Towards an “age-friendly-hospital”: Older persons’ perceptions of an age-friendly hospital environment in Nigeria.

Abstract Abstract: Like any other country in sub-Saharan Africa, Nigeria’s elderly population too is increasing rapidly. In Nigeria, those aged 65 years and above (the elderly) make up 3.1% or 5.9 million of the total population of 191 million, which in crude numbers represents an increase of 600 000 during the 5 year period 2012-2017. Many older people in Nigeria are exposed to multiple health problems, to such an extent that there is a need for an extended health care programme and support for sustainable good quality of life. This study explored older people’s perceptions of an “elderly-friendly” facility based at the University of Benin Teaching Hospital (UBTH) in Edo state, Nigeria. Thirty participants were interviewed between the months of March and December 2018. With the help of a key informant who is also staff of the geriatric section of the hospital a purposive sampling technique was used to select 10 in-patients and 19 out-patients among older adults for the study. A qualitative content analysis was conducted. Elderly-friendly services, the expectation from government and hospital management, and health policy related to senior citizens were developed as main themes. Most of the participants were satisfied with the treatment by the health personnel. The study found that the geriatric unit has very few trained health personnel. Elderly-friendly hospital guidelines and policy were however not developed in the hospital. Older people health record folders, health insurance for the elderly, support and advocacy for older people’s health and benefit, and the hospital environment at large, lack elderly-friendly infrastructures. Some of the common concerns raised by the older patients include the absence of wheelchairs, lifts rails, comfortable beds, and readable signage displayed throughout the hospital to facilitate orientation of the hospital environment. Bed heights were reported as inappropriate for older persons, while the waiting areas were deemed uncomfortable for the elderly. Government policy on the elderly is seen as the main obstacle to promoting an elderly-friendly environment and health care services in UBTH. The facilities and infrastructure in the hospital, elderly-related health policies, elderly-friendly personnel and elderly-care advocacy, should be developed.


PUBLIC INTEREST STATEMENT
The paper reports on the findings of a study that looked into older people's perceptions of an "elderly-friendly" health facility based at the University of Benin Teaching Hospital (UBTH) in Edo state, Nigeria. Thirty participants were interviewed. Participants in the study included, among others, 10 in-patients and 19 out-patients that we selected from older adults to get their views about an age-friendly hospital environment. The study found that the geriatric unit at the hospital had very few trained health personnel. Elderlyfriendly hospital guidelines and policy were not developed in the hospital. Furthermore, older people's health record folders, health insurance for the elderly, support and advocacy for older people's health benefits, and the hospital environment at large, lacked an elderly-friendly infrastructure. We recommend that the facilities and infrastructure in the hospital should be upgraded and aligned with elderly-related health policies and supported by elderly-friendly personnel and elderly-care advocacy. treatment by the health personnel. The study found that the geriatric unit has very few trained health personnel. Elderly-friendly hospital guidelines and policy were however not developed in the hospital. Older people health record folders, health insurance for the elderly, support and advocacy for older people's health and benefit, and the hospital environment at large, lack elderly-friendly infrastructures. Some of the common concerns raised by the older patients include the absence of wheelchairs, lifts rails, comfortable beds, and readable signage displayed throughout the hospital to facilitate orientation of the hospital environment. Bed heights were reported as inappropriate for older persons, while the waiting areas were deemed uncomfortable for the elderly. Government policy on the elderly is seen as the main obstacle to promoting an elderly-friendly environment and health care services in UBTH. The facilities and infrastructure in the hospital, elderly-related health policies, elderly-friendly personnel and elderly-care advocacy, should be developed.

Introduction
Mainly due to improvement in health care quality and economic development in developing countries there has been a gradual increase in the life expectancy (World Health Organization, 2017;HelpAge International 2015) that, in turn, has caused an overall increase in the numbers of those older than 60 years (the elderly population). According to the Population Division of the United Nations Department of Economic and Social Affairs (United Nations Department of Economic and Social Affairs, Population Division (UNDESA 2017), the proportion of persons aged 60 years and above make up 12.3% of the global population, and by 2050 that proportion will rise to almost 22%. Sub-Saharan Africa, which has the smallest proportion of elderly and which is ageing slower than the developed regions, is nevertheless projected to see the absolute size of its older population grow by 2.3 times between 2000 and 2030 (United Nations Department of Economic and Social Affairs, Population Division, 2017). People are living longer because of better nutrition, sanitation, healthcare, education and economic wellbeing.
Even though population ageing is seen as one of the great triumphs of human development because the majority of people are now expected to survive to old age (Help Age International, 2014), an ageing population has implications for, among others, labour markets, health care, and social security. With relatively low levels of social and economic development and little access to adequate health care, a country like Nigeria will be hard-pressed to meet the challenges of large numbers of elderly people, especially as traditional family support systems for the elderly are breaking down (Abanyam, 2013;Okoye, 2012).
Accordingly, many other low-and middle-income countries are now facing a number of challenges including double burden of disease, costs of providing health care for ageing populations, increased risk of disability in elder people and economic issues of an ageing population (Lunenfeld, 2002;Marais et al., 2006;World Health Organization, 2017). The approval of the Vienna International Plan of Action on Ageing in 1982 provides a basis for formulation of policies and programs on ageing. Since then, ageing and its health and medical-related issues have been a top priority in different countries. (United Nations Secretariat, 2002;United Nations, 2017). According to the WHO (2017), population ageing occurs faster in low-and middle-income countries, and in 2018 the WHO announced that Nigeria is currently the seventh country in the world with a projected population of 214.7 million to 411million people by 2050. Currently, the total population of Nigeria is 197 million (Population Reference Bureau, 2018), with a rising trend in particularly the elderly population due to advancement in primary health care services. The total number of older people in Nigeria, that is, those aged 60 years and above, went up slightly from 8.7million in 2013 to 9.6 million in 2016 (National Population commission, 2017).
Due to high costs of supplying healthcare facilities for the elderly population, the health system of Nigeria must be prepared for increasing demands of the future elderly population with common conditions such as falls, incontinence and immobility. Moreover, increasing visits to hospitals and healthcare centres and the prevalence of chronic diseases in the elderly inflict very high costs to Nigeria's health system. Therefore, health policymakers need to focus on the facilities and infrastructures necessary for the provision of preventive and diagnostic healthcare services to the elderly. However, welfare and social issues associated with ageing should not be overlooked.

Elderly-friendly hospital environments in international context
Given the growing elderly population, the WHO (2008) called for special attention to elderfriendliness of hospitals. Physical aspects of an elder-friendly hospital are defined as features of environmental design including safety, physical, social and psychological needs of older adults (Gutman & Love, 2008;Graneheim, & Lundman, 2004;Ahmadi et al 2015;Huang, Larente, & Morais, 2011). A variety of services are provided in elder-friendly hospitals, including easy access to the hospital, appropriate timing for visits, health services and medical care, training staff, appropriate physical environment, toilets and signboards, inpatient services, admission and billing for senior patients (Augustine, 2010, Rashmi, 2010aWorld Health Organization, 2008;2012), Brown and Lowis (2003). The WHO has specified certain principles for age-friendly hospitals, which include the following: (i) Information, including education, communication and training including training staff in clinical geriatrics and approaches to patient education.
(ii) Health care management systems, including adopting administrative procedures such as patient registration, considering the special needs of the elderly and supporting the continuity of medical care by having updated medical records ready and available at each visit.
(iii) Physical environments with clean and comfortable centres that adhere, as much as possible, to universal design principles, thus making them usable by people regardless of their age or disability.
In 2008, the WHO published a guideline for age-friendly primary health care centres. The guideline intended to improve primary health care responses, educate primary health care workers about the specific needs of their older clients and raise awareness of accumulation of minor and major disabilities experienced by older people. Furthermore, it provides guidance on how to make primary health care management procedures more responsive to the needs of the elderly, and how to do environmental audits to test age-friendliness. This guideline was developed after background research in primary health care models and this included focus groups discussion sessions with the older people and their health care providers in six countries (Australia, Canada, Costa Rica, Jamaica, Malaysia and the Philippines). Parke and Stevenson (1999). Becker (1994) and Flood & Allen (2013) believed that a cultural shift should occur in managers and providers of health services and medical care to meet the special needs of the elderly and think in a different way about caring for senior patients in hospitals and health care centres. They developed a framework for an elder-friendly hospital in Canada comprising four areas including care systems, policies and procedures, social-cultural and behavioural atmosphere and physical environment design. The framework has clearly defined the vision, mission and principles of hospital care for elderly patients (Parke & Brand, 2004). Woo (2007) studied elderly care services in Hong Kong and highlighted some challenges such as the lack of a well-developed primary health care system and a high rate of the elderly population. Chiou and Chen (2004) developed a framework for healthpromoting and age-friendly hospitals in Taiwan based on the basic principles of WHO for agefriendly hospitals which included four similar WHO guideline as management policy, care processes, communication and services and physical environment. Another framework was developed for geriatric acute care by Boltz, Capezuti & Shabbat (Boltz et al., 2010) in the United States. The core components of this framework were organizational structures, guiding principles, interdisciplinary resources and processes, leadership, suitable physical environment, patient-and familycentred approaches and competent staff in geriatrics and elderly-sensitive practices. Each of these domains as a cluster had some sub-domains. A total of 113 items described dimensions of these elements. They (Boltz et al., 2010), believed that one of the challenges in the implementation of a geriatric acute care model is lack of outcome and process measures to assess the quality of ageing-specific care in the hospital setting. Rashmi (Rashmi, 2010a) studied two hospitals in Bangalore City of India based on the WHO toolkit and developed an assessment tool as a checklist to assess the preparedness of healthcare centres and hospitals in response to the needs of elderly persons. Huang et al. (2011) believed that healthcare for elderly people in acute care hospitals is becoming more challenging. They developed guideline principles in this regard and proposed a paradigm shift in the principles and practice in age-friendly hospitals of Quebec, Canada. Their framework included the following domains: a suitable physical environment, zero organizational tolerance for ageism, using the geriatric approach with an integrated process to develop comprehensive services in the organization, assistance with suitability decision-making and development relations between hospital and community. Woo et al. (2013), assessed current health service provision for older adults in Hong Kong based on the WHO principles of age-friendly hospitals and identified some desirable improvement in all fields of health care services for the elderly. In conjunction with The Regional Geriatric Programs (RGPs) of Ontario, the RGP Network in Toronto developed a five-domain framework for Senior-Friendly Hospital (SFH) care. This framework contained five domains: processes of care, physical environment, emotional and behavioural environment, ethics in clinical care and research and organizational support. It could be used as a toolkit to help policymakers, healthcare professionals and administrators to think differently about acute care in elder-friendly hospitals and lead to development towards becoming a more elder-friendly healthcare system (Regional Geriatric Program of Toronto, Senior Friendly Hospitals, 2011). Wong et al. (2014), using the Regional Geriatric Programs (RGPs) of Ontario framework in a system-wide analysis, studied 155 adult hospitals in the province of Ontario, Canada and identified practice gaps and some hopeful practices in this framework. Their study showed that one of continuing challenges faced with Ontario adult hospitals is recruiting staff with adequate expertise and skills in the care of older adults, but a success point most of the hospitals had policies and procedure guiding advance care directives (Wong et al., 2014). While all the frameworks/principles of an aged friendly hospital environment mentioned above are applicable to the various countries, there are still gaps that need to be filled. For example, little or nothing is mentioned about the caregivers, we cannot just talk about the older adults and the hospital friendly environment without considering the welfare of the care givers. The welfare of the caregivers in the hospital and also the family caregivers should be incorporated in the framework, principle and guidelines of the aged friendly environment discourse.
While there is increasing interest in the application of Senior Friendly Hospital models in developed countries, relatively little has examined specific issues concerning senior friendly hospitals in developing countries such as Nigeria and lack of knowledge and evidence of senior-friendly hospital models is obvious in this area. There is no special health care services or hospitals for the elderly in Nigeria, except in the case of the University of Benin Teaching hospital (UBTH) where a geriatric unit was created in 2013. The University of Benin Teaching Hospital (UBTH) in Nigeria was established in 1973 and created its geriatrics unit in October 2013. A prepared environment and trained interdisciplinary teams are pivotal in providing effective healthcare services for the elderly (Obehi, 2016). In developing the inpatient services, Obehi (2016) adopted the acute care for elders (ACE) model and worked in tandem with the "ABCs" of implementing ACE units. Results in the face of limited resources revealed that it was possible to establish a functional geriatrics unit with a trained interdisciplinary team. Family participation is central in their practice. Since October 2013, residents and house officers in internal medicine have been undertaking 4-and 12weekly rotations, respectively. According to Obehi (2016), there is a robust academic program, which includes once-weekly geriatric pharmacotherapy seminars, once-weekly interdisciplinary seminars, and 2-weekly journal club meetings alternating with seminars on geriatric assessment tools. The purpose of this research, therefore, was to examine older people's perception of an aged friendly hospital environment at the University of Benin Teaching hospital, Nigeria.

Study setting
This qualitative study describes and explains the perceptions of older adult patients about elderlyfriendly facilities and services at the University of Benin Teaching Hospital (UBTH) in Edo state, Nigeria. The data for the study were collected between the months of March and December 2018.
This study theme was generated based on the information provided by older adults who were admitted to the hospital and out-patient older adults who were not admitted but came for treatment to UBTH. This study was conducted to investigate the experience of elderly-friendly hospitals through the voices of older adult patients at the UBTH.

Participants
Firstly, UBTH was selected for this study because it is a teaching hospital with a Department of Geriatrics. Secondly, with the help of a key informant who volunteered to participate in the research and by using a purposive sampling technique, participants were selected from the inpatient and outpatient departments of the hospital. One key informant who volunteered from the geriatric section of the hospital was interviewed. The research team made an appointment with potential participants available at the time. Apart from the key informant who was 55 years the inclusion criteria for the other participants were (i) age above 60 years, (ii) admitted to UBTH, or visiting UBTH for treatment (iii) ability to communicate and (iv) willingness to participate in the study.
Further, sampling and data gathering were carried out concurrently. Through a purposive sampling method and the help of the key informants, 30 participants were interviewed. Ten participants were inpatients (three females and seven males) and 19 were outpatients (10 males and nine females) in UBTH and then the key informant (male) was also interviewed. The sample size was determined by data saturation.

Data collection and methods
A pilot study was conducted before the initiation of real interviews commenced. Two participants were taken for an in-depth interview in the pilot study, one inpatient older person and one outpatient older person, and after that, the interview commenced because there were no modifications in the interview guidelines. These two participants did not take part in our final study, because they are already aware of the questions and their presence and responses would influence the other participants.
Data were collected through in-depth interviews. All interviews were conducted in the local Edo language by three Master's students of the University of Benin who understood the language. We trained the interviewers on the use of a recorder and note taking during interviews. Informal and formal ways of interviews were conducted with the help of a semi-structured interview schedule. Several interviews were carried out with participants in order to support data analysis. A second interview was conducted with the participants if the first interview lacked sufficient clarification of the information. All the interviews were tape-recorded, and at the same time, the note taker had to take the notes. Each interview took an average of 45 minutes. Data were collected based on the main research question, and it was probed by the moderator (the principal researcher) to clarify the participants. Other sub-questions were developed to meet the objectives of the study. The main questions were as follows: How would you describe your experience of the elderly-friendly hospital at the University of Benin Teaching Hospital? What do you, as an older patient, expect from this hospital? All the tape-recorded interviews were transcribed from Edo and converted into English.
Next, one key informant who is a staff of the Geriatric section of the hospital volunteered to participate in the study and he was also interviewed. In this case, the interview took an average of 50 minutes. Information was collected based on the following main research questions: Could you explain the special services that are offered at your hospital for older adult patients? Are there any guidelines or policies related to elderly-friendly hospitals in Nigeria?

Data analysis
Information was extracted from tape recordings and transcribed from Edo into English. All the transcripted data were rechecked by the researchers and the final code was confirmed. The data analysis was done with NVivo version 8 software (NVivo Qualitative Data Analysis Software, 2010) Firstly, coding was done rigorously and carefully integrated into both examination and interpretation of data. Patterns and characteristics of the events were analyzed and were developed based on the coding. All the transcripts had been read and highlighted line by line and word by word which had produced important categories.
Secondly, the underlined keywords, appropriate code names were given to symbolize it. Code names were produced through the participants' information. After reading the transcript, the research team members reached consensus on extracting the significant keywords and codes.
Thirdly, significant statements were used to originate meanings. Concepts were identified, named and developed under the same categories that shared common characteristics. Each underlying meaning was coded in one category, and others were placed under the subcategories. Research members then compared the developed meanings with the original meanings in order to maintain the uniformity of descriptions. All the statements and developed meanings were checked appropriately by the research team to confirm whether the methods were accurate and consistent or not.

Ethical consideration
The protocol of this study was approved by the ethical review committee of the University of Benin Teaching hospital (UBTH). All the interview documents were kept anonymous. Privacy and the right to withdrawal were granted to all the patient participants and the key informant. Oral consent was taken from all the participants.

Trustworthiness of the study findings
Validity and reliability of the qualitative research comprised the strength of the data collection, data analysis, and descriptions. The pilot study that was conducted had increased the credibility of the study, even though there were no mistakes in the interview guidelines. Theme and concepts were developed after an agreement among different research members and validated by an expert.

Demographic characteristics of respondents
A total of 30 participants were interviewed for this study. Ten participants were inpatients (three females and seven males) and 19 were outpatients (10 males and 9 females) in UBTH and then one key informant (male) who is a staff was also interviewed. The age of the participants ranged between 55 and 80 years old and most of them were widows and widowers. There were no unmarried or separated participants as of when we carried out the study. They were either widows or widowers or still married. As of the time of the interview, all the participants had surviving children. Some of the participants had retired from public service and were receiving some pension while some were involved in some petit trading. Most of them stayed in their own apartment and in the rural communities, while a few of them resided in the urban areas.
Three main themes emerged from the findings: (1) Elderly-friendly services (The first theme produced nurses' attitude toward older persons, doctors' attitude toward older persons, and hospital facilities, that is the available physical and health facilities and general hospital environment); (2) The expectation from government and hospital authorities (the second theme produced nutritious food, free medication, free medical services, and transportation services); (3) Health policy related to older persons (the third theme produced right to information, information dissemination, older people's health medical record, older people's health benefits, and advocacy for older people).
The narrations of the participants according to these three themes are discussed below:

Nurses' behaviour/attitude toward older persons
The older patients who participated in this study were satisfied with the treatment and care of nursing staff in UBTH. They were helpful, friendly, and had good communication with older patients. Most of the participants were happy and satisfied with their work and their responsibilities and the care showed to them. Patients received the medicine on time and were encouraged to eat healthy foods.
As the ageing population continues to grow exponentially, their demand for hospital care also increases. Many nurses and doctors have had little if any, specialist education in the care of older people and therefore do not understand the extent of their needs. Coupled with the lack of specialist services and knowledge is the low status of older persons' care in most hospitals. As with the population at large, health care professionals hold both positive and negative views about old age and this is reflected in the services and attitudes towards the older people in hospital settings.
The nurses are doing a good and God's job. They are trying to see that I get well. They come and give me medication and talk to me nicely.

[In Patient, 65years old, male]
Despite positive compliments from the elderly persons, in some cases, nurses showed rude behaviour and bad attitude towards the patients. Sometimes, nurses were unable to give proper attention to older patients when they called them for help. Nurses were also very rude to their caregivers. This is described as follows by two of the participants: When I complained that the bedsheets on my bed was dirty the nurses shouted at me saying that it is cleaner than one I use in my house. The nurse also told me that you don't sleep on bedsheet in your house. Those words are not good to me at all. It makes me cry all the time. [In patient, 60 years old, male] Some of the nurses are experienced and God fearing and they look after us (older patients) very well but majority of them are not experienced and they talk to us as if we are children. I don't think the rude ones have any training on geriatric care. They should go and have training before talking to us. We are not children, we are elderly people and must be respected. [Out Patient, 66 years old, female]

Doctors' attitude toward older persons
All the older participants were satisfied with the behaviour/attitude of the doctors towards them. The doctors used to explain all the processes of treatment and side effects of the medication and in addition to giving motivation and kind words to get better soon. In every visit, the doctors used to ask about the improvement in their health and any other problems which made the patients very happy, as illustrated in the following comment: I feel much better and even feel cured when I am asked about my health situation with a smiling face and soft voice. I also feel very good when the doctor touches my hand. The doctors are better than those untrained nurses. [In patient, 67 years old, woman].

Hospital facilities (available physical and health facilities and hospital environment)
Most of the participants were not very satisfied with available health facilities as they had faced problems due to improper hospital facilities regarding manpower, hospital environment, and hospital infrastructure. Properly functional lifts and ramp ways were of the most essential infrastructures that must be present in the hospital.
This hospital is very poor and very dirty. The lifts are not functional so I had difficulty moving when I was in a wheel chair. The first day I came to the hospital, I was carried like a baby by two men. If their lifts were functional I wouldn't have passed through such pain and humiliation. [Out patient, 70years old, man].
The majority of the participants faced common problems related to the bathroom which was slippery, unhygienic, dirty and smelling. Further, patients-especially those who suffered from arthritis-also had problems using toilets. Few of the participants complained that bed covers and bed sheets were dirty and were not changed on time. Some of the participants explained it as follows: I am an asthma patient so I have difficulty in going to-and-from the toilet since it is very far from my bed. Also, having arthritis it is difficult for me to use the toilet because the toilet pot is too low and dirty.[In patient, 67 year, old man] Most of the older persons are from a village background so they don't know how to use a western toilet properly. [Key Informant, 55year old, male].
Hospital ward facilities were not sufficient and appropriate for older patients, as indicated by the following comments: I have requested to be admitted to the ICU but due to unavailability of beds they kept me in a general ward. The general wards are too crowded and noisy. I cannot rest when I want to.

[In patient, 60years old, woman].
The majority of the participants faced difficulty with transportation because most of them don't have cars and there are no transport services available in UBTH for older persons coming to the hospital. Most of the older persons stay in the rural community and have to pay very high fees for transportation to get to UBTH. One participant explained: I paid a very high amount for transportation. It will be easier if ambulance services or buses are provided to the patients outside Benin City to come to the hospital for treatment. My friend suffered a stroke and died, if there was an ambulance she would have been rescued [Out patient, 67 years old, Man].
Next, in as much as some patients needed privacy (staying in separate rooms), most of the participants wanted to share their hospital room with a person of similar age so that they could have a better conversation with other admitted patients.
It will feel good and easier to talk with a person of the same age and pass the time. Women talk too much and they talk nonsense things. I want to stay with a man so that we can have a reasonable .conversation [In patient, 60 years old, Man].

Nutrition
The majority of older patients demanded healthy and safe food from the hospital authorities. They expected a safe and clean canteen so that they could consume healthy and safe food during their stay and visits in the hospital. Said, one female participant: The hospital authority does not give us good food. We just eat anything they give us. We need fruits and vegetables. They should also give us a clean canteen where we can sit and enjoy good environment for food. (In patient, 60 years old, woman)

Free medication and free medical services
The majority of participants were not able to afford expensive medicine. During treatment, participants expected some sort of concession on medicine so that their illness could be treated properly without any delay and obstacle. On top of that, older people faced difficulty while waiting in a queue to purchase medicine at the pharmacy. These concerns were expressed as follows: Medicines are more expensive than treatment cost in this hospital (UBHT). Just a small aspirin cost so much money. It is very difficult for me to afford all my medication. The management of the hospital provides some form of medication to the elderly people who had been civil servants. This is explained as follows.
Government has provision of free medicine for older patients in allocated amounts; we only provide that medicine to older patients who had worked in the civil service. [Key In formant, 55 years, Male].
Older patients expected free medical services along with concession in medical investigation and surgery. They explain: We had requested for concession in treatment, but still we didn't receive any concession from the government. They say I was never a civil servant so I cannot benefit from any free medication. [Out patient, 70 years old, man].
Apart from the medication provided by the hospital management to the elderly persons who had worked in the civil service in Nigeria, the hospital management, also provides for investigation services of the type of illnesses to the elderly persons. This is captured as follows: Hospital is providing free investigation services in total blood count, ECG, X-RAY, stool and urine test as well 50% off is given in investigation related to diabetes, heart disease, and thyroid. [Key In formant 55 years Male].

Transportation service
The majority of the older patients were from rural communities in Benin City. They expected the hospital to provide free or low-cost transportation facilities for easiness in checkup and follow-up. However, a few participants also expressed that they did not have any kind of expectations from either the hospital or the government. Rather, they wanted to recover soon and get discharged from the hospital as their main concern was their own health. As one participant put it: I am already 78 years old, I just want to be treated well, other than going home and coming back to this hospital. I don't have any transportation expectation from this hospital officials.
The University of Benin Teaching Hospital is situated in the city centre, which makes it very difficult for older people who stay in the rural communities to visit the hospital for treatment. Even those who stay in the urban areas and who don't have cars find it very difficult to visit the hospital for treatment. The hospital does not have transport facilities for elderly people who visit the hospital. This is reported as follows by the hospital spokesperson.
We don't have any provision to provide free transportation or incentives for older patients. We advise our patients to get someone to bring them to the hospital early enough or they get transport to the hospital when they are ill. [Key In formant 55 years Male].
Nigeria does not have any special transport services for older people. They have a general system of transport where everyone uses as a means of movement from one place to another.

Right to information and information dissemination
The majority of the participants were not aware of the medical health services that were provided by the hospital or government. Most of them did not know about the insurance scheme for older adults who had been employed by the Nigerian civil service: I am a farmer; mostly we are engaged in farming. We don't have time or even radios to get information concerning us. The hospital authority must be transparent and notify us about all the facilities that are provided by the hospital or government to us. [Out patient, 60 years old, woman].
The same sentiment was also expressed by some elderly people, i.e. that if proper information was disseminated by the hospital, then services would be received without any trouble. One of the participants explains: Every hospital should have a way of sending out information to the elderly people so that every individual can get the information through it. They should either visit the churches or visit us in our homes and give us information. [Out patient, 60 years old, man] The hospital spokesperson responded as follows to this complaint: There are caregivers and some elderly people who come to us in the hospital to seek information. For those who seek information regarding older citizens, we provide full information regarding this context. [Key In formant, 55 years, Male].

Older people health records folders and identification of older people's health benefits
The health record folders play a vital role in maintaining the history of the patient. A health record folder for older people could help older patients to receive health services in an easier and faster way, either in UBTH or in another hospital. Most of the participants expected it from UBTH.
It would be easier if we were given our health records folders so that we could go to any hospital to get treatment if we wanted. We could even use our native drugs if we knew exactly what is wrong with us. [Out patient, 60 years old, woman].
In Nigeria, most of the hospitals don't give out health records folders to patients. This is because some patients may abuse the use of drugs. Some may just go over the counter and get medication without knowing how to administer the drugs. The hospital spokesman captured it this way.
Our hospital does not issue health record folders to older persons. We keep them for record purposes and for monitoring their drugs intake. [Key Informant, 55 years, Male].

Advocacy for older people's health
Most of the participants were not able to pay their health expenses. They were dependent on their children or were in need of someone's help. Thus, on the basis of personal experiences and thoughts of the participants, most of the older persons felt the importance of advocacy.
The elderly people complained of lack of funds to purchase their medication and wished that someone could advocate on their behalf to enable them to raise funds for their medication. Some of the elderly people have to sell their property in order to raise funds for their medical bills. Some of them had this to say. Elderly people in Nigeria who don't have anyone to pay for their medication depend on charity organizations. Individuals go out of their way to raise funds for the vulnerable older people. The hospital spokesman had this to say.
I personally want to be involved in raising the voice with older people for right of the older people's health. [Key Informant, 55 years, Male]

Discussion of findings
This study highlighted that older patients were both satisfied and dissatisfied with nurses' and doctors' behaviour in the hospital. Our findings are in line with previous studies which highlighted that the older patients are vulnerable with complex health problems and they need frequent support and care from medical staff (Hickman et al., 2007). The finding of our study concerning poor and impolite behaviours of nurses towards older adults concurs with that of Sushmita et al. (2015) who suggested that polite behaviour of health professionals could be helpful to reduce health problems and psychological support.
Findings from our study showed that few of the health professionals received training on geriatric care and geriatric medicine so far, but they are trying to provide necessary services for older patients. The literature suggests that trained health professionals could provide good caring and quality services to older people (Sushmita et al., 2015).
Previous studies revealed that the hospital environment could affect the quality of life and functional ability of older patients (Parke & Chappell, 2010). This is reflected in most of the reports we got from our participants. Most of them complained of poor treatment from the nurses, a dirty hospital environment, etc. A patient-friendly hospital environment, including toilet facilities, lift and ramps, separate wards for male and female patients, and pleasing words from medical doctors and nurses were commonly desired by older patients receiving treatment in UBTH. However, hospitalized older patients explained that they did not get such an environment while being hospitalized in UBTH.
In our study, the key informant remarked that physical facilities are constraints and less accessible for older patients in the hospital. This is in contrast with previous studies which revealed that health service guidelines must be developed by hospitals to maintain a senior citizen friendly hospital environment (WHO, 2007). Other findings suggested that an appropriate hospital environment can increase the efficient capacity of older patients (Légaré et al., 2014). Older patients from our study have different expectations from hospitals including free and easy treatment, medicine, transportations, and food. Previous literature supported our finding that affordable care, medical supply, and support were highly expected by older patients (Sushmita et al., 2015). Older patients in our study also were dissatisfied with available transportation systems and complained about transportation costs and suggested that there was a need to provide them with transport to the hospital. A similar finding was revealed from previous literature (Sushmita et al., 2015) that good transportation during illness was highly expected and is an essential requirement for older patients. They also suggested that older patients need to be supported for free health services.
The older persons who participated in our study showed concerns about the poor and dirty physical environment of the hospital and suggested that the government or the management of the hospital should improve on it. Our findings also revealed that there is no functional policy related to elderly-friendly hospitals in Nigeria. This finding concurs with studies carried out by Parke and Hunter (2009) in some parts of the sub-Saharan region. Their findings show that most hospital environments are poor and dirty and they highlighted that policies related to older patients need to consider the physical infrastructure of the hospital environments.
A further finding of our study was that UBTH doesn't have transparent policies for the elderly people and some elderly people suggested that the hospital management should instigate the government of Nigeria to implement transparent policies in health services for older patients. Hospitals, non-government organizations, government, and individuals need to advocate for elderly-friendly health services. This concurs with studies conducted by Shanley et al. (2008) as well as O'Keeffe (2004) who suggested that every hospital and government should have its own policies and guidelines for older patients.
The key informant reported that the hospital was unable to provide all the facilities to older patients because of budget constraints, and unavailability of space for extension of the senior ward, outpatient departments, and other facilities. The hospital has also notified that government there is no transparent policy when it comes to the elderly people in Nigeria which is a major obstacle for development. There are no guidelines and policy available that can enhance the skillful manpower in hospital. However, older patients benefit from hospital services, including free medical laboratory tests for some elderly people. Even then, patients were not satisfied with the given hospital facilities and the high cost of the treatment. Older patients reported having different expectations from hospital and government, and even those expectations are beyond the government and hospital policy. Patients were satisfied with the behaviour of medical staff during the tenure of the hospital stay.

Strengths, limitations, and future research
This study has strengths and limitations which may inhibit the generalizability of the findings. Participants were recruited using non-probability sampling and could not be representative of the whole target population in terms of demographic variables including education, and cultural factors. Therefore, the findings of this study may not be applicable to all older patients in Edo state. Further, information obtained from the key informant may not be distinctive of all the workers in the hospitals. We did not exclude the patients who had been admitted many times in the hospital which persist the information bias. Further, we did not consider the length of stay in the hospital. In addition, the strength of this study was the rigour and depth analysis conducted by the research team members, we developed theme and concepts. Future research might be conducted to cover different geographical areas and also add a quantitative approach to recognize the occurrence of these values in diverse populations.

Conclusion
This study's findings advance that there is an essential requirement to be aware of experiences and desires of the older people, and thus to grow agendas for this population that can effectively promote elderly-friendly hospitals and health services for all Nigeria's older people. These agendas should focus on addressing elderly-friendly hospital policies and guidelines, health benefits, and friendly services. Older people in Nigeria are not getting their share of proper health care, despite the fact that they are a growing cohort in the population. These challenges are therefore set to mount in the future. The government needs to set policies that will protect the elderly in Nigeria especially in the hospital settings.