Long - term & Palliative Care Science and Education 2017 Edited by P. Bamidis MSc, PhD L. Despotova-Toleva MD, PhD Cover Design W.Nowak © All rights reserved. No part of this publication may be reproduced or transmitted in any means electronic or mechanical including photocopying, or any information storage and retrieval system without permission in writing by the editors. ISBN 978-960-243-706-3 Contents 3 CONTENTS: - Bamidis, P...............................5 Web and mobile technology advances in support of palliative care patients, their carers and other health professionals - Bamidis, P.................................14 The role of family physicians in palliative care - Vinker, Sh.........................26 The current and the future of long term care (LTC) system in Balkans: solution proposal End of life care in Waltham Forest - Khan, A., Richards, J.............................46 Bulgarian legislation and tobacco control rov L..................................................................................................................54 Evidence on economic status of palliative management: a literature review Developing a social funding model by cooperatives business for palliative care management Approach to palliative ill at home - Stavrich, K., Shukriev, Lj., Kovachevich, K., Tundzeva, M...................................................................................................91 Undertreatment of cancer pain – the open problem of Bulgarian oncology - The Concept of Empathic Interactivity – a Precondition for Realization in Palliative Medicine - Mihaylova, V., Bivolarski, I., Tarnovska, M., Lyochkova, M...................................................................................................121 4 Long Term & Palliative Care Communication with palliative sick at the end of life - Stavrich, K., Contemporary possibilities in vascular surgery of treating chronic arterial Cheshmedzhieva, B., Anastasov, V., Vazhev, Z................................................147 Spiritual needs Toneva, L..........................................................................................................156 Care of ill with decubitus wound - Stavrich, K., Shukriev, L.,Kovachevich, K., Tundzeva, M.....................................................................................................161 ropathy and its correlation to foot ulcerations - Nikolova P., treatment of patiences with multilevel atherosclerotic disease. What is the best solution? Cutaneous manifestation in internal diseases I -Zisova, L., Chokoeva, A...195 Cutaneous manifestation in internal diseases II -Zisova, L., Chokoeva, A...195 Calligarphy as Art therapy - Nowak, W.........................................................215 Aging: medical and social services and urban practices Toleva-Nowak, N..............................................................................................221 Aging: medical and social services and urban practices 221 AGING: MEDICAL AND SOCIAL SERVICES AND URBAN PRACTICES part of vast interdisciplinary case study One Architecture Week 2016 arch. Nina Toleva-Nowak Introduction Trakiya is residential plattenbau neighbourhood, built in the late 1970s and the early 1980s. It was planned to house predominantly young working class families. The plan of the complex included lots of open spaces, green areas and parks, schools, kindergartens, yet with only one hospital1. The planned administrative centre with the social, cultural and commercial facilities was never built, due to the changed political and economic situation in 1989. Today Trakiya is the third biggest plattenbau neighbourhood in Bulgaria and is a home for ~60 000 people (“Lyulin” residential complex with 122952 residents, “Mladost” with 108972 residents).11 It represents 1/6th of the population of Plovdiv - 18.2% of the population is people in retirement (males over 63 and females over 60), more than the age group 0-18. Most of them are owners of the apartments they live in (90% of the people over 60, and 60% of the people between 18-59 years old). Figure 1. Residents in different districts Figure 2. Demography: gender structure 222 Long Term & Palliative Care Figure 3. Demography: age structure Figure 4. Inner circle: ownership people over 60 years old; outer circle – people between 18 and 59 years old Aim and Objectives The aim is to analyze and to evaluate the medical and social services and to reveal the social and cultural aspects and practices of the elderly citizens of the neighbourhood. In order to achieve this, the following objectives were laid: - mapping the medical infrastructure of the district; - exploring the social facilities in the neighbourhood; - exploring the social practices and rituals of the elderly; - exploring their cultural practices; - identifying their challenges and their struggles. Materials and methods The vast interdisciplinary and multi-aspect research of the neihbourhood was implemented in the period February 2016 - October 2016, including neighbourhood, interviews with locals and administration, meetings with locals and administration, small questionnaire on local project (68 people), vast quasi-representative sociological study among 477 Trakiya residents and two workshops. More than 60 people: specialists, professionals, students, volunteers in accordance to their competence. Demography demographic structure. In terms of gender structure there are no huge differences between the two different age groups – 18-to-59 years old and over 60 years old. As for the education status, an expected shift from secondary to higher education (in the younger age group) is observed (Fig. 6). Aging: medical and social services and urban practices 223 Figure 5. Inner circle: sex structure people over 60 years old; Outer circle – sex structure people between 18 and 59 years old Figure 6. Inner circle: education status in people over 60 years old; Outer circle – education status in people between 18 and 59 years old. Also contrast in the marital status of the different generations and the number of people sharing one household are observed (Fig. 7). Most of the elderly are living either by themselves, or with another person (spouse or child), while the household of the age-group of 18-59 years old consists mostly of 2, 3 or 4 people (Fig. 8). 224 Long Term & Palliative Care Figure 7. Inner circle: marital status in people between 18 and 59 years old; Outer circle – marital status in people over 60 years old. Figure 8. Number of people in household according to age group. Concerning the work-status, even though the majority of the elderly is not or senior clerks and managers. Figure 9. Inner circle: workstatus people above 60 years old, outer circle – work-status people between 18-59 years old. Aging: medical and social services and urban practices 225 Figure 10. Comparison in work-status between people over 60 years old and people between 18-59 years old. Results Figure 11. Map of the medical cabinets, medical services, shops for medical utilities and laboratories (SeptemberOctober 2016). Major part of the research was the creation on a map with the wide variety of information concerning urban aspects, socio-economic activities, natural and build environment, medical and social facities, etc. It includes the data during practitioners, 6 specialized (ENT, urology, ophthalmology, neurology, paediatry) and 13 dental specialists. Another proof for the intensive development of the region can be found in an online platform showing the pharmacies and the drugstores and their 11 – whether in a particular pharmacy the pharmacist prepares the drugs, whether the pharmacy is municipal or private, or whether it is working with the National Health and Insurance Fund. Only for the period between August 2016 and February 2017 two more pharmacies opened in Trakiya, according to the information in the platform (by August 2016 there were 14 pharmacies and 4 drugstores, while by February 2017 there were 16 pharmacies and 4 drugstores (Fig. 10). The platform itself develops fast and the information in it becomes 226 Long Term & Palliative Care fuller and more accurate, as well as new features are integrated in it. Overall, we may conclude that during the past 28 years the medical coverage had undergone a huge change - a full 3 stages of medical coverage has developed, including general practitioners, specialists and hospitals. The change from one hospital to more than 45 medical cabinets of general practitioners, specialists and dentists, one new private hospital is accompanied by supplementary medical infrastructure, such as drugstores, pharmacies, laboratories, dentist cabinets, etc. (Fig. 11). Figure 12. The number of pharmacies by August 2016 (left) compared to the number of pharmacies compared to February 2017 (right) Figure 13. The development of medical facilities and practices: 1989 (left) and by 2016 (right) Aging: medical and social services and urban practices 227 A particularly interesting phenomenon is another type of transformation of the urban and built environment – the different types of emerging new cabinets and facilities are most often located in reconstructed and transformed apartments, Fig. 11 to Fig. 14), (which is a trigger very interesting social practice, which will be explained further in the paper), and rarely in new separate buildings (Fig. 15). Figure 14. Dentist cabinet in the basement Figure 15. Figure 16. Shop for medicines and herbs Figure 17 with external independent exit Figure 18. Newly built medical facility – dental centre For the last 28 years, also a fully developed social infrastructure emerged, including social housing for elderly with physical disabilities, social housing for elderly with mental disabilities, social canteen, community centres, senior clubs, 228 Long Term & Palliative Care and programmes for social assistance. Most of the housing facilities provide options for cultural events, organized trips. Some of them offer the residents In terms of conditions, the three housing facilities for elderly offer: Social housing for elderly with Social housing for elderly with Temporary physical disabilities “Hadzhy mental disabilities “St. Vrach” housing facility Gyoka Pavlov” 80 beds housing dietary food provision 58 beds housing dietary food provision 10 beds housing for 3 months food medical and rehabilitation care social assistance medical and rehabilitation care social assistance medical care social service cultural events, trips, vacations cultural events, trips, vacations cultural service yard with swimming pool, tennis court, football playground, etc. veggies As House, Landis and Umberson state, there is a big impact of the social relationships onto the health of the elderly5, which shows the need of exploring the local socio-cultural microclimate of Trakiya and the practices of the elderly citizens. Along with social and the housing facilities, in the area of Trakiya residential district there are two senior clubs with more than 200 members altogether, which are very socially and culturally active. Among the events they organize are healthy lifestyle talks, cultural trips, hiking trips. The seniors are involved in a variety of artistic activities, citizen initiatives, planting and greenery campaigns, etc. They also provide rehabilitation and medical help. The members of one of the senior clubs instantly become members of Bulgarian Association for Patient Rights. Aging: medical and social services and urban practices 229 Figure 19. Map of the social services in the region: Among the provided social services for elderly either by the Municipality, the Red Cross, the volunteers (or together) including specialized transport European Social Fund; social canteen with the help of the Red Cross; - food delivery for the elderly during the winter months; social assistance for In terms of available cultural services, on the territory of the district there are two Community halls – “Savremennik – 1986” and “Mladost – 1983”. Both of them have library, clubs for dances and singing for elderly, clubs for social contacts and other activities (Fig. 17). Yet, from socio-cultural point of view, even though there are more than 100 cultural events per year, a part of them (the biggest) are out-sources in the centre of the town due to the lack of suitable space. Thus, stimulating volunteers for social activities with elders may also be considered as good option. 230 Long Term & Palliative Care Figure 20. Distribution of the two Community halls in Trakiya district Figure 21. Distribution of seniors and youngsters visiting the Community halls In the group of the 18-59 years old, there is active weekend escape from the city to the countryside. On the other hand, in the over 60 year old age group, even though they are no longer involved in paid work the majority of elder people prefer to keep their workday-weekend schedule patterns – observed in comparing Fig. 21 and Fig. 22. During the preferred activities in the spare time most often are the ones that are for free, or ones with a symbolic fee (like membership in the local Community Hall Library). Most probably the reason for this is the economic struggle for making a living among the elder people. Aging: medical and social services and urban practices 231 Figure 22. Preferred spare-time activities during the work-days, Inner circle - amongst people above 60 years old, outer circle –amongst people between 18-59 years old. Figure 23. Preferred spare-time activities during the weekend, Inner circle - amongst people above 60 years old, outer circle –amongst people between 18-59 years old. Both age groups are rather inactive in terms of shopping outside the neighbourhood. Yet there is a difference between mundane shopping and longlasting personal good or technical devices. Overall, both the younger and the elder people are inactive and tend to stay and to be active within the neighbourhood boundaries, although there is some difference between the mundane shopping and the shopping of long-lasting goods and technical devices. “Trakiya has everything so we do not feel the need to go outside the neighbourhood for shopping” was a common phrase during meetings and interviews with locals. There are multiple shops – groceries, utensils, some hyper-markets. Actually, we may consider Trakiya as a shopping hotspot, as there are multiple shops and restaurants that are attractive urban cores for citizens from all around Plovdiv. The variety of both bigger and smaller shops has its own impact of the elderly, as the variety of shops and places to buy food and groceries often provide better and more affordable 10 . 232 Long Term & Palliative Care Figure 24. Shopping everyday goods, Inner circle - amongst people above 60 years old, outer circle –amongst people between 18-59 years old. Figure 25. Shopping long-lasting goods, Inner circle - amongst people above 60 years old, outer circle –amongst people between 18-59 years old. In terms of practicing sports: The elderly are very inactive in terms of sports activities and they prefer to stroll in near adjacency to their homes and tend to avoid certain places (especially in the dark hours). Yet, during the meetings and the interviews a lot of the elders expressed their satisfaction with the option of situated next the children playgrounds, they are considered to be safer places physical and mental status of the elders , but on the negative side, that near 2,6 facilities. Figure 26. Sports activities, Inner circle - amongst people above 60 years old, outer circle –amongst people between 18-59 years old. Aging: medical and social services and urban practices 233 One of the key factors of the health and the well-being of the elder people is considered to be the crime environment8. The fear of crime is reducing the physical activity and the willingness of being active outdoors especially for the elderly persons3. On the negative side, more of them (compared to the younger people) tend to avoid certain places when they walk around the neighbourhood, especially in the early mornings, late afternoon and in the evenings. The fear of crime relates not only the crime levels, but also to the overall microclimate of deteriorating spaces, abandoned buildings, contaminated spaces and the presence of homeless people and stray animals7,9. In Trakiya, the overall percent of people avoiding particular places due to fear of crime is quite low, but the contrast in the perception in the two age-groups is very visible (Fig. 26) – the elder people fear more, compared to the 18-59 age groups. They shared they tend to avoid being alone in parks, or outside after dark. Figure 27. Avoiding places due to security issues, Inner circle - amongst people above 60 years old, outer circle –amongst people between 18-59 years old. Figure 28. Participation in citizen activities, Inner circle - amongst people above 60 years old, outer circle –amongst people between 1859 years old. The people above 60 years old are extremely active when it comes to the well-being of the community - the percentage of elder people that are involved in some kind of charity and citizen initiatives is almost twice as big compared to the age group of 18 to 59. They are most active in activities bettering the immediate building benches, while the younger people prefer to join passive activities 234 Long Term & Palliative Care – charity events and donations. On the other hand, this phenomenon may be explained with the different economic status of the respondents – younger people spend their scare spare time in communal activities. Figure 29. Preferred citizen activities and charity events Overall, the elder citizens are willing to take more responsibility for the community. Another proof for that is their active participation in the relations between the municipality and the community, a bright indicator for this is the dogs, the poor quality of the green spaces, etc. (Fig. 29). Yet, these complaints are accompanied by strong willing to share or to take more responsibility in the decision making process in terms of governing and managing the neighbourhood (46% in comparison to 31% of the younger people) (Fig. 30). Figure 30. Filing complaints, Inner circle - amongst people above 60 years old, outer circle –amongst people between 18-59 years old. Aging: medical and social services and urban practices 235 Figure 31. Perception on who should have the leading role in the development and governing the region, Inner circle - amongst people above 60 years old, outer circle –amongst people between 18-59 years old. The elder citizens complain more, but they are also do more for the community. Also, they rate their communication with their neighbours better in comparison to the younger age-group (Fig. 31). They also tend to spend their time together. Figure 32. Rating of neighbourly communication (1 – poor; 10 – excellent) Among their preferred outdoor activities are playing cards, backgammon, developing local urban micro-rituals, like gathering for coffee and sweets in front of the building, using the alcoves for having their dinner in neighbor company – salad and drinks, especially during the summer; basking in the sun, gardening and taking care of the adjacent territories of the building, gathering at the children playground and community halls, and so on (Fig. 32). A particularly interesting example for social ritual, that is unique for Trakiya neighbourhood - the gathering of older people in front of the medical cabinets staircases). What they do there is bask in the sun, gossip and discuss their health issues, often becoming friends with the doctors (Fig. 33). 236 Long Term & Palliative Care Figure 34. Urban rituals: gathering for coffee and sweets in front of the building, gathering for play of backgammon; buying and selling personal goods Figure 35. Gathering in front of medical cabinets and pharmacies Conclusions Overall, the elder people in Trakiya are very active, very engaged with the well-being of the community and the betterment of the environment they live in. A big part of them are involved in lots of outdoors activities – planting trees herbs in the backside of the buildings), creating and maintaining alcoves and sitting places outside the buildings where they tend to gather for a chat, a snack or even for a dinner. On the other hand, giving the people the opportunity to Aging: medical and social services and urban practices 237 activity, but may actually have impact on their nutrition with better and cheaper On the other hand, most of the elderly feel isolated from the rest of the town due to the lack of proper public transport, they feel unsafe and often need not support. As the elder people often become less mobile, the part of the urban environment they actively use may shrink over time to include only the immediate surroundings of their homes4. Thus, their engagement in more local communal activities is of crucial importance, along with stimulating different outdoor activities. By this, a more sustainable local societies can be built. Trakiya is a neighbourhood with very good coverage in terms of accessibility and various medical services. It has very good options for social inclusion, external help and medical care. The distric has a wide variety of medical specialists, public and private medical facilities (hospitals, cabinets, laboratories); The elder people in Trakiya are particularly good example of active aging. They are vital part the urban life in the neighbourhood. They are key-actors in the local micro-community and they should not be disregarded, but being involved even more instead. Potential for further development of the research could be a comparison with the Japanese medical practices and social aspects of the aging society will be made in near future, the data for which were collected in Japan, during Ausmip+Erasmus Mundus Programme at the University of Tokyo, Japan. The cross-border cooperation, in accordance with the specially developed methodology of research could not only enrich the research, but could achieve optimal usage of the available medical and non-medical services in order to cover most possible of the needs of elderly people. Acknowledgements The authors expresses her gratitude to the great team of volunteers and students involved in the research, the team of One Architecture Week 2016, to Trakiya Municipality, and to her family for their bright example. REFERENCES: 1 Architecture 4 (1979), p. 12 2 Brownson, Ross C., Elizabeth A. Baker, Robyn A. Housemann, Laura K. Brennan, and Stephen J. Bacak. “Environmental and policy determinants of physical activity in the United States.” American journal of public health 91, no. 12 (2001): 1995-2003. 3 Dowd, J.J., Sisson, R.P. and Kern, D.M., 1981. Socialization to violence among the aged. Journal of Gerontology, 36(3), pp.350-361. 4 Glass, Thomas A., and Jennifer L. Balfour. “Neighborhoods, aging, and 238 Long Term & Palliative Care functional limitations.” Neighborhoods and health 1 (2003): 303-334. 5 House, J.S., Landis, K.R. and Umberson, D., 1988. Social relationships and health. 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