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

RESEARCH Open Access © The Author(s) 2024. Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creativecommons.org/licenses/by-nc-nd/4.0/. Porcel-Gálvez et al. BMC Geriatrics (2024) 24:845 https://doi.org/10.1186/s12877-024-05430-2 BMC Geriatrics *Correspondence: Regina Allande-Cussó [email protected] Full list of author information is available at the end of the article Abstract Background Recently, the countries in the Mediterranean basin (which share cultural ties) have been showing a common trend of declining social support for the elderly, with deficiencies in social care models for this demographic. Thus, this Delphi panel study analyzed the gaps in social and integrated care among the participating countries in a European research project. Methods 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. In this project, experts were identified according to their level of expertise in the subject matter, their gender, and their membership in different social groups. Subsequently, they were asked to identify the current situation of social care, set future goals, and locate the gaps regarding the social and healthcare models for older people in the participating countries. The median score (Mdn) and interquartile range (IQR) were calculated to assess the degree of consensus on the different priorities. Results Among the participating countries, there was a lack of state agreements to maintain social care models, a lack of coordination between public and private institutions to provide social care services, territorial inequalities in terms of access and coverage of rights, and job insecurity for professionals. The desired situation was to integrate social and healthcare services with a person-centered social care model, thus promoting autonomy and empowering users and families in participation and decision-making. Conclusions This Delphi study reveals significant disparities in social and healthcare policies for older adults across Mediterranean countries, highlighting shared challenges and specific national needs. European nations like Greece and Spain face fragmented systems, while non-European countries such as Lebanon, Egypt, and Tunisia lack specialized geriatric services and social security. All countries urgently need better professional training, social and economic empowerment of older adults, and integrated national strategies. These findings offer key insights for policymakers to develop equitable, sustainable solutions for aging populations. Priorities and challenges in social and healthcare policies for older people living in the Mediterranean basin: A Delphi panel study Ana MaríaPorcel-Gálvez1, ReginaAllande-Cussó2,5,6*, ElenaFernández-García2, SalmaEssawi2, MohamedSalama3, Saly SamiSaad3, Rafael-JesúsFernández-Castillo2 and Marta LimaSerrano4 Page 2 of 13Porcel-Gálvez et al. BMC Geriatrics (2024) 24:845 Background 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 nonEuropean 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 personand 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]. Keywords Social and healthcare services, Public health, Older people, Social care model, Delphi panel study Page 3 of 13Porcel-Gálvez et al. BMC Geriatrics (2024) 24:845 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 nonEuropean 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 4or 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 COVID19 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 Table 1 Starting point of the five participant countries in the Delphi study Starting point European Countries Non-European Countries Greece Spain Egypt Lebanon Tunisia Life expectancy years181 83 70 74 74 Old population 65 + 219.4% 16.9% 4.63% 9.1% 8.41% Working population 15–64267.9% 70.6% 74% 72.4% 74.9% Old age pension system yes3yes4yes5Introduced in December 20236 yes7 1Source: https://data.worldbank.org/indicator/SP.DYN.LE00.IN 2Source: https://data.who.int/countries/ 3The Greek Pension System includes: Main pension provision through the EFKA fund for salaried employees, self-employed persons, seamen, and agricultural workers; Auxiliary pension provision via the ETEAEP fund for additional pensions and specific benefits, including lump sum payments and dividends for certain professions (civil servants, military staff, engineers, lawyers, etc.); Means-tested benefits for uninsured elderly provided by OPEKA, with dividend benefits managed by the relevant Dividend Fund. Source: https://economyfinance.ec.europa.eu/document/download/2704c5dc-e3ae-485e-9244e32978a31b7e_en?filename=2024-ageing-report-country-fiche-Greece.pdf 4The Spanish Pension System is primarily public and mandatory, with optional private schemes for supplementary savings. The main public component is the Social Security system, which covers old-age, disability, and survivor pensions, and includes a special scheme for civil servants, judiciary, military, and police (closed to new entrants since 2011). Both systems are mandatory, earningsrelated, and defined benefit. They cover three types of pensions: old-age, disability, and survivors (widows, orphans and familiars). The public system also includes a non-earnings-related scheme, with specific details on coverage, funding, eligibility, benefit calculation, and indexation rules. Source: https:// economy-finance.ec.europa.eu/document/download/392994f2-c025-4066bea8-f65cf4bcd411_en?filename=2024-ageing-report-country-fiche-Spain.pdf 5It consists in a mix of contributory and non-contributory elements. Social assistance is provided through two main cash transfer schemes: Takaful, for poor households, and Karama, aimed at the elderly, the disabled, and orphans. In 2019, a Egypt’s new consolidated pension and social insurance law (Law No. 148) applies to workers across both private and public sectors, managed by the National Authority for Social Insurance. Key changes include raising the normal retirement age to 65 by 2040, increasing contribution rates for pensions, and adjusting benefits to 65-80% of the minimum wage. The law also introduces a revised unemployment insurance scheme and imposes penalties for noncompliance. Source: 2019 Law No. 148 (Official Gazette, 19 Aug 2019) 6The Tunisia Pension System is implemented through two schemes: (a) Caisse nationale de retraite et de prévoyance sociale (CNRPS) (a national pension and social insurance fund); and (b) Caisse nationale de sécurité sociale (CNSS) (a national social security fund). The CNRPS covers the public sector while the CNSS serves the private sector. Both pension schemes are operated on a payas-you-go (PAYG) basis. Source: https://www.unescwa.org/sites/default/files/ pubs/pdf/tunisia-social-protection-profile-english_0.pdf 7The new pension scheme under the National Social Security Fund (NSSF) has mandatory and voluntary enrollment criteriathose 49 or older can choose between the new pension system or remaining under the End-of-Service Indemnity scheme. The scheme ensures a minimum pension based on either a percentage of the minimum wage or a formula involving the contributor’s career earnings. The scheme includes provisions for retirement, disability, and survivors’ benefits. Source: https://www.ilo.org/sites/default/files/wcmsp5/ groups/public/@arabstates/@ro-beirut/documents/genericdocument/ wcms_909323.pdf Page 4 of 13Porcel-Gálvez et al. BMC Geriatrics (2024) 24:845 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. 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). 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). Fig. 1 Quadruple helix model (The number in each square is the absolute frequency and percentage of experts invited) Page 5 of 13Porcel-Gálvez et al. BMC Geriatrics (2024) 24:845 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 Table 2 Expert participants from each country Countries Nº Experts invited Number of Experts % Women (Means) Round 1 (N;%) Round 2 (N;%) Round 3 (N;%) European countries Greece 45 15;33,33% 12;26,67% 0;0 43% Spain 66 40;60,60% 32;48,48% 26;39,4% 63,8% Non-European Countries Egypt 37 27;73% 21;56,75% 12;32,43% 48,1% Lebanon 34 16;47% 16;47% 0;0 62,5% Tunisia 41 24;58,53% 18;44% 18;44% 70% Fig. 2 Flow chart of the Delphi process Page 6 of 13Porcel-Gálvez et al. BMC Geriatrics (2024) 24:845 Countries Current state Desired state Gap Initiatives European Countries Greece Need for adequate primary care and health coverage, and targeted training for healthcare professionals. Homeand family-based healthcare services are inadequate. Much-needed government intervention in social care laws and policies. Need for research and evaluation (resources and funding) of population groups. Minimal social activities for older people. Empowerment of older people and elimination of stigmas related to old age. Emergency preparedness. Adequate medical care, comprehensive health coverage, and use of services. Home and family support and care. Social integration and care outside (closed) institutions. Increased state intervention and adequate financial resources/program funding. Coverage of psycho-emotional needs. Adequately trained staff through university curriculums and CPD programs. Enhancement of tele-tools and technological familiarity. Comprehensive and equitable retirement plans/pensions. Primary care development. Protection of human rights for older adults. Education and training of professionals A national strategy for reforms on older people’s care (legislation, better pension schemes, benefit plans, social care models, and structures). Partnerships with municipalities to organize empowerment programs for senior citizens, and ways to include them in social and volunteering events. Better training programs for staff, family, and individuals (medical professional trainees and the general population). Focus on psycho-social health and the introduction of new bodies such as psychological support teams in and out of established institutions. Development of technological tools. Disease management programs for conditions related to old age. Spain Territorial differences. Universal coverage problems. No guarantee of human rights. Lack of home support. Absence of medium-long stay centers. No job security. No public-private coordination. Highly dependent on political changes. Quality is highly dependent on economic resources. Digital divide. Dehumanization of care for the elderly. Lack of focus on the social determinants of health. Accessibility. Integrated policies to promote long-term care. Promotion of active aging and palliative long-term care. Territorial equity. Person-centered models. Residential alternatives. Gradual and flexible care, depending on the seriousness of the problem. Quality assessment. Interdisciplinary team. Favorable working conditions. Adequate professional-user ratio. Socio-sanitary specialization and professionalization. Dependency, as part of the life cycle. Key primary care in the coordination and delivery of care. Cooperation and integration between public and private social agents. Integration of health and social history. Family participation in the decision-making process. Bureaucracy. Professionalization. of services. Integration and coordination of the social and health system. Equity of services, regardless of territory and economic status. Processes of social support. Ability to respond to people’s needs and preferences in any situation. Development of long-term care. Sector transparency. Sustainability of the model and maintaining certain standards. State agreements and regulations. Territorial equity. Social awareness. Integrated and person-family focused care. Bureaucracy reduction. Professionalized home services. Adequate professional-user ratio. User-family empowerment. Creation of specific standardized protocols. Table 3 Summary of the gap analyses by the participating countries Page 7 of 13Porcel-Gálvez et al. BMC Geriatrics (2024) 24:845 Countries Current state Desired state Gap Initiatives NonEuropean Countries Egypt Only a few specialized physicians and centers for geriatric health, among the many general geriatric healthcare homes. A healthy lifestyle is not embedded in society. Lack of information on socio-economic and demographic characteristics. Without quality assurance measures or standard training, the risks for older people are increasing. Limited charitable efforts (mainly religious or international organizations). Specialized geriatric healthcare available and accessible to all, regardless of income or socio-economic status. Full understanding of healthy aging among older people and their caregivers. Opportunities to make the elderly more active, both mentally and physically. Equality across all socio-economic strata regarding health and care outcomes, including quality of life and well-being. An efficient national information system. Care agencies (both home and residential care) that are subject to quality assurance measures. Lack of political awareness of health policies directed toward older people and people at risk of social exclusion. Changing laws, policies, and incentives for specialized care for older people. Introducing topics related to aging and providing respect and understanding to older people within school curriculums. Continuous education and raising of public awareness. Availability of public facilities equipped to help older people. An efficient national health information system, as an absolute priority. Lebanon Financial insecurity. Malnutrition. Lack of protection of human rights. Inequitable retirement plans. Absence of primary care. Absence of preventive care plans. Lack of housing support. Stigmas related to old age and cultural issues. Comprehensive coverage of healthcare and utilization of health services. Legislations and laws for the protection of human rights of older adults. Social security for old age. Comprehensive and equitable retirement plans/pensions. Home and family support and care. Infrastructure, including facilities and transportation for the elderly. Networking and collaboration between stakeholders dealing with older adults (private and public). Education and training of professionals. National Strategy for Old Age Care (including basic old age care, financial and social support, retirement, pension plans, and safety nets). Emergency Plan for Old Age. Disease Management Programs for Conditions Related to Old Age (Alzheimer’s, dementia, chronic diseases, terminal illnesses requiring palliative care, etc.). Governmental support and services. Training and development of staff and professionals working with older people. Elderly-Friendly Cities. Community mobilization and partnerships with municipalities. Social and financial support initiatives (work, volunteer opportunities, social activities). Community mobilization and partnerships with municipalities. Tunisia Absence of a national precariousness register or a centralized database shared by all social and health actors. Lack of vision of a national social development plan allowing vulnerable people to leave precarious situations, instead of merely helping them while in poverty. A social model is required, with a body/institution higher up in the ministry that specializes in assessing and promoting the health of older people. A lack of communication with older people. A lack of promotion regarding existing social rights of vulnerable groups. Adopt the Social Economy: conducting a national survey on the living conditions of vulnerable older people and defining the risk factors underlying their precarious situations. Table 3 (continued) Page 8 of 13Porcel-Gálvez et al. BMC Geriatrics (2024) 24:845 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. Results Gap analysis Each participating country reported its final results from its internal Delphi panel (see Supplementary Material 2). According to these findings, the Delphi study on social and healthcare policies for older people in the Mediterranean basin highlights significant differences between European and non-European countries. Current situation In Greece and Spain, governmental intervention in social care laws and policies is limited, with a clear lack of robust regulatory frameworks to support the social wellbeing of older people. In contrast, in Lebanon, Egypt, and Tunisia, the lack of health coverage and social security is more acute, reflecting broader structural weaknesses in state support. Furthermore, emergency preparedness is a shared concern between Greece and Lebanon, indicating that the capacity to respond to critical situations remains a common challenge across the Mediterranean region. However, in Egypt and Tunisia, the focus is more on the lack of access to specialized geriatric healthcare services and the shortage of adequate medical resources for older people. The empowerment of older people emerges as a pressing need in all countries, though it is particularly urgent in non-European nations, where the stigma associated with aging is more pronounced. In terms of social support, European countries like Greece and Spain continue to rely heavily on families for elderly care, a trend also observed in Lebanon. Across all countries, there is a widespread shortage of adequately trained healthcare personnel, highlighting a cross-cutting barrier to delivering quality care for this population. Desired situation Both European and non-European countries recognize the need to establish equitable and comprehensive pension and retirement schemes, though this demand is more pressing in Greece and Lebanon, where deficiencies in the financial security of older people are more pronounced. In both Greece and Lebanon, there is a focus on empowering older people, although, in non-European countries, this empowerment carries an additional dimension related to the elimination of social stigma. In terms of social support networks, both European countries and Lebanon stress the importance of strengthening family-based care, underscoring the prevalence of familycentered care models in this region, as opposed to more institutionalized service provision seen in more developed European contexts. Gaps between current and desired situation The gaps identified highlight a more significant deficit in non-European countries in terms of professional training and access to specialized services. In Greece and Spain, while the need to improve professional training is evident, the healthcare systems are more advanced compared to Egypt and Tunisia, where the lack of specialized geriatric professionals is much more pronounced. In Egypt, for example, geriatric care institutions are limited and non-specialized, creating a considerable gap in the quality of care. By contrast, European countries show more issues related to the lack of integration between health and social care systems, whereas in non-European countries, the challenge lies in building basic infrastructures that guarantee access to essential care services. Proposed as-needed initiatives In Greece and Lebanon, there is a strong emphasis on developing a national strategy for the care of older people, which encompasses both financial support and the creation of social safety nets, while in Egypt and Tunisia, the priorities are more fundamental, such as establishing specialized healthcare systems for aging populations and introducing geriatric training curricula in universities. In all countries, there is a recognized need for programs to manage age-related diseases such as Alzheimer’s and chronic illnesses, although the lack of resources and capacity presents a more significant obstacle in nonEuropean countries. The training and capacity development of staff is crucial across all contexts, though European countries already have more developed infrastructures for continuous training compared to nonEuropean nations, where formal and regulated training in geriatrics is either limited or non-existent. Additionally, Page 9 of 13Porcel-Gálvez et al. BMC Geriatrics (2024) 24:845 dialogue with policymakers is essential in both European and non-European countries to ensure that the needs of older people are prioritized within policy frameworks. Lastly, both Greece and Lebanon emphasize the need to develop age-friendly cities, highlighting the importance of adapting urban environments to meet the needs of an aging population. In summary, while there are common challenges across European and non-European countries in the Mediterranean, such as the lack of professional training and the empowerment of older people, the differences become more pronounced in terms of available infrastructure and resources. European countries tend to have more structured, albeit fragmented, systems, whereas non-European countries face more fundamental gaps, requiring significant investment in infrastructure and basic services for older people. The final graphical abstract Figure 3 presents the graphical abstract of the main results agreed upon by all of the participating countries. It includes three main components: (1) the current situation of social healthcare models for older people, dependent people, and/or those at risk of social exclusion in the Mediterranean basin; (2) the desired situation, which implies a vision of the future and the basis on which such models will be developed; and (3) the gaps encountered, which represent the challenges in achieving the desired situation. Discussion The present study examined a project between Spain, Greece, Lebanon, Egypt, and Tunisia, which focused on the gaps between each country’s current social healthcare situation for older people at risk of social exclusion and the desired situation. Due to the COVID-19 pandemic, data collection was performed by using an online version of the Delphi technique. In this case, this technique was useful for finding the lowest common denominator among the experts, while avoiding direct contact with them, thus overcoming possible personal animosities [35]. Nevertheless, in the consensus-building process across the different countries, some difficulties can still emerge such as a low response rate, additional dropouts as the process progresses, or a lack of fluency in English [36]. The present study selected the calculation of the IQR to determine the degree of consensus and used a cutoff value of < 2. Generally, the literature suggests that for a 10-point scale, the cutoff should be < 2, and for a 5-point scale, it should be < 1 [28]. However, the Coordination Team, based on the proposals of Weschler [29] and intending to be as comprehensive as possible given the social nature of the project, agreed with the other participating countries to adopt a cutoff IQR of < 2 on a 7-point scale. Regarding the profiles of the experts, the final panel consisted of those belonging to the business sector, public administration, research and/or educational centers, and civil society, forming a quadruple helix model. Hence, the Fig. 3 Final graphical abstract