ERSTE Foundation Fellowship for Social Research Ensuring Income Security and Welfare in Old Age
Basic Human Rights of the Elderly Women in Rural Areas in Serbia: Evaluation of Social and Health Security of the Elderly Rural Women Sanja Jankelic
2009 Research Fellow Program of ERSTE Foundation
Basic Human Rights of the Elderly Women in Rural Areas in Serbia: Evaluation of Social and Health Security of the Elderly Rural Women
Sanja Jankelic Marija Tasic
RESEARCH FELLOW PROGRAM OF ERSTE FOUNDATION, 2009
Basic Human Rights of the Elderly Women in Rural Areas in Serbia: Evaluation of Social and Health Security of the Elderly Rural Women Authors: Sanja Jankelic, Sociologist, Specialist degree in Gerontology1 Marija Tasic, MD, MSc2
The Research Study is carried by support of ERSTE Foundation through the 1st Research Fellow Program of ERSTE Foundation in 2009 year. All copy rights are reserved by authors of the Research Study and ERSTE Foundation.
Department for Programs and Projects in Health Care and International Cooperation Secretariat for Health Care, City Government of Belgrade, Serbia 2 Institute for Gerontology Belgrade, Serbia Basic Human Rights of the Elderly Women in Rural Areas in Serbia: Evaluation of Social and Health Security of the Elderly Rural Women Page 2
I INTRODUCTION ------------------------------------------------------------------------4 THE DEMOGRAPHIC TENDENCY OF AGING POPULATION IN SERBIA - THE FEMINIZATION OF AGING----------------------------------- 5 LIVING CONDITIONS OF THE RURAL ELDERLY WOMEN THE FEMINIZATION OF POVERTY ------------------------------------------------5 II METHODOLOGY ----------------------------------------------------------------------8 SAMPLE ------------------------------------------------------------------------------------9 III RESEARCH RESULTS --------------------------------------------------------------III-1 The main socio-demographic data ---------------------------------------------III-2 Utilization of the health care services and health status -----------------III-3 Utilization of the social care services ------------------------------------------III-4 Informal care services -------------------------------------------------------------IV DISCUSSION --------------------------------------------------------------------------Conclusion ----------------------------------------------------------------------------------Bibliography ---------------------------------------------------------------------------------
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I INTRODUCTION There are many reasons why the phenomenon of the feminization of population aging has significant socio-economic and political implications in most modern countries. The population of women is a significant part of the world population and it increases constantly. Demographic projections indicate that the number of older women of a 60+ years will increase from 336 million (as recorded in 2000 in world's statistics) to over 1 billion by the year 2050 (25). Projections of total population in Serbia indicate that the number of people aged 60+ years will increase from 1,582,504 in 1991 to 2,411,621 in 2021. The process of population aging is followed by the increase of unbalance between the number of older men and older women, which increases with age and in favor of women. Although we do not have precise projections that indicate in which percentage the number of older women in Serbia will increse in the next years, it can be supposed that the number cannot be insignificant. (15) Developed countries address the implications of demographic tendency of aging population and the feminization of the elderly by gender-defined programs and policies on the overall social, economic and cultural development of the community. Considering that developing countries face an intensive process of aging population, and taking into account the expected increase on the number of elderly women, the inclusion of the basic principles of gender equality in strategic programs and policy on development of the community becomes a priority. However, when developing countries are concerned, especially the countries in process of social transition, such as Serbia, (which is characterized by a large gap between traditional and modern, between urban and rural) it is necessary to consider more carefully the actual living conditions and needs of the elderly women in rural areas. In other words, in order to achieve effective sustainable social development, there is a need to explore the gender specificity in the context of urban and rural areas, in the context of modern and traditional, as well as in the context of the unequal economic development of the country. For these reasons, the aim of this paper is an attempt to contribute to the exploration of specifics of the position of women in these contexts through studing the basic sociodemographic, socioeconomic and health characteristics and needs of elderly women in rural areas of Serbia. The Study was carried out on a sample of selected rural settlements of suburban municipalities of Belgrade, rural settlements of Subotica municipality (North Region); rural settlements of the municipality of Kragujevac (Central Region) and rural settlements of Nis County (South Region) THE DEMOGRAPHIC TENDENCY OF AGING POPULATION IN SERBIA - THE FEMINIZATION OF AGING Republic of Serbia is not an exception when it comes to world demographic trends. Today, at the beginning of the 21st century, Serbia is already in the group of countries with an aged population, i.e. with a high percentage of the elderly within total population (16.5%: among them 18.6% of the women and 14.5 % of men) (16), with a present tendency of further demographic aging of the population. Due to the longer life expectancy of women associated with the increasing number of elderly in the total Basic Human Rights of the Elderly Women in Rural Areas in Serbia: Evaluation of Social and Health Security of the Elderly Rural Women Â Page Â 4
population, it is expected that the number of older women will increse, especially in rural areas where there is a trend of "feminization of the rural", influenced by the migration of male labor population to urban areas. Data show that there are intensive demographic trends of aging rural population and increase of the number of elderly households in rural areas in Serbia, (20.5% of total rural households according to Census 2002). The Study on Life of Serbian citizens pointed out the even more upsetting fact that there are a high percentage of single elderly households, 59% within the total number of single households.(15) Taking into account the longer life expectancy of women, it can be assumed that these single elderly households, in most cases are "female". This information leads to the general conclusion that Serbia face an increase in the number of older women in rural areas who are living in single households. Older women, particularly elderly rural women, represent a significant part of the total population of the Country and they are an important human resource who participates in the process of economical, social and cultural development of the community. For these reasons, there is high responsibility of all political authorities to analyze the real needs of the elderly women in urban and rural areas to ensure their participation in the creation of social development policy. At the same time, politicians and professionals have responsibility to provide efficient and adequate care to vulnerable groups, including the achievement of basic human rights such as the right to social and health security. LIVING CONDITIONS OF THE RURAL ELDERLY WOMEN - THE FEMINIZATION OF POVERTY Aging population and the feminization of the aging process in Serbia have additional features that are caused by a number of specific socio-political events in the country in the last two decades, such as civil war, economic crises, population migrations, transition. Political events, economic crisis and the war in former Yugoslavia influenced the marginalization of the needs and rights of the older population in general. Most affected were all segments of everyday life of vulnerable groups, including older women in rural areas. During the process of social transition, rural areas which had not been in the center of development policy became even more marginalized, and rural women became almost completely invisible. Agriculture, as the dominant activity of the rural population, unfortunately is a marginalized economic sector, which has resulted in prominent poverty of the population of agricultural areas and their exclusion from economical, cultural and political processes. Poverty has become a rural phenomenon, and social and economic problems over the years have led to the feminization of poverty and significant pauperization of female rural population. (13) The Study on Life of Serbian citizens showed that the poverty index in 2007 year was significantly higher in rural areas (18.7%) than in urban areas (3%), which once again Basic Human Rights of the Elderly Women in Rural Areas in Serbia: Evaluation of Social and Health Security of the Elderly Rural Women Â Page Â 5
confirms the fact that poverty in Serbia is predominantly a rural phenomenon. Data of the Study indicated that older persons are on much higher risk of poverty than other age groups and that the risk is even 40% higher than for the average population. The alarming fact is that the percentage of poor living in rural areas increased from 55% in 2002 to 61% in 2007. (15) Therefore the phenomenon of poverty in Serbia is mainly present as a "rural" and an "elderly" phenomenon that many data indicate. To these attributes "female" can also be added. As for poverty, and the dominant traditional and paternalistic culture, elderly rural women in Serbia are left in most cases without choice and without the opportunity to achieve the basic human rights. Existing knowledge about the living conditions of older women in rural areas in Serbia indicates a low level of their education, a high percentage of illiteracy, lack of health, social and pension insurance and difficult access to social, economical and cultural resources. (4, 10, 13) Under the influence of dominant traditional decision-making mechanisms, customs and practices women are often excluded from community life and decision-making on its development. Women in rural areas mostly stay on the margins of social and economic changes. Elderly rural women, due to the lifetime marginalization of their rights and needs, remain deprived of basic human rights such as the right to social and health security. They have been absent from statistics and their daily lives have been rarely described. Sociocultural and economic living conditions of rural women have significant implications for their health. (25) The data about health status indicate that older women in rural areas in Serbia in the much larger extent than urban women suffer from chronic diseases and multiple morbidity. (27) The level of utilization of health care services is low (27), because of low availability of facilities and also because of inadequate knowledge and awareness about the importance of individual responsibility in the care for their own health. Providing adequate support, especially a effective and qualitative care to the elderly women in rural areas and particularly to vulnerable groups of chronically ill, disabled, etc., is difficult because of geographic isolation of rural areas in the Country, underdeveloped infrastructure, lack of public transportation, etc. The process of decentralization care services is slow. Alternative forms of providing support services are not developed in the rural areas. The public care services are hardly accessible to the rural elderly population. We assume that services of private and civil sector also are hardly accessible or almost do not exist in rural areas of the Country. Within the present situation of social transition in Serbia, the population of elderly rural women remains on the margins of democratic development. Experience shows that the existing NGOs, both at the national and local level, that deal with women's issues, mostly focus on the economical and political emancipation of women in urban areas and on the issues of sexual abuse or family violence. Unfortunately, issues of improving the basic human rights of women in rural areas, including primarily the right to health and social security, remain marginalised in most of the projects of the current civil sector that works in this field. Basic Human Rights of the Elderly Women in Rural Areas in Serbia: Evaluation of Social and Health Security of the Elderly Rural Women Â Page Â 6
Elderly rural women are restrained within traditional rural culture in which social networks, family members, friends and neighbours, have an important role in providing support and care. The question is what will happen with vulnerable elderly female population in rural areas in the context of tendencies of disappearing social networks caused by intensive rural-urban migration, of increasing member of single elderly households, as of slow technological development and a slow decentralization of services. Policy makers and political authorities at the local and national level have a responsibility to bridge the gap in which the "traditional Serbian village unexpectedly disappears quickly, and a modern one is slowly developing" (3). From the start they have to take into consideration an assessment of the real needs of elderly rural women in Serbia and, in accordance to the existing settings, to organize short-term and long-term answers to the identified needs. Existing research knowledge and experience about this issue is mostly partial or it is often part of wider studies on the standard of living (Study on Life of Serbian Citizens, 2007), part of national studies on the health status of the population of Serbia (Health Status, Health Needs and Use of Health Care of Population in the Republic of Serbia, 2002), or part of some scientific papers in the field of gender equality and women's rights. Most of these studies underline an important fact: that the population of elderly rural women is especially vulnerable. For the reasons mentioned, the real needs of the elderly rural women should be examined to help define the important issues on their social and health security in the current situation of economical and social deprivation. Especially important is the selfassessment of the researched needs. Research findings and available knowledge would help to define priorities in improving the basic human rights of elderly women; above all, in improving the quality of their health and social care. Such recommendations could be helpful for the local community authorities. The research objectives of the current study took into consideration several assumptions: • The educational and socioeconomic status of the investigated population is low • There is a low level of care services (public, civil and private) utilization by the population investigated • There is low availability of care services, particularly services aimed at the prevention of social deprivation and at health promotion • There is a high prevalence of chronic diseases • Social activities of the elderly rural women are rare • There is high socioeconomic dependence on family members among elderly rural women • The level of social and health security is to a great extent determined by the individuals’ social networks, thus family has a crucial role in providing care and support Generally, the main purposes of the research reported here are to contribute to the exploration of the poverty issue among elderly rural women from a different point of view, and to show that their poverty goes beyond the statistical estimations of average Basic Human Rights of the Elderly Women in Rural Areas in Serbia: Evaluation of Social and Health Security of the Elderly Rural Women Page 7
income. The problem of poverty among rural elderly women is “deeper” and often includes sociocultural, psychological, emotional divestment and their complete social exclusion. From the basic human rights perspective there is a great probability that they are deprived of rights on personal integrity and human dignity as well. II METHODOLOGY Research was based on quantitative and qualitative methodology. Quantitative methodology included the application of descriptive statistics methods in the processing of collected data. The main source of data was a survey carried out by standardized questionnaire and direct interviews. It’s validity was tested in a Pilot study. The questions were designed to be simple, and understandable to the elderly population. Data published by the Bureau of Statistics from the last Census of Population, Households and Housing (2002) was also analyzed. The questionnaire includes 42 questions divided into 5 thematic areas: • basic social and demographic characteristics • availability and utilization of public health and social care services • evaluation of basic health and social status and psychosocial wellbeing • self-perception of needs for care services, support and aids • evaluation of availability and benefits of informal services including availability of civil care services and social network support The data collected were processed and analyzed in SPSS. Wider information was collected through literature review and qualitative observation and it has been taken into consideration in the exploration of the results. Considering the complexity the issue investigated and the certain limitations of the questionnaire, it was suggested to interviewers that whenever possible to carry out in depth interviews, and kept written records of their observations and comments, which were taken into account in the process of analysis and exploration of results. Some knowledge on common problems of rural elderly women has been described by the descriptive analysis of the data. The training have been provided to all interviewers and short guide was distributed. SAMPLE The target population was women aged 65+ years who live in rural areas of Serbia. The study population included N=800 women aged 65+years from 8 rural settlements in the municipalities of Kragujevac and Subotica, and of Nis and Belgrade (Beograd) County. In each areas a quota of 200 randomly selected women was interviewed.
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The published data of the Republic Bureau of Statistics from the 2002 Census were used for sampling villages in each municipality. Three villages were selected in each municipality. In two villages of each municipality the survey has been done; a third village was selected as a reserve in case of insufficient respondents. Sampling of the rural settlements or villages has been done according to to the following criteria: 1) the highest percentage of the elderly 65+ and 2) highest mean age of total population The survey was done in: 1. rural settlements Krsna and Koraćica (Belgrade -Beograd County) 2. rural settlements Sabanta Gornja and Resnik -Kragujevac (Central Serbia) 3. rural settlements Bajmok and Novi Žednik -Subotica (North Serbia) and 4. rural settlements Baličevac, Gornja Topaonica and Oblačina - Niš County (South Serbia) City of Belgrade (Beograd) is the capital city of the Republic of Serbia, which is located on the surface of 3227 km2 with 166 settlements. According to the Census of 2002, its population was 1,576,124 inhabitants what is 21% of the total population of the Republic of Serbia (without Kosovo and Metohija). The mean age of the population is 40.4 years. Data of last Census showed that there were 247,029, or 15.7% elderly population 65+ among total population. Population growth is negative and was -4287, 2007. Belgrade (Beograd) city has 17 municipalities, of which 10 are urban (Vozdovac, Vracar, Zvezdara, Zemun, Stari grad, Savski Venac, Cukarica, Rakovica, Novi Beograd and Palilula) and 7 suburban. The research included the suburban municipality of Belgrade: Barajevo, Grocka, Sopot, Mladenovac, Obrenovac, Lazarevac and Surčin, with a total of 127 rural settlements in which 233,006 residents live. Considering the sampling criteria, the survey have been done in the village Velika Krsna (mean age 42.5 years) and in the village Koracica (mean age 42.3 years). These are villages with demographically old population, which are situated on the territory of suburban municipality Mladenovac that belongs to the city of Belgrade (Beograd). City of Kragujevac is the most important economical, administrative and cultural center in central Serbia, with a relatively good perspective of economical development. According to data from the last Census in 2002, registered population on the whole territory of the municipality was 175,802 inhabitants. In the urban area live 146,373 inhabitants and in rural settlements there were a total of 29,429 inhabitants. The participation of the elderly 65 + within the total population of the municipality was 14%, which means that the age structure of Kragujevac is “younger” than the age structure of the Country. Anyway, the mean age of rural settlements within the territory of Kragujevac is 44.3 years, while the mean age of population of targeted villages was 45.6 years, which makes them some of deepest demographically aged areas. Subotica is situated in North of the Country in the Autonomous Province of Vojvodina, and it is one of the economically developed urban centers. The total number of population of Subotica was 148,401 inhabitants and with 15.5% percentage of the elderly 65+years. There are 17.4% of elderly in rural areas of Subotica, thus a higher Basic Human Rights of the Elderly Women in Rural Areas in Serbia: Evaluation of Social and Health Security of the Elderly Rural Women Page 9
percentage than in the whole of the municipality. The mean age of rural population within the municipality of Subotica was 40.9. Nis County - The Merosina is a small municipality that is located in the southeastern part of Serbia, and belongs to Niš County; it has a total of 14,812 inhabitants and 27 rural settlements. The percentage of the elderly 65+ within total population of the municipality according to the last Census was high, 23.2%. The mean age of population in whole territory of municipality was 42.9 years. The village Balicevac had a population of 1185 residents and the mean age of the population was 41.7 year. Oblacina village has a total of 443 inhabitants and the mean age of the population was 46.6 years. III RESEARCH RESULTS III-1 The main socio-demographic data The mean age of the investigated population of women was 75.2 years. Marital status. Data on marital status showed some difference between the regions. Although we expected higher prevalence of widows among respondents women, given the mean age of all respondents, the data showed that there were higher percentages of married women in settlements in Central (Kragujevac 63.1%) and South Serbia (Nis County 51.5%), while in the rural settlements of Subotica (31.5% ) and Belgrade (38.5%) that percentage was slightly smaller. Among respondents in Subotica and Belgrade, the higher percentage of widows were in Subotica (64%) and (59%) in the rural settlements of Belgrade Graph 1. Marital status
For all the selected localities there was a small percentage of divorced women, from 2 to 3%.
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Number of children. Data on the number of children indicate that there is no significant difference between the rural environments of Belgrade and Subotica, and the largest percentage of respondents have two children (51% in Subotica) and (57% in Belgrade). The percentage of respondents with one child was 28.5% in Subotica and Belgrade 21.5%, and that was higher than in Central and South Serbia. In the North of the Country, in Subotica there was an insignificant percentage of women with three and more children - 2.5%, while in Belgrade that percentage was 14.5%. It is well known that North of the Country has the lowest fertility rate.
Graph 2. Number of children
In the regions of Kragujevac and Nis County there were the lowest percentages of women without children, 9.1% in rural settlements of Kragujevac and 10.5% of rural women within the territory of Nis County. Education. The results about education of rural elderly women have been within the expectations and confirmed the initial assumption that the highest percentage of elderly rural women are without schools or with incomplete elementary school, and there was a much smaller percentage of women with the secondary school.
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Taking into account the educational level, it was expected that the main occupation of the majority of respondents would be “housewife”. Farming as the main occupation through the life was present among 1/3 respondents in Kragujevac and Belgrade. Much lower percentage of women to whom farming was the main occupation over the life were found within the territory of Subotica, and within the rural areas of Nis County. In Subotica this low percentage can be explained by higher economical development of the region and bigger labor market where more women had been employed in industry. In South of the Country, lower industrial development influenced greater involvement of man into farming and thus more women traditionally stayed at home by caring for households. The Central Serbia is the main agricultural part of the Country and because of it more population had been involved in farming.
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Graph 4. The main occupation through the life
Income. Information about regular sources of income show that only small number of women have their own pension, which indicates too that the majority of women who were involved in farming work over their life course didnâ€™t pay pension contribution. Family pensions are the main source of income for the majority of widows. Higher economical dependency from family member in the regions of Nis County and Kragujevac are an implication of the greater poverty of these regions, as well as of the more traditionalistic and patriarchal culture. It should be taken into consideration that within the territory of Belgrade and Subotica there was a higher percentage of widows, and thus there was a higher percentage of women with family pensions. The question is to what extent these respondents had a personal source of income during the life before having inherited the family pension.
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Graph 5. The main source of income
It was interesting a large number of respondents who lived in marriage, on the question of â€œwhat is your regular source of income? answered "pension", although they did not have their own pensions (the husband it had a pension). These data may point lack of awareness of their economical dependence on the spouse, and also of the social exclusion. Further obtained data through interviews indicated that the stated pension actually was the regular income of their spouse. Additional source of income - In rural areas of Belgrade, the majority of women (68%) did not have additional source of income and 30% of women said that they had additional income through land rents. On the territory of Subotica, 51.5% respondents stated that they did not have additional sources of income, while 35% confirmed that had also some income through land rents. In Central and South Serbia, the situation was somewhat different. Within the territory of Kragujevac, 87.4% of rural elderly women said that they did not have any kind of additional source of income, and only 7.6% had some income through land rents. Within Nis County, 72.0% stated that they did not have additional income and only 2.5% did have additional source of income through land rents. Much more rural women from Nis County than women in other regions answered that they had additional income such as financial support from family (25% among the total number of respondents). In all areas investigated data confirmed that among the respondents that did not have any source of income, and financially depend on family members, there were the largest percentage of those without elementary school, or with incomplete elementary school. With regard to the ownership of property, the data indicate that women rarely appear as owners of the property in which they live. Subotica was the exception, where 50% respondents said that they were owners. Unfortunately, in other regions that percentage Basic Human Rights of the Elderly Women in Rural Areas in Serbia: Evaluation of Social and Health Security of the Elderly Rural Women Â Page Â 14
was significantly lower. This difference among investigated areas may have to be caused by the ethnicity of respondents and the influence of culture. Namely, in North of the Country majority of respondents are Hungarian with different cultural customs.
Table 1. Owning Property -Property you live within is own by whom? Own property Beograd Subotica Kragujevac Nis
9.5% 50% 20.7% 22.5%
Family property 79% 40% 74.2% 68.5%
Childrenâ€™s property 11% 8% 3.0% 7.0%
Other 0.5 2% 2.0% 1.0%
Women in Serbia are rarely owners of properties. The dominant traditional custom is that the right to inherit property after the death of the father exclusively belongs to children. Patriarchal culture is particularly evident in the predominant right of sons on inheritance. Other studies about the social status of rural women in Central and South Serbia indicate that women do not have the right on inheritance, given the extremely dominant paternalistic pattern of establishing and maintaining property relations, and that the in vast majority of cases, property and the house are inherited by son, brother, and before by son-in-law than by daughter. (4) Information about the size of household indicates that the highest percentage of our respondents live in family households with two or more persons, in most cases with husband and children. This group was followed by those living within elderly households with their spouse. The highest percentage of single elderly household in our sample was within the territory of Subotica. Considering marital status, it is noted that up to 1/3 of widows lived in households without children in all regions. They are the most vulnerable group. On the other hand, 2/3 of widows live with family, a fact that influences their better social and health security in old age. This fact explains the relatively small percentage of the stated need for different types of services, assistance and support among this vulnerable group. Table 2. How many people live with you - size of household? living alone Beograd Kragujevac Subotica Nis
16% 14.6% 38.0% 18.5%
living with spouse 22% 36.9% 33.5% 24.0%
living within family household with two and more members 62% 48.0% 28.5% 57.0%
The main socio-demographic data confirmed the initial expectations of low educational status of the elderly rural women and their relatively high economical dependence of the family. Life within extended family with children to a large extent provides basic social security. Due to the low education, the needs to meet other, different and wider social and cultural needs are not recognizable among our respondents.
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III-2 Utilization of the health care services and health status Contemporary knowledge, as well as information on health status of the population in Serbia indicates that chronic diseases are leading causes of morbidity and mortality in the world and the Country as well. (25, 27) World statistics indicate that almost 80% percentage of mortality due to chronic diseases occur in developing and underdeveloped countries. (25) Risk factors of chronic disease are highly present among the elderly in Serbia, such as increased blood pressure, obesity, lack of physical activity, etc... Furthermore, when associated with poverty and low level of information among rural population, they together increase the risks for the development of complications and deterioration of health in old age. (15). The elderly rural women’s health reflects past inadequate access to basic services, food and nutrition throughout their lives, as well as the hardships of their childbearing years – including too many births that took place too early, too closely spaced and in poor circumstances. Because of unhealthy life styles, under education, etc., they are at high risk for pathological aging and development of functional dependence. Although the research did not include objective health assessment, data obtained through self-estimation of the health status and through "self-report" diagnosis confirmed that the epidemiological characteristics of rural elderly women in Serbia are not different from expected. On the question of whether they had some health problems or disease, the greatest number of respondents from the Kragujevac region indicated problems with high blood pressure, 19.8%, and diseases of the heart and blood vessels 33.8%. Furthermore, in order of frequency, on the third place are different rheumatic diseases 15.2%, then diabetes, which was reported in 9.1% of respondents. Different digestive diseases were reported in 4.0% of women. An interesting fact is that only 2 women reported that they had gynecological problems. Unfortunately, data showed that a visit to the gynecologist is one of the seldom performed health controls. Data on health status, and health problems through the self report diagnosis among rural elderly women in Nis County was more difficult to obtain in a large number of respondents, than was in Kragujevac. In fact, 54.5% women in this County said that had no diagnosed diseases, and 18.5% pointed out that they suffered from hypertension, 9% had cardiovascular diseases, 4.5% respondents reported diabetes, 11.5% had rheumatic diseases, and 2% reported diagnosis from cerebrovascular diseases. According to the collected data it was difficult to generalize knowledge about the common diseases of the rural elderly in the Nis County, because we assume that statements about the absence of diseases are not objective. An argument which confirms our assumption was fact that the functional status of elderly women within rural areas of Nis County was the lowest. Some explanation can be found in data on the utilization of health care services among these women who have shown very low level of attendance to health controls. In general, through obtained data we can assume that Basic Human Rights of the Elderly Women in Rural Areas in Serbia: Evaluation of Social and Health Security of the Elderly Rural Women Page 16
cardiovascular diseases are the leading cause of morbidity among rural elderly women in south Serbia, a finding that is in accordance with international and national epidemiological statistics. In rural areas of the region of Subotica, on the basis of "self-report" diagnosis, it was found that the highest percentage (50%) of respondents suffered some kind of disease of the circulatory system, among which the most common was high blood pressure. Percentage of 9% women reported diseases of the musculoskeletal system and connective tissue, and 8% had problems with endocrine, nutritional and metabolic diseases, mostly diabetes, which is very frequent in outpatient morbidity in Vojvodina. Within the territory of Belgrade region the situation was similar. The highest percentage of the rural elderly women suffered from diseases of the circulatory system (55%), among which the most frequent was high blood pressure. In the second place were reported diseases of the musculoskeletal system and connective tissue, 11.5%, 9% of respondents suffered from some endocrine, nutritional and metabolic diseases, mostly diabetes. Assessment of functional status of the elderly people is beneficial to get the objective evaluation of their needs for care services. The set of questions (Graph.6,7,8,9) that are related to the assessment of functional status showed that the largest percentage of respondents in each region was functionally independent and they could perform activities of daily living. Increased need for support was correlated with performance of more complicated, and physically demanding daily activities. Graph. 6 ADL- Can you walk outside without help?
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Graph. 7 ADL- Can you wash and take a bath by yourself?
Graph. 8 ADL - Can you dress and undress by yourself?
Data showed that rural elderly women within the territory of Belgrade and Nis County have lower functional status and higher level of functional dependency. Among them we found higher percentage of respondents who had difficulties in performing daily activities, such as dressing and undressing, and maintenance of personal hygiene, and thus in greater extent they needed the support of other persons.
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Graph. 9 ADL –Can you perform housekeeping work such as washing windows, general cleaning etc?
The assessment of the need for different kinds of aids indicates that the highest percentage of rural elderly women use some types of aids. The most common were glasses and dentures, followed by stick for walking. Hearing devices were the rarest used aids, although, according to the observations of the interviewers hearing problems were often present (e.g. 21.5% in Kragujevac, in Subotica 7.5%). Assessment of health care services utilization in rural areas showed the expected results. In rural areas of Serbia there is a health station or ambulance, where GP services are provided. Specialized health care services, home care services, regular medical examinations were not used by our respondents in high percentages. Graph. 10 Have you been visiting the GP since last 12 months?
Data shows that the majority of rural elderly women used the services of GP in primary health care facilities, usually in the nearest ambulance station (Graph. 10). Elderly women in Nis County visit GP in a lower percentage than in other regions. However, should keep in mind that the main reason for visiting local GP is prescription of regular drugs. Basic Human Rights of the Elderly Women in Rural Areas in Serbia: Evaluation of Social and Health Security of the Elderly Rural Women Page 19
The elderly are usually the most frequent consumers of home care services. Data have shown that home care services are not available in all rural areas of the Country in which they are needed. Home care teams had visited only 2.5% of elderly women in rural areas of Kragujevac; in Nis County 14% percentage of respondents said that had been visited by home care teams; 10.5% in Subotica and 21.5% in Belgrade (Graph.11). Comparing these findings to data about reported needs of rural elderly women for home care services there is obvious gap between provided services and the need for them. Graph. 11 Have you been visited by home care professionals since last year?
Specialized medical examination including modern diagnostic procedures and therapies is available only in clinics and hospitals situated in urban areas. Only the respondents from the rural area of Belgrade in the last 12 months used these services in a greater extent (73.5%)( Graph.12) Graph. 12 Have you been visiting medical specialist in last 12 months (at local hospital)?
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Discrimination of the elderly regarding the referral to specialized medical examinations is not an unknown phenomenon in general. It is not rare that because of discriminatory attitudes among professional staff and often due to insufficient professional education in the field of geriatric practice, the elderly may be left deprived of specialized medical examinations. Reasons lay also in the fact that hospitals and specialized health care facilities are located in urban centers, and these services are centralized and thus often unavailable to population in the distant rural areas. Even more, undeveloped traffic infrastructures within rural areas and transport problems, associated with declined functional mobility of the elderly population, make additional reasons of why these services are less accessible to older population in rural areas. Graph. 13 Have you done medical examination in private practice in last 12 month last year?
Utilization of private health services, which requires direct payment, was at lowest level among rural elderly women. It should be noted that the private health sector in Serbia is not included in the regular national system of health insurance. Therefore, health care service done in private practice cannot be reimbursed from the National Fund of Health Care Insurance. Among total number of respondents who used private health care services there are mostly women living with family and children. Elderly women living alone were rarely among consumers of private care services. This data confirms once again that there is high social dependency of elderly women on family and that women living in single elderly households in the less extent have access to economical, social and health resources.
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Graph. 14 Do you check your health regularly according to medical recommandation?
Smaller percentage of elderly women in rural areas of Nis County than in other regions did regular health controls according to the recommendations of GP (Graph 14). Generally, these trends affect the complications of chronic disease in old age. Quality of life among chronically ill older persons can be affected by this attitude. Data on health life style among the rural elderly women, in particular in those related to regular gynecological examinations, has shown that women in our sample may had lower individual responsibility to own health. Namely, on question of "When did you visit last time the gynecologist?" the largest number of respondents said "long time ago, so do not remember when it was": in Kragujevac-79.3%; in Nis County 95%; in Subotica 75.5 %. Rural elderly women from Belgrade made exception – 29%. It could be explained by better health culture of respondents within Belgrade County, but also by better work of health care professionals in this region. On the question “Do you have difficulties to get to the nearest ambulance or health center?” most women said that they did not have difficulties (Graph 15). Still, some percentage of women in Nis County has a problem to rich the nearest ambulance: 42.5%. Among the total number of women in Nis County who reported difficulties, 66.67% stated transportation problems as the main difficulties, while 28.74% women stated functional disability or different health problems that affect functional mobility.
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Graph. 15 Do you have difficulties to get to the nearest ambulance or health centers?
Respondents generally reported more often a distance or transportation barrier as reasons for difficulties to get to the nearest ambulance center rather than physical immobility. Although higher percentages of the elderly rural women acquire medicines by themselves, still there is considerable percentage of them who need the support of the family member in order to do that. Graph. 16 Who helps you to get medicines ?
The results about the basic characteristic of health and functional abilities of rural elderly women in Nis County, as well as data about level of health care services utilization, are different from the same data on elderly women in other regions. In the area of rural settlements in Nis County, older women significantly less used the health care services, especially the specialized medical services. This to some extent explains the stated Basic Human Rights of the Elderly Women in Rural Areas in Serbia: Evaluation of Social and Health Security of the Elderly Rural Women Â Page Â 23
absence of diagnosed diseases, but also affects lower functional status of respondents. Functional disability, whether partial or complete, together with the undeveloped transportation infrastructure, make the availability of care services to the elderly from Nis County difficult. Support of family and social network has a crucial role in maintaining basic health and social security among elderly women in rural areas of Serbia. The question is “how long can professionals, as well as local political authorities, count on the informal support of family members in maintaining the basic health and social security of older women in rural areas?”. In other words, to what extent does the policy of care services decentralization aimed at increasing services availability, correlate with the demographic tendency of ageing population and with the significant increase of single elderly households in rural areas of the Country.
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III-3 Utilization of the social care services Data on the utilization of social care services in rural areas of the Country showed the very low level of availability to the elderly rural population. Basic services of social care such are the provision of financial aids have been used by a very small percentage of women. Among them the largest percentages were elderly women living alone and in state of social need, i.e. they were existentially very vulnerable. Also, other social care services such as housekeeping support have been rarely provided to our respondents. Table 3. Use of the basic social services Financial aids Beograd Subotica Kragujevac NiĹĄ
1% 4,5% 0.5% 5%
Housekeeping services 0 1% 0 2.5
The visits of social workers to elderly women in rural areas of Central and Serbia (Kragujevac, Belgrade, Subotica) have been stated very rare. Visits of workers to investigated population in the territory of a Nis County have been to extent more often and 15.5% of elderly women stated that they are visited by a worker (Graph 17).
North social some social
Graph. 17 - Visits of social workers in last 12 months?
Although the utilizations of social care services are to some extent frequent in rural areas of Nis County, there is still high disproportion between the services utilization and real needs, what will be confirmed by reported needs for services care, support and aids among the women. Basic Human Rights of the Elderly Women in Rural Areas in Serbia: Evaluation of Social and Health Security of the Elderly Rural Women Â Page Â 25
Low level of social care services utilization points to several significant problems and highlight few important issues. First of all, the reason lay in the high centralization of social services in the urban centers and lack of available services in rural areas. Namely, in the rural settlements there are no units of centers for social work that provides adequate and necessary service, and even information. I.e. primary health care services are provided to rural population by the health station or ambulance in rural settlements. Providing of services for social care to the rural elderly women in the villages is very rare, and usually is in extreme cases of their neglect. The second reason is luck of information about rights for different types of social care services (financial support, aids, different kind of material support etc). Luck of information is caused by low educational status of the target population, as well as by not providing adequate information by professionals. In particular the question is in what extent the national social care system is focused to providing care services to the extremely vulnerable people and in state of social needs, and in what extent it includes prevention and improvement of social welfare. Considering social care policy in the Country it is obvious that system doesn’t include the services aimed to prevention of social health, maintaining the social integration of elderly population, especially of those living in single households in the rural areas. Gerontological residential care did not noticed among our respondents. Also, it should be emphasized that in the system of social care in Serbia there is no "respite care service". The most accessible source of social care remains the support and assistance of informal social networks; such are family, friends and neighbors. Social activities. The social activities significantly determine the level of social integration and the psychosocial well-being of individuals, as well as the overall mental health. Analysis of data on the content and extent of social activity indicates that the most frequent social activity of the respondents was the participation in different types of family gatherings at the time of birthdays, glory, etc. Traveling and visits to cultural events almost were not represented. Institutions of culture rarely exist in rural settlements in Serbia. Institutions of culture in rural areas well known as a “home of culture” which existed in small towns and in villages have disappeared with the disappearance of socialism and communism in the Cuntry, where they have been more political centers for recruiting members than real cultural centers. The intensive migration of young population from rural to urban areas influenced failing any interest of local authorities to organize and maintain cultural activities in rural areas. As the rural settlements are smaller and more distant from the urban center, the situation is worse.
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Graph 18. Social Activities – Family gathering
Graph 19. Social Activities-Participating in Church Activities
Furthermore, the data on the intensity and content of social activities of our respondents indicate that in some extent elderly women in the region of Belgrade and Subotica, are more socially active in the sense that more often participate in family gathering, as well as in religious activities in local church. Analysis of data relating to social activities also
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points to the fact that the informal social network is the most important human resource in the maintaining of quality of life of elderly women.
Graph.20 Social Activities-Traveling
Graph.21 Social Activities Visits to Cultural Events
Largest percentages of rural elderly women spend their leisure time watching TV, and then socializing with members of family or friends and neighbors. Small percentage of respondents indicated travel as a way of using leisure time and in most reported cases that was visiting to family members or children which are living in urban centers. Physical activities and outgoing almost not exist as the way of spending leisure time among elderly women in rural areas of Serbia. Membership in different associations and clubs almost was not present. Exception was found in rural settlements within municipality of Subotica where there are well developed Basic Human Rights of the Elderly Women in Rural Areas in Serbia: Evaluation of Social and Health Security of the Elderly Rural Women Â Page Â 28
and decentralized network of social services, clubs and associations. Therefore, women from Subotica more often stated the membership of clubs and retirements’ associations.
Psychosocial wellbeing. Information on being alone and feelings of loneliness can be beneficial for understanding the psychosocial health and predisposition for the deterioration of psychological health. Data showed that elderly women in rural areas in a small percentage are never alone. Graph. 22 How often are you alone?
Data about feeling of loneliness of the elderly rural women showed some differences between regions. Elderly women in Subotica feel more often lonely than women in other regions. Graph 23. How often do you feel lonely?
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Feeling of loneliness is in correlations with marital status and life in the single or family household. Feeling of loneliness was most presented among widows and women living in single households. Widows within the territory of municipality Kragujevac stated in 61.6% that they feel often and sometimes alone, and among women living in single households, even 89.6% respondents stated that they feel often, and sometimes, alone. The elderly women in rural areas of Belgrade, who live in single households, also stated in 56.2% percentage that they often feel lonely. Feelings of loneliness affect the evaluation of satisfaction with present life. Living in single households, lacks of social contacts, rare and poor social activities cause the social isolation and the increase risk for depression, what furthermore affect the overall health status of person. Low psychosocial wellbeing increases the risk for the occurrence of different forms of neglect and abuse of elderly. (9) For these reasons, the appropriate identification of elderly persons who are at risk for social isolation and deterioration of psychological health, associated with organization of effective psychological and social support to such people, is the best way of improving psychosocial welfare and social security. The worldâ€™s studies indicate that gender significantly affects the mental health and psychosocial well-being, which is in correlation with factors such as age and social support. (25) Some studies have shown that depression and dissatisfaction with present life among women are closely related to negative attitudes towards them, and lack of recognition for their work, lack of opportunity for education and employment, etc. The risk for mental health and poor psychosocial well-being is in correlation with the indicators of poverty. (21, 25) Self-assessment of financial (economical) situation of the majority of respondents points to some self-control in their assessment of the real situation, because the largest percentage of them estimated the current financial situation as satisfactory. More real picture on the financial situation of elderly women in rural areas in Serbia we have got when we asked respondents to compare financial state with the situation ten years ago. Basic Human Rights of the Elderly Women in Rural Areas in Serbia: Evaluation of Social and Health Security of the Elderly Rural Women Â Page Â 30
Highest percentage of elderly rural women assessed financial situation as worse in comparison to ten years ago. Exceptions are the elderly women of the rural settlements of region of Kragujevac, where more respondents said that financial situation is better (16.7%) than ten years ago, but also a great number of them were no willing to say. Therefore, it is difficult to assume that women from Kragujevac really assessed their financial situation as better. Generally, it is difficult to conclude how much is this self-assessment associated to the aging process, and in what extent it is a consequence of the economicsâ€™ crisis in the Country.
Graph. 24 What do you think about your economical situation at the moment?
Graph. 25 What do you think about your economical situation in comparation to it ten years ago?
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Satisfaction with present life is an important dimension of psychosocial wellbeing of the individual as well. Self-assessment on satisfaction with present life in a great extent reflects the real living conditions of elderly women in rural areas than other data. On the question of “How much you are satisfied with the present life?” a significant percentage of respondents, except in Belgrade, declared that they are unsatisfied or very unsatisfied.
Graph. 25 Are you satisfied with present life?
Needs for care services, support and aids. Self-estimation for a variety of support Basic Human Rights of the Elderly Women in Rural Areas in Serbia: Evaluation of Social and Health Security of the Elderly Rural Women Page 32
services and aids confirmed that different services are not available to older women in rural areas of Serbia as much as it needed. Rural elderly women from Kragujevac region have not been willing to answer on question whether they have a need for a support services or aids. Services which were are offered included support in housekeeping, manicure and pedicure services, support in preparing and bringing food, support in socializing and talking, home care services, support for visiting GP, help to acquire drugs, need for hearing aids, glasses, other aid (state). Majority of women said that they don’t have a need for one of these services. Such position, which we supposed was not in accordance with the objective assessment of the need for a service, it is difficult to explain, except with some cultural patterns of behavior. Namely, in traditional and patriarchal culture, women are trained from the youngest on sacrifice through the life course in favor of male family members. Long life denial of the needs on behalf of better life of her husband and children, associated with the lack of own income, limited access to family economics’ resources, lack of information on the rights, etc, among the elderly women creates a feeling of inferiority and negative attitude that "nothing is needed." On the other hand, the rural elderly women within Nis County stated in a larger extent needs for different kind of support services and aids. The most significant need is support to acquire drugs in 60.5% percentage of respondents; 59.5% of women stated that they need support in visiting GP; 53% respondents also stated that they need home care services. Data showed that 39% of respondents have a need for support in housekeeping and over 51% of persons stated that they have need for providing hairdressing services and cutting nails on their feet in their house. Also, 24.5% of elderly women did not hide their need for different kinds of psychosocial support such as need for someone for socializing, talking and so on.
Graph. 26 Self-assessment of the needs for different types of service care, support, and aids
Assessment of the needs for different types of services, support and aids, is an important indicator of priorities in developing appropriate care and support services.
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Elderly women in the rural area of Subotica reported in less percentage needs for services and support comparing with women in other regions. The most common need among women in Subotica was need for home care services:19.5%, and support to visiting GP:19%. North part of Serbia, especially Subotica has developed network of gerontological public and civil care services, so we can assume that the many needs of the elderly well provided by it. On the question can they afford the payment for some of the services if they need it, 40% women from Subotica Region reported they could. Graph. 27 Subjective assessments of the needs for different types of service care, support, and aids
Elderly rural women within the Belgrade territory reported in the highest percentage need for home care services and support in housekeeping (64%). On the question “Can you afford the payment some of service”, 42% percentage of women from Belgrade Region answered that they could. Elderly population from Central and South Serbia cannot in larger extent afford payment of some of services if they need any, what was within expectations considering poorer living standards in this part of the Country Table. 5 Could you afford the payment of some services?
Beograd Subotica Kragujevac Niš
YES 42 40 29 32
NO 58 59 42 64
Diffcult to say 0 1 29 3
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Among women who stated that they can afford the payment majority were women living with family (either with spouse or with children), what confirms fact that there is a high socioeconomically dependence of elderly women on their family members. ...... Generally, all data indicate that the family and life within the family household is the most important determinant of support and security in state of need. Self estimation of life satisfaction, the feelings of loneliness, the intensity of social activities, as well as self estimation of the need for different types of services are determined by the social networks, i.e. family. Any kind of dependency (economical, social or psychological) influences the terms of social security of the elderly rural women, particularly does in the situation of transition which affects the changing the structure and roles of traditional family. III-4 Informal care services Almost all data show that the informal support of the social network, family and friends are the most important resource of support and care in the present situation. The importance of informal support is still high because of low availability of other formal forms of care (public and private services). Activists of civil organizations rarely appear as a provider of support services in distant rural areas. Family members and social network are most often used as resource of help and support, whether it is a material or financial support, support in acquirement of drugs, help to visiting GP, or in performing activities of daily living, etc..
Graph. 28 Who is the most often source of support and help in overcoming your daily activities?
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The most frequent source of help and support in all Regions is spouse and children, and in less percentage neighbors and friends. The strength (functionality) of the informal support was measured by frequency of providing help and support in performing everyday activities. Graph. 29 How often you have support when is needed?
In the municipality of Kragujevac, the relationship with neighbors and friends in 71% of the cases described as close relationships with mutual help when it is necessary, 26.8% of women described the relationship with the member of wider social network as good relations but with rarely visits or help. Low percentages of respondents do not have any contacts with neighbors.
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On the territory of the Nis County, relationship with neighbors 63.5% of respondents described as a close with mutual support and assistance, 3.5% of elderly women described relationship with neighbors as good, but without the mutual support. In the rural settlements of the Belgrade region, the largest number of respondents, 87.5% of them, have good relations with neighbors, 11.5% have good relations without mutual visits and support, and only 2 respondents do not have any contact with neighbors. In the north of the country, in Subotica, 59.5% of women reported that they have very good relations with neighbors, with the mutual support, and 37.5% of them have good relations but without mutual support and visits, and only 6 (3%) women do not have any contact with neighbors. Providing support services by civil sector to vulnerable groups have been developing in recent years in Serbia. Unfortunately, the wide range of services is mostly provided in urban centers. Geographicaly distant rural settlements are often out of reach of missions of many non-governmental, non-profit and humanitarian organizations and associations of citizens. In the investigated area of the municipality of Kragujevac, 87.9% of elderly women have never been visited by representatives of civil organizations or by volunteers. Also, 97% of the elderly rural women said that never received some type of help, support or service of civil society. Within rural territory of Nis County, availability of the services provided by civil organizations is low as well. The percentage of 82.5% of women said that they never have been visited by some of NGOs, and 88.5% of women didn’t receive any type of support services of civil organizations. The same number of older women said that they would accept some support from non-governmental, humanitarian and similar non-profit organizations if there is need. While in the region of Belgrade there is the largest number of networks and organizations of civil society, unfortunately, their activities ends somewhere on the boundaries of the urban areas of the City. In rural settlements of the city of Belgrade, 88.5% of older women have never been visited by some NGOs, only 7% of women believed that there were no need for it, and 4.5% of elderly women said that do not want and they wouldn’t receive anything from NGO. Only one respondent received help of a humanitarian organizations and that was fuel. In north of the Country, in Subotica, as it was said, there is a better developed network of services, such as public, private and civil, so we found a lower percentage of respondents that have never been visited by representatives of civil society. The percentage of 39.5% elderly rural women believed that there were no need, and 0.5 % of respondents do not want and would not have received support.
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IV DISCUSSION The results of this study confirmed the majority of initial assumptions (hypothesis). Obtained results are within the expectations, as well as according to contemporary knowledge about the population of elderly women in the rural areas of underdeveloped and developing countries. Low level of education, a high percentage of illiteracy, unemployment over the life course, lack of own income, lack of pension insurance, have resulted in low socioeconomic status of the elderly women living in rural areas of the Country. All of these factors predispose poor and unequal terms of social and health security in years of ageing. Social exclusion of all important resources over the rural womenâ€™s life course had drawn them on high risk for poverty and deprivation of basic terms of health and social security Research has confirmed the assumption that the majorities of elderly rural women achieved the right on health insurance either through husband employment or as benefit guaranteed by Low on Health Care as they rich 65+ years. From the legal point of view, the State provides terms for health and social security, and elderly women have the formal right on health and social care services. However, this formal right does not mean the real security and it does not mean the availability of care services. This is confirmed by data about the level of health and social care services utilization which is in gap with reported needs for it. This is particularly obvious in needs and usage of health care services among our elderly women. As we supposed the level of health care services utilization is low in all regions, and moving from north to south of the Country it decreases. Within the territory of south Serbia (Nis County) situation is worst and rural elderly women in the lowest percentage used different types of health care services. Implications of it are deterioration in functional status and increasing functional dependency, which are followed by often reported needs for services, support and aids among rural elderly women in Nis County, particularly need for home care services, support to visiting GP and need for support to acquiring drugs, which was in the great extent have been reported among elderly women within Nis County. Namely, according to data about morbidity obtained through self-reported diagnosis it is difficult to generalize information about the health status of respondents. Within the territory of municipality of Kragujevac, rural elderly women in a greater extent are familiar to their health status, because in the higher percentage they do regular health controls and more often use public health services. We can conclude that this control of the own health affected the better functional capacity of the elderly women from the rural areas of Central Serbia. The level of health care services utilization within the territory of the Belgrade and Subotica is somewhat higher, especially when it comes to the use of specialized health care services which is recognized, first of all, as a result of higher economic standard of the regions, as well as results of more developed institutional and transportation infrastructure of these areas of the Country. According to better health control of these women, a lower percentage of the respondents stated need for different types of services. Women from Subotica reported in significantly less percentage the need for different type of care services, what could be explained by more developed network of care services in Subotica and its better availability. Basic Human Rights of the Elderly Women in Rural Areas in Serbia: Evaluation of Social and Health Security of the Elderly Rural Women Â Page Â 38
Health status of the rural elderly women is in part a consequence of aging and decline of many biological and psychological functions, but in a part it is affected by absence of public care for health of elderly population. As we have seen, visits to the GP in the nearest ambulance were present in nearly 80% of percentage among the elderly women in all regions. Question is in what extent a low percentage of specialized health care services utilization among respondents is a result of distance of specialized hospitals and problems related to transport, or it is result of lack of referral to specialized health care institutions by the GPs. Geographical distance and difficulties related to transportation are the causes which are easily visible and measurable. However, the other causes can be found in prejudices and stereotypes about the elderly and aging what could be common attitude among general practitioners, as well as in their low training in geriatrics care and gerontology. (9). Attitude that ageing necessarily means “disability and illness” and acceptance of each symptom of disease as implication of ageing process results in unfair deprivation of modern diagnostic procedures to this population, and/or lack of providing all the necessary information ("That is the age, nothing can be do"). Shortage of providing specialized diagnostic procedures and therapies to the elderly population is one of the frequent latent types of elder abuse and age discrimination. Non unavailable high-quality health care services to vulnerable groups leads to impairment of health status that furthermore increases the risk for the functional immobility, risk for hospitalization or even for permanent institutionalization. This trend affects, not only quality of life in old age, either it could influences costs of the care. Due to greater prevalence of chronic diseases and multiply pathology in old age the elderly population needs much more ongoing care, which is the best, provided by home care service. It is well known that elderly population is the largest customer of home care services. (27) Therefore, availability of home care services should present a priority for local health authorities. Data regarding to needs for different type of services and support among respondents confirmed that the most reported need of rural elderly women in all regions was need for home care service. The level of social care service utilization in investigated rural areas is low. The two most frequently used services from the social care system are two types of financial aids and it were used by small number of women. The same situation is with housekeeping support service. Social care services in Serbia are mainly focused at solving the basic existential problems of individuals that are in state of social need. Research also confirmed that the local centers for social work (social worker visits) interfere only in extreme cases of need, where the elderly women lived alone, without relatives and/or children, without income and usually seriously ill and neglected. Care for the social health, including services aimed to improve psychosocial wellbeing through the maintaining the social activity and social integration into social network, and to maintain the satisfaction with the present life are not developed as part of preventive care in public social care institutions. In such circumstances it is difficult to identify people who might be at risk for abuse or neglect. Basic Human Rights of the Elderly Women in Rural Areas in Serbia: Evaluation of Social and Health Security of the Elderly Rural Women Page 39
Social health is a significant dimension of overall health. However, many findings have confirmed that social health (in the sense of social engagement, maintaining of social roles and social integration, etc) has a greater impact on quality of life and satisfaction with present life than it has physical health (6.10). Rural women are mainly over the life course focused to care for family, raising children and providing care for the family member. Aging naturally brings changes in all aspects of social life including loss of social roles, diminishing social networks, etc. Intensity of social activities reduces and itâ€™s followed by rising feelings of loneliness and dissatisfaction with present life, which affects the increase of risks for mental health. The results showed that the level of satisfaction with present life is in correlation with the intensity and content of social activities. Elderly women who have stated that they are not satisfied with their current life in the over 50% of the cases are rarely participated in the family gathering, which is one of the most favored social activity of elderly women in rural areas of Serbia. The social care system in the Country does not include services that would be aimed at the prevention of social health in particular to the vulnerable groups, as it was not recognized psychosocial support services to investigated population of rural elderly women Low level of social care services utilization points to several significant problems and a few important issues. First of all, in the Country and regions there is high centralization of social care services in the urban areas. Namely, in the rural settlements there are no units (as a part of local social care centers) that provide necessary service, and even information. Primary health care services are provided to rural population through the work of local ambulance, at least. Providing social care services for population of elderly women in the villages are very rare, and in extreme cases of neglect. The second important issue is lack of information of elderly women regarding to their rights on the different types of care services. This is influenced by low education and illiterate among rural elderly women and at the same time lack of appropriate information. Providing adequate health and social security to elderly women in rural areas is difficult due the absence of developed integrated care system, and as well as due the lack of comprehensive and holistic approach to assessment of health and social needs which are closely related in old age. Unfortunately, experience shows that that the coordination and cooperation between these two sectors in the Country is inadequate. In general, the Constitution and low guarantee rights on social and health security to the elderly population, but elderly female living in rural areas very often are not in a situation to achieve those rights in everyday life. There is obviously gap between the official and legal rights versus the empowerment of women to achieve these rights. The reasons are many and can be divided on several levels:
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On individual level - low level of education; high social and economical dependency; luck of information of elderly women about their rights for different types of services, functional dependency in old age On institutional level - high centralization of care services in urban institutions, lack of institutional capacity, and that lack of trained professional resources in these areas. The content, scope and intensity of available health and social services often are not sufficiently adapted to the real needs of elderly women in rural areas. On community level – geographical distance of rural settlements, underdeveloped rural traffic infrastructure and transportation barriers etc.(Among population who have difficulties to get nearest ambulance majority reported a geographical distance and transportation barrier as reasons for it more than it was physical disabilities On regional level – the lack of strategy for sustainable social and economical development of rural areas Experience of developed countries indicate that the deficits of public services to some extent is compensated by strengthening the civil services and close cooperation between the public and civil sector in providing services and support to vulnerable groups. The civil sector has been developing intensively in Serbia since last decade. Activities and missions of the civil sector are various, and many of NGOs through its activity substituted lacks of public care services. Since the latest time there is strong development of a female movement centered on promotion of women’s rights. Unfortunately, experiences show that even the existing NGOs in the Country, which are dealing with issues on women’s rights, are mostly directed to the economical and political emancipation of women, sex abuse and family violence. This issue on quality of life among rural women is still marginalized within current projects of the civil sector. Even NGOs that deal with issues on elderly care ends with their activities somewhere on the periphery of the cities and suburban settlements. Limited funds and lack of support of local governmental authorities usually restrict the implementation of the activities of NGOs. On the territory of the investigated regions there are many registered non-governmental organizations, associations, and humanitarian organization. According to data of Directory of the Center for Development of Non-profit Sector in Serbia, within the territory of Kragujevac there are currently 70 registered non-profit organizations, within the territory of Nis there were 59 different NGOs, in Subotica there are 55 different civil organizations. Belgrade certainly has the most developed network of NGOs and civil society in general; currently within the territory of Belgrade there are over 600 registered non-governmental organizations. Judging by the number could be concluded that the civil sector is well developed in the investigated areas. On the other hand, the numbers of visits of non-governmental organizations to rural elderly women are rarely reported by respondents.
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Conclusion Considering general data and existing experience and knowledge, as well as the results of this research we have come to next conclusion: The basic social and health security - in mean of well provided and available wide network of integrated care services, which are adjusted to real need, and which affect the maintaining of social and health wellbeing of the elderly rural women, - is determined to a greater extent by the existence of social network, which play crucial role in providing services, support and aids. As the research showed, the informal social network appears as the most important resource of financial, social and psychological well-being of the elderly women. Living with the family, as well influence the subjective perception of health and correlate with satisfaction with life. Living within the family also affects subjective estimation of personal possibilities to pay some care services. Taking into account research results and data of other studies in the Country it is confirmed that elderly rural women in Serbia “suffer” of over life social exclusion from the main economical and social resource, such as education, employment, health, social and political decision-making processes, and in a large extent they socioeconomically depend on the members of family. The social exclusion in this extent, together with some characteristics of ageing process, influence the achievement of the basic human and civil rights of this vulnerable group. Besides their personal “poverty”, low level of basic social and health security of elderly rural women in Serbia is determined by centralizated policy care, insufficient development of rural areas in the Country and by absence of GENDER SENSITIVE STRATEGIES for social and economic development in the Country. The local community to a greater extent can rely on the support of social network and family in providing elderly care in rural areas at the moment. Unfortunately, the social transition and the contemporary political and social changes affect the changing of rural family. Therefore, the first step of local communities would be development of alternative sources of care which will follow changes of traditional rural family. As a priority, taking into account many obstacles in achieving modern and adequate system of care, could be legislative and financial support to the development of civil sectors in rural areas or to support their services availability to the rural regions. The improvement of the availability of public and institutional care capacity in rural areas should be realized as long-term goal, considering the economic conditions of regions and Country. In contemporary Serbia the population of younger women in rural areas live in similar socio-cultural milieu, still with low educational level and functionally illiterate, without regular own income, economically dependent and trapped in the traditional and patriarchal culture. Taking into mind the fact that the process of social reform slowly arrive in the rural parts of the Country, it can be expected that the elderly rural women of Serbia will face the problems of inadequate health and social security for a very long time. Basic Human Rights of the Elderly Women in Rural Areas in Serbia: Evaluation of Social and Health Security of the Elderly Rural Women Page 42
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To know how to grow old is the master work of wisdom, and one of the most difficult chapters in great art of living Henri Frederic Amiel (1821-1881) Basic Human Rights of the Elderly Women in Rural Areas in Serbia: Evaluation of Social and Health Security of the Elderly Rural Women Â Page Â 45