in any way the answers of the survey, and as it was mentioned earlier the computer survey can be conducted anonymously.
The EDIFAR allows conducting studies permanently. The computers are installed in the place of the given study, for example in a polyclinic, enterprise, and university. The inflow of the respondents should be organized. The room, where the survey is conducted works in the reception hours of the doctors, for example.
The EDIFAR system is convenient to use there, where the constant data collection on the particular structured problems with a miscellaneous extent of question openness is necessary. The respondent does not comment, does not explain the answers, but can offer own replies, distinct from those proposed in the questionnaire. However, such method does not suit for careful analysis of any process, which requires rationing, for example the calculation of nutrition norms for students in schools, labor loading for the adolescents etc.
The usage of EDIFAR requires a smaller psychological loading on the operator as compared to the regular interviewer or moderator in focus groups. Sometimes the surveyed starts to tell about his life. Elderly do this especially frequently. EDIFAR allows determining the interesting and significant respondents, and the method of analysis of life histories can be utilized as a logical prolongation for finding deeper arguments of reasons or results of this or that phenomena. 
Among perspective directions of computer programs usage for the analysis of population needs  or state policies results, conducting constant monitorings is proposed. Besides, monitorings are suggested to be used for the improvement of the system of preventive measures to reduce sickness rate. Monitorings are expensive to organize.
The application of EDIFAR system also allows permanently collecting data from the population, but its operation is not expensive to organize. It can be done on a barter basis, for example for the opportunity to obtain the data. And, the given study can also bear educational component. When the patient in polyclinic asks, why the study with the help of EDIFAR system is conducted, he is answered, that it is done for an estimation of his health status. After the survey he may be recommended additional examinations,  informed about the unfavorable sides of his health and life style) He receives an advice if necessary where to address for further actions. In many respects, this information depends on the operator, which should be both psychologist and social worker simultaneously. It is necessary to pay special attention to training of the qualified operators – interviewers. 	

Chapter 5. The Study of Some Aspects of Elderly Health and Social Status by Means of EDIFAR Technology
 The purpose of the monitoring survey was better learning about the conditions and needs of the population of the given area, including elderly, to develop the recommendations for improvement of their economic and social status. With the help of the monitoring survey, population health conditions and estimation of the risk factors and risk groups have been carried out also. The purpose of the given paper is to study how the monitoring helps to improve targeting nature of the programs for elderly patients, and evaluate public programs. The data were collected on a constant basis in 1999 and results of 2000 reports were used also in the paper.
275 persons older than 60 years took part in the survey, from which men made up 23 % (64), and woman - 77 % (211). The sex composition of the respondents corresponded to the published official statistics. The age group of 60 years and older has been specified according to the standards of World Health Organization. We discuss here only some questions designed for the elderly. The detailed results of this research study were reported in the number of publications including monograph “Computer Technology EDIFAR Designed for Data Acquisition from Population to Develop Local Social Policy " (co-authors – Potanina Yu.A., Dartau L.A., and Belokogne O.V.).

5.1. The Condition of the Nervous System 
The survey has shown, that the constant problems with the dream have 26 % of the men and 39 % of the women. Women often address to a doctor on this occasion. The study of the mental status has revealed, that the obsession ideas, fears due to some reasons have 33 % and 42 % of the respondents, accordingly. Fears and ideas without any reasons have appeared in 9 % of all respondents. The women are also found to have obsession ideas and fears for concrete reasons more often. As to sedatives, about 19 % of the men and women - participants of the survey permanently take them. These medicines are used from time to time by 55 % of the women and 46 % of the men. It is possible to draw a conclusion, that  not all females’ visits to the doctor were  ended in prescription of drugs. They seem to be caused by temporary disorders of a nervous system, as the women are more emotional on a whole than men. As a whole morbidity from diseases of a nervous system is identical for the respondents of two sexes  and is rather high. 
The demand for neuropathological services is very high in Moscow, and frequently people visit him owing to temporary emotional disorders (especially elderly). It seems that the availability of the geriatrists and gerontologists could offload the neuropathologist work.
The series of questions in the questionnaire concerns the relations of the elderly person and society. The loneliness is experienced frequently by 26 % of the women and 15 % of the men of all surveyed, that also calls for the benefit of geriatric rooms creation in polyclinics, which elderly with the problems of communication could visit to alleviate psychological problems. 
Psychologically the state support has a large influence on the elderly conditions, first of all the size of the pension. Those who feel offended by the state among persons of 60 years and older are twice as high compared to the people who do not experience offence. And this is understandable, because it is more difficult for the elderly people to reconcile, to start thinking in a new manner. Indirectly this is confirmed by the answers to the question of the questionnaire “Do you feel offended by the state?” About 66 % women and men answered that they do. That is that two thirds of persons older than 60 years can not reconcile to the behavior of authorities. About 36 % of them are offended with all together. The half of women (54 %) and the third of men (30 %) are offended by the size of pension.
About the quarter of both men and women do not hope to get support and care from relatives, if it is required, while considering the public service at homes as the best form of public assistance for elderly. And for about 16 % of women and men in general it is difficult to speak on the subject, what kind of the modern forms of the state services to the elderly seem to them to be most preferential (only about 3 % has selected nursing homes). 
The answers to these problems urge to think of modern relations between fathers and children, disappearance of gratefulness feeling to the elderly, keenness to their needs. The quality of nursing home for elderly also needs to be increased. The amount and quality of nursing homes in Russia does not correspond to the number of the old persons in need and does not meet their requirements. The experience of different countries may be useful to study. For example in Malta, which have initiated the training programs for different experts specializing in aging processes from developing countries, there exists a ramified system of nursing homes, starting from traditional philanthropic hospices accommodating 15-40 persons (usually under church authorities, total amount of places available - about 550 persons), privately-owned 5-stars hotels for the elderly for 90 inhabitants (it is interesting, that they are constructed by the owners of large hotels), and huge state-organized homes for 380 persons. 

5.2. Distribution of charge-free medicines
The questionnaire contains a block of questions dedicated to the program of free medicine distribution for definite population categories (the invalids of 1 and 2 groups, veterans etc.) The comparison of the answers on the questions “Do you regularly take any medicine during the year and longer?” and “Do you have a possibility to obtain medicines on reduced prices?” has allowed to draw a conclusion, that for those who regularly takes any medicine, this program is very relevant. The numbers of people regularly taking medicines and regularly using the given program coincide (about 69 % among the women and men). For some people the doze of drugs in great demand is lower than for others and they require obtaining it two times in half-year for example, and for some it is needed each month. This fact was revealed by analyzing the answers on the question “When did you acquire medicines on reduced prices for the last time?” Therefore in the conditions when the funds allocated for the program on distribution of charge-free medicines are scarce, the distribution of these drugs in a correct way plays a very important role. 
During the survey by means of EDIFAR technology in the pre-treatment room of the polyclinic # 111 (regular health check of war veterans in April, 2000) many elderly people complained of the shortage of the necessary charge-free drugs and paid attention to the exact record-keeping while distributing these medicines. One of the surveyed told, that for obtaining necessary drugs elderly have to come each day in the early morning and to stay in the long line, frequently leaving with empty arms. It is inconvenient for the old people often experiencing difficulties with walking. The above mentioned patient even addressed to a head physician with the proposal how to adjust and improve the distribution of drugs.
Originally this block of questions was intended to reveal the range of persons using this program not only for themselves. Their share appeared quite minor (about 1 %). The analysis of the answers to an anonymous question “Have you ever acquired the drugs on reduced prices not only for yourselves?” have allowed to draw a conclusion, that the distribution of drugs taking into account the size of the dose, frequency or record-keeping of their distribution would reduce the costs, connected to the obtaining of drugs to the others for the unclear purposes.

5.3. Miscellaneous problems
The part of surveyed elderly has financial difficulties in purchasing hearing aids, glasses, dentures etc. 9.4 % of the men and 1 % of the women used the hearing aid in the period of the survey. The quality of the available dentures was considered to be unsatisfactory by many respondents: 34.05 % of the men and 48.4 % of the women were dissatisfied with it. The targeting assistance may be provided for those people in the social assistance centers which telephones can be received from the operator. The stick or crutches are constantly or temporarily used on the moment of the survey by 12.5  % of the men and 10.5 % of the women. The survey allows revealing persons with functional disorders and also providing them with the information from social centers.
22 % of the men and 39 % of the women have answered the question “Is your life exposed to the danger “ that in their opinion it is dangerous everywhere. And this is important to warn the elderly about the criminal cases of swindling to prevent them from getting into dangerous and unpleasant situations. Thus the EDIFAR technology allows revealing some of those cases and warning others about them. This can be done during the survey, in the geriatric rooms or during the visits of the social worker.

Chapter 6. Policy recommendations
1.	Many researchers indicate the urgent necessity of gerontological services creation in the Russian polyclinics, which elderly could attend, where they could be consulted concerning the condition of their health and be treated in the case of need; our survey also has revealed sharp necessity of gerontological services creation in the local health centers;
2.	Special work hours of neuropathologist are to be provided for the elderly; the service to call  specialists-doctors to elderly at home should be organized;
3.	Creation of almshouses organized at churches, supported by the private and public organizations should be induced;
4.	The survey revealed the necessity of creation of hobby and sports clubs; 	
5.	It is necessary to provide special psychological training for communication with elderly and social workers have to test their professional suitability;
6.	Family psychologist consultations are useful in some cases as the survey show (including on the problems with children); 
7.	The legal help in family and property questions may be provided by  free legal services for the elderly.
	
References
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