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Challenges of Ageing Societiesin the Visegrad Countries

EDITED BYZSUZSA SZÉMAN

WARSAW

PRAGUE

BRATISLAVA

BUDAPEST

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Challenges of Ageing Societies in the Visegrad Countries: Hungary, Czech Republic, Poland, Slovakia

Hungarian Charity Service of the Order of Malta, Budapest, 2013Imre KozmaZsuzsa Széman, Institute for Sociology, Centre for Social Sciences, Hungarian Academy of Sciences Dániel SolymáriElayne Antalffy978-963-89445-4-2

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contents 3

Lajos Gyôri Foreword

Zsuzsa Széman Challenges of Ageing in the Visegrad Countries: Introduction

Zsolt Spéder, Lajos Bálint Ageing in the Visegrad Countries: Selected Demographic and Sociological Aspects

Jolanta Perek-Białas Some Socio-economic Consequences of Population Ageing in Selected Central and Eastern European Countries

Bernardina Bodnárová Population Ageing – Impacts and Challenges in the Slovak Republic

Ágota Scharle Integrated Employment and Rehabilitation Services: New Evidence from Hungary

Olga Tóth Intimate Partner Violence Against Older Women

Kai Leichsenring Constructing Long-term Care Systems in Europe – Theoretical Considerations and Examples of Innovative Practice

Tünde Turai What is a Migrant Care Worker? Being at the Crossroads of Servant, Family Member and Nurse Status

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Iva Holmerová, Hana Vanková, Petr Wija Opportunities and Challenges for Integrated Provision of Long-term Care Services in the Czech Republic

Teodóra Németh Rácz The Impacts of an Intervention Program on the Quality of Life of Elderly Recipients of Social Services

Lucie Vidovicova Future Cities for the People of the Past, or Vice Versa? The Dynamic Chal-lenges of Ageing and Urbanization

Greta Garniss A Brief Discussion of the Factors Driving the Demand for Independent Senior Housing: Poland Zsuzsa Széman Elderly-friendly Housing Model: Results of an Action Research

Csaba Kucsera Improving the Quality of Life of the Elderly with ICT – Results of an R&D Project

Zsuzsa Széman Skype as a Means of Integrating Older People In Long-term Care: An Action Research


Lajos Bálint

He is research fellow at the Demographic Research Institute of the Hungarian Central Statistical Office. Graduated from University of Pécs in Sociology and Social Policy. He earned his Ph.D in Geography at the University of Pécs. His main scientific interest is spatial models, quantitative geography and spatial demography.

Bernardína Bodnárová, PhD

Graduated from Comenius University in Bratislava with a major in sociology and political economy. In 1977 started to work in the Slovak Academy of Science at the Institute of Sociology, where she later completed her PhD. Here she specialized in surveys aimed on rural population structure and rural migration. From 1998 she worked in the Research Institute for Labour, Social Affairs and Family where she specialized in social policy transfor-mation. In 2001 she returned to the Slovak Academy of Science (Institute for Forecasting) where she continued in the study of issues of social policy transformation and ageing. Now she works in the Institute for Labour and Family Research where she has been concentrating on various research issues such as services for families, domestic violence, poverty in Slovakia, child beggars and so on. She has also participated in international research programmes: “Local Democracy Innovation” coopera-tion of Norway, Czech Republic, Hungary, Poland and Slovakia; “Family, Employment and Education” coop-

eration between Czech Republic and Slovakia); “Quality of Life in Caregivers of Dependent People Affected by Incontinence in Europe” cooperation of Netherlands, Italy, Slovakia and Sweden; “Reflections of Recent Demographic Conditions on Family and Social Policies in CEE Countries”, participation of Belarus, Hungary, Lithuania, Romania and Slovakia. She has authored and co-authored expert studies and books on social policy transformation, domestic violence, local democracy in-novation, family issues.

Greta E. Garniss, MA

Fulbright Scholar at the Institute of Economics and Management at Jagiellonian University (2011-2013). She has over 10 years of experience performing market and feasibility studies for affordable and senior hous-ing developments in the United States and has been performing real estate and senior housing research in Poland for four years. A graduate of Boston Univer-sity (Boston, Massachusetts), she received her Masters degree from Jagiellonian University in 2011, with her thesis focusing on senior housing issues and needs in Poland. Affiliated with the European Property Insti-tute in Krakow, she is continuing and expanding her research on seniors and housing needs in Poland.

Iva Holmerová, MD, PhD, Assoc. Prof

Founding director and consultant geriatrician at the Centre of Gerontology in Prague 8 (Gerontologické centrum) since 1992. Associate professor of the Faculty of Humanities, Charles University in Prague, Ph.D. in social gerontology (quality of care), postgraduate de-gree in public health, general and geriatric medicine. 2007-2008 member of group on palliative care (Alzhe-imer Europe), since 2008 board member of Alzheimer Europe and since 2011 its vice-president. 2007-2011 president of the Czech Society of Gerontology and Geriatrics and committee member of IAGG (on behalf of the CGGS), since 2011 vice-president of CGGS and full board member of EUGMS. Co-founding member (since 1997) and chairperson of the Czech Alzheimer Society. Head of CELLO-ILC-CZ (Centre of Exper-tise in Longevity and Long-term Care) at the Faculty of Humanities, Charles University in Prague, president of International Longevity Centre, Czech Republic. In her publications she focuses on dementia, geriatric long-term care, and the organisation of services for older persons.

Csaba Kucsera, PhD

Researcher at the Centre for Social Sciences, Hungar-ian Academy of Sciences. He earned his PhD in Sociol-ogy at the Eötvös Loránd University, Budapest. His


main field of scientific interest is the ageing of societies, and related issues such as ICT use in eldercare, social networks, loneliness, social support, subjective quality of life, research methodology. He has teaching experi-ence in research methodology and public opinion research, and social psychology.

Kai Leichsenring, Dr.phil

Studied Political Sciences, Communication and Languages at the University of Vienna. He lives and works as a self-employed researcher and consultant in Italy, collaborating on European and local development projects in particular with the European Centre for Social Welfare Policy and Research in Vienna (Austria), emmeerre soc.coop. (Italy), E-Qalin Ltd. (Austria) and other agencies in the area of health and social policies. His research and consulting focus entails comparative social research in the area of long-term care and public health, especially with respect to older people in need of help and care (rehabilitation, social services, quality management). Kai has participated in a large number of transnational research and consultancy projects funded by regional, national and EU agencies and was the Coordinator of ‘Health systems and long-term care for older people in Europe – Modelling the interfaces and links between prevention, rehabilitation, quality of services and informal care’ (INTERLINKS) during the European Commission’s research programme. He has also designed, organised and/or evaluated numerous

workshops, seminars and conferences on a national and international level. He has published a great number of reports and articles and edited some books, e.g. (ed. with J. Billings and H. Nies) (2013) Long-term care in Europe – Improving Policy and Practice. Basingstoke: Palgrave Macmillan.

Teodóra Németh

Graduated from Eötvös Loránd University in social policy. In 1989 started to work in the practice field of social policy (catering services for families, later started to work for elderly people). Meanwhile became a lecturer at Széchenyi István University Gyôr, where she started to lead group work for students doing their long-term practice course. Then her next course (still leading it) was social work with elderly people. In 2002 she became deputy manager of the United Health and Social Care Institute Gyôr. From 2008 the Institute is also a Regional Methodological Centre for Social Care and she is responsible for its work. She is a member of the National Specialists of Social Policy in the field of social care of elderly people. Her main interest is the possibilities for improving the quality of life for eld-erly people, especially for those who live in residential homes or are users of any kind of social services for elderly people. For that reason she researches the ef-fects of physical exercise intervention programmes on the quality of life.

Jolanta Perek-Białas, Dr., PhD

Statistician and economist (PhD, 2001, Institute of Sta-tistics and Demography, Warsaw School of Economics, Poland). She was a participant of the Young Scientist Summer Programme in IIASA, Vienna, Austria (1997) and received a Prof. Leslie Kish scholarship in the Institute for Social Research, University of Michigan, Ann Arbor, USA (2002). She was also a fellow of the ERSTE Foundation under the “Generations in Dia-logue” Programme in 2009-2010. Currently she works at the Warsaw School of Economics and since 2001 also in the Institute of Sociology of the Jagiellonian University in Kraków, Poland. Since 1999 she has been involved in international projects under the 5th, 6th and 7th Framework Programmes of the EU related to active ageing policy and relevant topics: PEN – REF, ACTIVAGE, TRIPLE-DOSE and ASPA. As well she has been active in projects financed by the Norwegian Research Council of Science, VW Foundation, other European projects and just recently – since February 2012 – OECD/LEED Programme in Poland. She is also an expert and advisor in projects on ageing issues at the national and regional level of Poland. Her main scientific research interests include socio-economic consequences of population ageing in Poland, and in selected Central and Eastern European countries, active ageing policy, reconciliation of work and care, social exclusion/inclusion of older people.

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Ágota Scharle, PhD

Senior research partner at the Budapest Institute for Policy Analysis, responsible for designing and implementing quantitative evaluations of public policy interventions. She has over 15 years of experience in research and public administration. Her main research interests are the effects of taxation and the welfare sys-tem on labour supply and income redistribution. Her recent work includes quantitative evaluations of the employment effect of rehabilitation services, public works, and a targeted wage subsidy. Previously she was Head of research in the Hungarian Finance Ministry between 2005 and 2008. Her recent publications in-clude From pensions to public works (an edited volume on two decades of Hungarian employment policy), Jobs quality in post-socialist accession countries (chapter in Hurley, Fernandez-Macias, Storrie: Transformation of employment structures in the EU and USA) and Hungary: fiscal pressures and a rising resentment against the (idle) poor (chapter in Clasen and Clegg: Regulating the risk of unemployment).

Zsolt Spéder, Dr., PhD

Director of the Demographic Research Institute of the Hungarian Central Statistical Office, full profes-sor at the Department of Sociology, Arts Faculty of the University of Pécs, member of the board of the European Association of Population Studies (EAPS).

He carries out research in the field of poverty and inequalities, fertility, family formation and ageing. He has extensive experience in empirical data analyses, especially in the area of longitudinal follow-up stud-ies. In his analyses he attaches great importance to international comparative investigations. For decades he has been participating in various Hungarian and international research co-operation projects. In recent years he has participated in the FRERTINT, REPRO and LIFETIMING research programs. He is one of the founders and an active member of the Generation and Gender Program (GGP). He regularly publishes in Hungarian and international journals such as Demográfia, Szociológiai Szemle, European Journal of Population Studies, Population Studies, and Demo-graphic Research.

Zsuzsa Széman, Dr., PhD

Senior Research Fellow of the Institute for Sociol-ogy, Centre for Social Sciences, Hungarian Academy of Sciences. She has authored and edited more than 20 books and more than 300 articles and research reports. She has been a member of the editorial committee of the European Journal of Ageing for many years. She has worked on various EU projects since 1992 (includ-ing ENABLE-AGE, MOBILATE, EUROFAMCARE, Ageing and Employment, Employment Initiatives for an Ageing Workforce, HAPPY AGEING, CARICT) and other international research projects (NISW,

Japanese projects: PIE; Nonprofit sector). Her main re-search interests include: ageing workforces, eldercare, long-term care, migrant care workers, pension reform, social ageing, ageing on the labour market, social policy and ageing, good practices, quality of life, and the nonprofit sector. She has initiated several action re-searches and started model programs and intervention programs. She has been one of the experts elaborating the long-term Hungarian Strategy for Ageing People. Dr Széman has given numerous lectures and presenta-tions in Hungary and abroad.

Olga Tóth, PhD

Senior Research Fellow at Institute of Sociology, Centre for Social Sciences, Hungarian Academy of Sciences. She finished her education at Karl Marx University of Economics, Budapest. Her main fields of research are: changing gender roles, domestic violence, changing family patterns and connection between generations. Since 1998, she has been a participant and principal researcher in a number of international comparative studies.

Tünde Turai, PhD

Graduated in 2000 from Babes-Bolyai University, De-partment of Ethnography, Folklore and Anthropology and the Department of Hungarian Literature and Lan-


guage. She obtained her MA degree in the Hungarian Social- and Ethno-Linguistics Study Program. She continued her studies at Eötvös Lóránd University and obtained a PhD in 2009 in the European Ethnology PhD Study Program. Tünde Turai’s fields of interest are: the elderly, international migration, migrant care workers, multigenerational relations, care work, net-work, border regions. She has done fieldwork in several countries: Hungary, Romania, Austria, Italy, Republic of Moldova, Ukraine, Israel, Serbia.

She has published many articles and chapters in books. Her main results have been published in two books: Öreg ember nem vénember. (Elders, not olds) Balassi Kiadó, Budapest, 2010; Az életút végén. Szilágyborzási idôsek társadalomi helyzetének vizs-gálata (At the End of the Life Course. Analysis of the Social Situation of the Elderly of Bozieş). Cluj: KJNT, 2004, 196 pp. Tünde Turai began her scientific career as a museologist at the Museum of Ethnography (Budapest). Since 2006 she has been a researcher at the Hungarian Academy of Sciences, Institute of Ethnology. Recently she has also been teaching at the International Student Program of Corvinus University.

Hana Vanková, M.D. Graduated from 3rd Faculty of Medicine, Charles University, Prague, in 2002. She specializes in research in long-term care for seniors, quality of care,pain assessment and management, and instruments for

functional capacity assessment. Since 2005 she has been working as researcher and research co-ordinator at the Centre of Expertise in Longevity and Long-term Care,International Longevity Centre of the Czech Republic at the Faculty of Humanities of the Charles University and at collaborating Gerontological Centre Prague 8, where she serves also as a physician. She is a lecturer at 3rd Faculty of Medicine, Charles Uni-versity. At present she has been studying in doctoral programme in biomedicine at the Faculty of Humani-ties of the Charles University.

Lucie Vidovicova, MA, PhD

Sociologist, Faculty of Social Studies, Masaryk Univer-sity & Research Institute for Labour and Social Affairs, Brno, Czech Republic.

Her long-term research interests include sociology of ageing, environmental gerontology, age discrimina-tion, and active ageing. She is also involved in research projects in the field of family and social policy. She con-ducts research for national as well as European bodies and works as a consultant on a number of implementa-tion projects such as Ageing in the media and Teaching about ageing. Lucie also cooperates with different governmental and NGO bodies in the field of senior ad-vocacy. Her experience includes involvement with the European projects DIALOG (HPSE-CT-2002-00153) and ActivAge (HPSE-CT-2002-00102), and coop-eration with EUROFOUND. Recent projects she has

been involved in include surveys of older consumers, age discrimination (www.ageismus.cz) and ageing in big cities (http://starnuti.fss.muni.cz).

Petr Wija, MA, PhD

Graduated from the Faculty of Philosophy, University of Ostrava. In 2007 he completed doctoral studies with a thesis on ageing and social policy. Between 2003 and 2010 he worked at the Ministry of Labour and Social Affairs, where he specialised in social policy and age-ing, long-term care, and international co-operation. He has served, among others, as national focal point on ageing and secretary of the Government Council for Seniors and Population Ageing. Currently he works at the Institute of Health Information and Statistics and as research assistant at the Centre of Expertise in Longevity and Long-term Care, International Longevity Centre of the Czech Republic at the Faculty of Humanities of the Charles University. Petr Wija is a member of the professional associations in social medicine, gerontology and geriatrics, and demography.

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The European Union is in a process of significant population ageing, the working-age population is shrinking, while the over-65 population is increasing. The strongest pressure is expected to occur during the period 2015-35 when the baby-boom generation enters retirement. This presents challenges for sus-tainable public finances, in particular the financing of health care and pensions, and could weaken the solidarity between generations. But this view neglects the significant actual and potential contribution that older people — and the baby-boom cohorts in particu-lar — can make to society.

The focus of the present book is to explore the

problems of ageing societies in the Visegrad countries: the Czech Republic, Hungary, Poland and Slovakia, that is, to analyse problems of the ageing workforce, good care practices for those in long-term care, the situation of (formal and informal) carers. The conditions in the Visegrad countries, due to their geo-

graphic and historic situation, show a varied picture with differences, similarities, problems and solutions, including innovative responses to the challenges. The book hopes to serve as a link between the English and non-English speaking world by disseminating the newest results that can give a better understanding of the ageing process of the four Central Eastern Euro-pean countries, the Visegrad countries. As ageing is an urgent challenge in all European countries, the book offers a good opportunity to learn the newest research results and best practices transferrable to old and new members states. The authors of the papers have already been maintaining good partnerships, partici-pating in several joint projects and so they continue to disseminate their experiences and knowledge making it accessible for a wide audience also in this e-book. 2012 was designated as the “European Year for Active Ageing”. The initiative aimed to help create better job opportunities and working conditions for the growing numbers of older people in Europe to help them take

an active role in society, encourage healthy ageing and seek solutions to the steadily ageing population and its impacts on public services and finances.

The “Challenges of the Ageing Societies in the Visegrad Countries” provides an opportunity for researchers, policy-makers and the general public to get to know these countries.

ForewordLAJOS GYÔRI


The ageing trend in Europe and in the world is well documented, countless research projects have been launched on the topic and the old EU Member countries are leading in research analys-ing the most varied aspects of ageing. Abundant literature reporting on their findings is available in English. The European Union too gives high priority to the problem and supports research on various aspects, attaching importance to the participation of new Member countries. One example is the 2013-2016 research project – MOPACT

“Mobilising The Potential Of Active Ageing In Eu-rope” – with the participation not only of Hungary and Poland but also of Romania and the Baltic countries at the specific request of the EU “to ensure that New Member State perspectives are fully represented”. As a result one or more countries of Eastern Europe are present in the majority of the EU research projects. At the same time a great deal of national research is also being carried out in the new Member countries; only a fraction of this is known internationally, mainly in cases where the research is linked to an EU project. The advantage of the old Member countries over the East European countries’ research on ageing is their dominant use of English. The publications presenting the results of research on ageing in the countries of Eastern Europe in national languages are less known and are accessible with difficulty or not at all for the old Member countries. The “West” still has a tendency

to regard the “East” as a homogeneous unit. In reality the new Member countries of Eastern and Central Eastern Europe are highly diverse even geographically: many of them, including the political group known as the Visegrad Four comprising Poland, Slovakia, the Czech Republic and Hungary, belong to Central Europe. (Other countries also belong to the Central European region: Hungary’s neighbours Romania and Slovenia.) There are both similarities and differences in the social challenges raised by ageing in the Central European region and in particular in the Visegrad Four. But they share one characteristic in common. Their research findings are hardly or not at all accessible for the “English-using” world with the result that it still has a distorted image of ageing in “Eastern Europe”. The present book aims to reduce this gap by showing the ageing challenges in the Visegrad Four.

The original aim was to publish the papers of a conference held in November 2011 on Challenges of

ageing societies in the Visegrad countries. The present book covers a much broader spectrum as the confer-ence revealed a variety of recent research that not only paints a comprehensive picture of the challenges of ageing in the four countries, but also formulates answers and presents the results of action researches serving as good examples that can be applied in practice. The book is thus in line with the direction represented by the European Union that urges the exploration, publication and demonstration of the transferability of good examples that can be put into practice in the near future. Each of the articles is a separate unit but together they trace an interlocking picture. The first part of the book focuses on the analy-sis of challenges of demographic trends, population ageing, macro socio-economic, labour market trends, societal, environmental, ICT and care challenges with special emphasis on long-term care. This is followed by the “answers”, solutions easing the problem along three main lines: human resources (e.g. migrants, and the “use” of a new type of volunteering as a human care resource), architectural/environmental; infocommuni-cation. The innovative ways of “handling” the problem, action researches and intervention programmes are presented with the intention of arousing interest: it is possible to handle the problem, there exist easily transferrable solutions.

There is one “odd man out” in the book: the study on violence committed in the family against elderly women. Although the theme does not appear to fit into

Introduction: Challenges of Ageing in the Visegrad CountriesZSUZSA SZÉMAN

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the train of thought outlined above, its publication is important because it throws light on a new and so far unexplored problem and so it is in harmony with the book’s emphasis on innovation.

The essay by Spéder and Bálint lays the foundations, placing the demographic trends and phenomena of the Visegrad Four in a comprehensive context, revealing the similarities and striking differences between them (such as the fact that Hungary is the only country in the region where the ageing trend goes together with a substantial decline in population because of the poor mortality rates). It points out that even within the four there are no fixed clusters: a given country is grouped with another country in one respect and then from a different angle with another. Regarding the depend-ency ratio, for example, Hungary and Poland belong to one type (the 4.2 and 3.6 percentage points growth in their dependency ratios are by far the worst figures). But in the case of life expectancy at 65 Hungary is in the same category as Slovakia (16.5 and 16.3 years), while Poland (17.6 years) is grouped with the Czech Republic (17.4 years). An exciting part of the article analyses changes in “becoming aware of old age”, the social situation and perception of the elderly. The

“old-age awareness” of people in the Visegrad countries is close to the European average: it appears in those in their late fifties, but in many EU countries this awareness does not emerge until considerably later in life and even many of those aged 70–74 years still consider themselves as middle-aged. Regarding social

perception, the article points out that in the Visegrad countries the status of the middle-aged is judged to be the best. At the same time there is a substantial devia-tion in the perception of the difference in social status of the young and the old. In Poland and Slovakia the situation of the young is felt to be much better than that of the old, while in the Czech Republic and Hungary hardly any difference can be seen between the two.

In her paper Perek-Białas discusses the possible socio-economic consequences of population ageing in the Visegrad and Baltic countries by examining and comparing countries which joined the EU after 2004 and after 2007 (Bulgaria and Romania). She compares the employment rate of workers aged 55-64 and points out that for both men and women it is especially low in Poland and Hungary while in the Czech Republic, Lithuania and Slovakia it was over 50% for men; in all countries women over 50 years were characterised by a lower employment rate. The author notes different explanations for the low employment rate of older people such as the knowledge gap: the majority of older people lack the ICT/technical skills and foreign lan-guage knowledge required by employers. An important part of the paper is the examination of retirement behaviour, analysing the average actual age of retire-ment versus the official age. Increasing the retirement age is one of the remedies for the shrinking and ageing workforce. However the median ideal retirement age for men in all countries is 60 years while the median ideal retirement age for women in all countries is 55

years (in Estonia 58 years), but in Poland it was the low-est for women (53.2 years). The author points out that in recent years regulations have changed sometimes very quickly and unexpectedly and this may influ-ence the retirement behaviour of older people. The introduction of a higher retirement age in Poland (to 67 years) on the one hand will decrease the inactivity rate, but on the other hand in Hungary compulsory re-tirement at 62 for public service workers instead of the already though gradually introduced retirement age (to 65 years) will increase the already high inactivity rate. The paper concludes that the Visegrad countries (CEE) cannot be treated as one homogeneous group of countries with similar challenges. The heterogeneity is found not only in official and available statistical and demographic indicators, but is revealed by surveys and studies analysed in the paper, as well as cultural and public policy differences between these countries.

Bodnárová presents demographic trends in Slova-kia and describes their consequences for the macro-economic sphere and the labour market. The long-term decline in the birth rate and relatively stable mortality rate together with the longer life span are leading to an increase in both the number and proportion of older persons in Slovakia, representing a great burden for the pension system. The response to this problem was the introduction of a pension reform in 2004 and 2005 based on three pillars: social insurance (pay-as-you-go system); personal savings (a key change in the trans-formation of the pension system) and supplementary


pension scheme. The paper shows that Slovakia has been characterised by a very early age of departure from the labour market, and based on labour market surveys it points out the factors that could postpone exit (flexible working time, new skills, good state of health) and those which could encourage exit (loss of job, health problems or disability, favourable financial arrangement). Besides the increase of retirement age (as part of the pension reform), the paper emphasises also other factors favouring this increase such as anti-discrimination law, positive bonuses for those who con-tinue to work beyond retirement age; allowing people to receive a salary and pension without any reduction. As a consequence the former very low average exit age of 57.5 years for old-age pensioners and 56.8 years for early retirees increased in 2005. The paper points out gender inequality on the problem of increasing uniform pension age. According to a labour market survey women showed a negative attitude towards equalising the retirement age and go into retirement later: 57.6% of women (and one third of men) definitely rejected the idea. The reason for the desire of women for a lower retirement age may be the different family tasks, especially eldercare (as well as other care tasks) they have traditionally been responsible for. In the paper the Slovakian trends are parts of a wider context comparing the Slovakian figures with those for the Visegrad countries.

Scharle points out the labour market participa-tion of disabled workers and briefly reviews the de-

mographic factors behind it. The paper notes the negative trend, while employment of disabled workers decreased between 2008 and 2011 there was a big increase in their unemployment rate. The paper de-scribes the evolution of the policy context (regulation, sheltered workshop, rehabilitation services, incentive to employ disabled people, etc.) in order to identify options for improvement. The last part of the paper summarises recent research results on the impact of rehabilitation services and based on that, makes some recommendations for redesigning the system of state subsidies. It also presents the results of a three-phase survey of rehabilitation services provided by sheltered workshops and NGOs conducted in 2010. This shows that the reemployment chance of NGO clients is 30 to 50 times higher compared to disabled workers in a sheltered workshop, controlling for individual charac-teristics and the local labour market. The best service providers can place 33-49% of their clients in unsubsi-dised jobs in the regular labour market. It stresses that the full social integration of disabled people clearly requires reforms: a gradual reduction of employment subsidies, an expansion of rehabilitation services and better-designed incentives for all actors.

Based on an international project where two Viseg-rad countries, Poland and Hungary, also participated the paper presented by Tóth explores an “untouched” theme: the intimate partner violence against older women. To reveal it a variety of methods were used such as review of existing institutional data on intimate

partner violence against older women; institutional survey; staff interviews; victim interviews; national ex-pert networks. The author points out that it is very rare that a person becomes the victim of one type of abuse only, as victims they suffered 3-4 kinds of abuse such as physical, sexual, verbal, financial, neglect, sexual harassment, stalking. The paper analyses the perpetra-tor, circumstances of committing the act, perception of the problem of IPV against older women, social impor-tance and negligence of the problem and latency. Tóth emphasises the low degree of sensitivity to the topic, mentioning that only one-fourth of questionnaires sent out to institutions in Hungary were returned. When the institutions were asked “why”, the oral reply was that they considered the topic uninteresting, unimpor-tant. The paper concludes that the most important is the fact that experts’ attention has been drawn to the abuse of older women.

The problem of care and in particular long-term care already appeared as a side effect in the analysis of the pension system in Bodnárová’s paper. Leichensen-ring focuses on constructing long-term care systems in Europe from a theoretical perspective and based on the European INTERLINKS project also shows examples of innovative practice. He mentions the con-sequences of the lack of care work causing care migra-tion between Central and Eastern European countries Poland, the Czech Republic, Hungary, Slovakia, but also Romania, Bulgaria or Ukraine and in particular Austria, Germany, Italy, Spain to compensate for the

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lack of services by employing domestic assistants mainly without a contract or legal basis. With pensions and cash benefits the elderly are able to pay monthly wages for 24-hour care which, in the migrant carers’ countries of origin, would hardly be attainable. Besides the thorough theoretical analysis the author identifies on-going innovation in long-term care. The paper illus-trates a few of the roughly 100 practice examples of the project. It points out the reason for their implementa-tion, gives their description and their effects. The R.O.S.A. project (an acronym standing for Network for Employment and Care Services) for example aims to establish a system to support people who need or provide care by matching supply and demand through a network linking different institutional bodies and social stakeholders. Their important objectives are to support families in finding qualified Italian and mi-grant care workers; to sustain the supply and demand of home-care services by qualified and regular employ-ment contracts; to provide private (Italian and migrant) care workers with continuing education in order to guarantee quality of care work; to improve knowledge about undeclared work in home care services in order to combat it; to create a system that allows working women to balance work and family life. The Dutch Buurtzorg model was designed with the objective of providing integrated home care, i.e. with connections to social services, general practitioners, and other pro-viders, for all persons who need care at home. The aim was to deliver care by small self-managing teams of no more than 12 professionals. The Buurtzorg method

has six sequential components, which are delivered as a coherent package and cannot be delivered separately: assessment, mapping and involving the network of informal care as well as formal carers, care delivery, support of the client in his/her social roles and the promotion of self-care and independence. The model introduced on the strictly regulated quasi-market of Dutch home care in 2006 was widespread by mid-2010, teams were active in 250 locations, with a total number of staff in these teams of 2,600. The author concludes that LTC is under construction in ALL parts of Eu-rope and it is important to learn from other countries before planning an individual service or facility, and by adapting innovations from abroad to the local or regional context.

Turai’s paper is a kind of “answer” to one phenom-enon referred to in a previous paper. Leichensenring mentioned the East-West trend of migrant care work-ers and with Hungary among the sending countries. Turai’s paper based on a two-year empirical research focuses on the migrant eldercarer but also exploring the other side of the coin: Hungary is not only a send-ing country but a receiving country as well. Hungar-ian families employ “invisible” migrant elder carers in long-term care, who enter the domestic sector in the same way as the Hungarians in Austria, that is, often undocumented. It examines migrants coming to Hun-gary from Romania and Ukraine (in both countries from regions with Hungarian ethnic minorities) and carers from Hungary going to work abroad (among oth-

ers to Austria and Germany). Drawing on these results the paper shows how migrant eldercarers fit into the formal and informal eldercare system, the interface where migrants perform their activity, and the role played by migrant care workers in the informal sphere from the viewpoint of their very complex role. Turai points out several important research results such as the finding that residential care work performed by the migrant care workers outside of the formal system is at the intersection of familialistic work; the structural position of the care workers is partially the gap left by the social security system; monetary value of the care work has an impact on the shift of the migrant care workers towards professional nurses at a certain level; being skilled or unskilled in care work has no relevance in the selection mechanisms (to employ the migrants) as the personal experiences in care duties within their own family network seem to play a much more import role. The quality of relationships among the actors (family, migrant, the place of the care stage in the personal career and life expectations, and the monetary value of the care work; the main principles that shift the care work performed by the migrant women are less the structural factors, and much more the subjective elements.

The paper of Holmerová, Vaňková and Wija presents different approaches to understanding the role, scope and goals of the long-term care system. It points out that the role of LTC systems is not only to provide services to persons with loss or decrease


in self-care capacity, but also to address other risks needing protection such as costs of care, financial con-sequences, social exclusion of carers from the labour market, social exclusion of both persons providing and receiving care, abuse, dignity and freedoms of people dependent on long-term care. The paper describes a wide range of debates and interpretation of LTC, and analyses factors contributing to change in demand for long-term care. It also pays attention to the use of ICT in the provision of long-term care creating a supportive and safe environment for frail seniors. ICT can ease the burden and mitigate risks for informal carers as well and bridge barriers between the social and health services. The authors pay special attention to the role of healthy life expectancy and present different scenarios and theses. The provision of long-term care for seniors in the Czech Republic is analysed in this wider context. The paper shows that social services and health facili-ties have different systems of registration of providers, quality standards, system of financing, responsibility of state, regions and municipalities, sources and ways of financing. Despite important changes, very often long-term care in hospitals is insufficiently equipped, located in decrepit hospital buildings, sometimes also with significant architectural barriers. Family members are not satisfied with the quality of care even though it is free. One of the problems is that older per-sons with very similar health conditions and needs to those in health facilities can be found in the social care system (residential institutions) under other legislation. The authors analyse different types of social care and

the possibilities of integrated LTC provision in the Czech Republic and emphasise the innovative roles of scientific NGOs such as the Czech Alzheimer Associa-tion or GEMA with their projects and elaboration of new services and programs. The paper points out the indispensable role of the macro level for establishing a functioning system of integrated care services, im-plementing an active ageing strategy and age-friendly policies at local level as well.

Németh looks at an interesting intervention programme. According to the hypothesis the effect of physical activity on the mental state, attitude to life and quality of life becomes measurable and clearly perceptible over a longer period. An intervention pro-gramme (started in 2008) was elaborated for elderly persons living in residential homes and in clubs for the elderly in groups doing physical exercise and com-pared to a control group. The research clearly showed the improvement of both physical and mental state already over a short period (15 weeks of exercise). The autonomy and social participation of those taking part in the research and doing exercises is improved com-pared to the control group not doing exercise and there was a strong desire to continue the program. The paper emphasises that physical activity, especially in homes for the aged, can reduce conflict situations if the life of the residents is enriched with active participation.

The following three papers focus on the role of the environment. Vidovidoca points out that in the context

of East Central Europe little attention has been paid to the issue of the urban environment in which older people live. To find the quality of life of older people in cities of East Central Europe she compares the four Visegrad countries and focuses on the Czech situation. The project on “The Quality of Life of Older People Living in Cities in the Czech Republic included thir-teen larger cities in every region of the Czech Republic and the capital city. The study concentrated on quality of life for seniors who had left their home at least once within the last six months, in regard to the external characteristics of their environment. Beside the ex-pected results, e.g. persons with greater disability are usually among the people less satisfied with their sur-roundings or satisfaction falls with increasing age, an interesting research result is how turnover among the neighbours, the social-physical dynamic in their neigh-bourhood influences the perception of older people. It has a connection to the immobility of people over 60 in the Czech Republic who have lived in their homes an average of 30 years (the same phenomenon exists in Hungary) and the majority of them are not considering moving in the near future. As long as the majority is old neighbours, seniors rate the changes positively. But if there is a fundamental change in the composition of the neighbourhood and most old neighbours are gone the negative evaluation of the whole neighbourhood is considerably higher. The author points out also other factors influencing the feeling of older people towards their environment such as fears of danger, a general feeling lurking in the outside world, afraid at night,

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afraid during daylight but there are significant differ-ences between places and not all towns are equally age-friendly. The message, among others, is that to-day’s cities need an elder-friendly urban environment planning to counter the cumulative disadvantages.

Garniss’s paper focuses on the problems of older people’s housing from four aspects: individual, social, material, economic. It points out the Polish housing market’s goal to build and develop nursing homes and public/social housing units for the growing number of seniors who do not need or want the level of care in a nursing home and who are over the income level of eligibility for public/social housing. Recent research has shown that seniors do not plan on living with their adult children, nor do they want to be a burden to them when they are older. The author has been conducting quantitative research in two Polish towns (Cracow and Gdansk) and the results show that seniors have definite opinions about where they expect to live when they grow older and in most of the cases it is not with the family. Nursing homes not providing privacy are not viewed favourably either. Different problems of growing old however, such as high maintenance costs, obstacles in the home and in the outside environment need solutions. The architectural barriers can lead seniors to change their residence because they do not feel safe in their own homes. The paper emphasises the importance of new obstacle-free homes/flats.

Széman’s paper gives concrete examples of how the problem mentioned above can be solved. The main goal of a follow-up model programme (2003-2005) was to show that frail older people (aged 75+, receiving formal social care) could continue living at home safely and independently despite their changed functions and the deterioration in their health if the obstacles in their homes are removed and their immediate environment is adapted to their loss of functions, and that it would have a remarkable cost-effective impact on the macro level as well. The research that included different types of housing and was carried out in different types of settlements clearly showed the following. Obstacles in the home and not the state of health caused a quarter of the falls. The follow-up after one year of making a flat obstacle-free at relatively low cost clearly found a great reduction in the number of falls. But this success could be achieved only because the opinions of older people on the alterations were taken into consideration. Many of them not only preferred but wanted out-of-date, old-fashioned technical solutions, so innovative but tailor-made solutions were therefore needed. The life of older people who liked the alterations changed basically, ensured safety, security, freedom and in-creased their quality of life. At the same time, altering the home environment brings benefits at macro level as well. It was calculated that the relatively small cost of the one-off alteration is only half of the cost of a one-week hospital treatment for a hip fracture and less than half of the cost of a one-year stay in a residential home operated with state normative funding.

Kucsera writes about the experiences of an inter-national research and development project aimed at creating an ICT device that could potentially enhance the quality of life of elderly persons living alone with at least one chronic condition. While the spread of the use of different kinds of advanced ICT devices in everyday life in the wider society is a relatively new phenomenon, the idea of using ICT in eldercare and elder support is a novel one and many parallel projects are working on it simultaneously in various countries. This is not an area that offers straightforward technical answers to the problems in the life of the elderly; as their problems are very heterogeneous, and moreover the ICT use among the elderly is one of the lowest in the subgroups of society. Nevertheless, Kucsera reports on some interesting results, and shares the experience that might be useful for the wider R&D audience working on this field as well and shows how different modules elaborated in the project such as “Lifestyle monitor”, “Navigation assistant”, and “Personal as-sistant” (with the goal of helping to prevent falls, find objects, measure medication, etc.) can potentially improve the quality of life of the elderly.

The European Commission states in the Summary Reflections 2010 that loneliness, dependency and isola-tion are among the causes of depression and in serious cases lead to suicide among the elderly. The action research conducted by Széman in 2011 approached this problem. The basic hypothesis of this issue was that if the use of Skype that is already widespread


among young people were to be taught to older people who required long-term care, were lonely, depressed and had no computer and internet skills, they would feel less isolated despite their poor health. The model programme (in the capital and in a county seat) in-cluded 15 older persons, two with suicide attempts. It proved that even very elderly, sick persons in need of care are capable of learning to use Skype, something entirely foreign to them, if they have the motivation and are given sufficient help. Young volunteers gladly transferred to them their internet skills that are an integral part of their lives and in doing so they learn to love the elderly people, understand their problems and gain empathy. The enormous infocommunication gap between the youngest and the frail oldest generation will disappear and with the help of the young volun-teers they will have the very latest internet skills. In this way the young people can play an important role in social inclusion of the elderly and help to eliminate the social prejudice that elderly persons in need of care, with deteriorating functions and a poor state of health are incapable of acquiring the skills needed for modern technology. An important lesson is the change in interpersonal relations. They show not a shrinking but an expanding personal network, including family members, old friends and new ones acquired on the internet. By ongoing learning of computer and internet skills, old frail people will become integral, equal members of society and the care burden of both formal and informal care will be eased.

KEY WORDS: POPULATION AGEING, ELDERLY, VISEGRAD COUNTRIES, ASSESSMENT OF THE SOCIETAL STANDING OF THE ELDERLY, FAMILY STRUCTURE


Introduction

The aim of our analysis is to present a few aspects of a universal process characterising the developed societies, the ageing of the population, in order to show where the Visegrad countries stand in this comprehensive change and what distinguishing characteristics they have in this respect. Naturally, our analysis cannot cover all aspects: the problem of ageing is now the subject of research not only in demography but in practically all branches of the social sciences, not to mention medical science. We attempt to apply certain considerations of two disciplines, demography and sociology, and we will not deal with the aspects of social policy or economics. Even so, the task is too broad but the crystallised approaches and indicators of the two disciplines will allow us to examine essential characteristics of the process of ageing.

1. Demographic approach

Ageing is the result of demographic processes where the life expectancy is increasing and the level of fertil-ity is low and/or duratively decreasing, and as a con-sequence, the proportion of the elderly exceeds that of the young age groups. Ageing of the population at the level of society is a global phenomenon (UN 2008,

Vaupel 2010). This is also true for the postcommunist region, including the four Visegrad countries (Chawla et al. 2007). In order to show the processes of ageing characteristic of the region, wherever possible we have taken into account the values for the European Union as a whole, as well as those of neighbouring Austria that in all respects displays the features of Western European social development and demographic be-haviour patterns.

1.1. Population ageing: indicators and trends

Numerous demographic indicators are available for defining old age and measuring ageing (Sanderson

– Scherbov 2008, Siegel 2011). The simplest and still generally applied criterion regards the population 65

years and older as old. Other indicators use a higher age limit (for example, 75 years) taking into account the general improvement in the life expectancy of the population and the adjustment of the pension system to this. Accordingly, the widening social group of the elderly is not regarded as a uniform and homogenous age group, different sub-groups are distinguished within it by age (Siegel, 2011). In the case of the Cen-tral East European region the choice of the lower age limit can still be regarded as acceptable.

In the Visegrad countries with a total population exceeding 64 million, the elderly population increased by more than two million between 1990 and 2010 (from 6.99 million to 9.09 million) and as a result one citizen out of seven (14.2%) in this region is now over the age of 65, while at the time of the collapse of the socialist system their proportion was around 11%. However, comparison with the average for the EU member states shows a considerable difference. In the EU as a whole the proportion of the elderly in 2010 was 17.4%, and the same value was found in Austria (17.6%). The higher proportion of the elderly is due in part to the more favourable mortality rates in the societies of Western Europe and in part to the fertility dynamics of the earlier period and the migration balance of the different age groups. The steady rise in the proportion of the elderly population can be regarded as general in the countries and the region examined (Figure 1). But, unlike them, Hungary is the only country where the population ageing is accompanied by a substantial decline in the population.

Ageing in the Visegrad Countries: Selected Demographic and Sociological AspectsZSOLT SPÉDER–LAJOS BÁLINT

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Over the past two decades the proportion of the elderly in the region has grown by 2-3.5 percentage points. The differences that can be observed between the countries at the time of the change of system have remained largely unchanged, although there has been a more striking deviation between the Polish and Slovak trends. Despite the adverse mortality rates, among the Visegrad countries the proportion of the elderly contin-ues to be the highest in Hungary. As we will see, this

is not due to the longer life expectancy in Hungary but rather to characteristics of the age structure which, with rare exceptions, can be attributed to the past effect of fertility (Siegel 2011). Thus, from the demographic viewpoint the macro-level processes of ageing cannot be separated from the trend in fertility. In the early nineties the level of fertil-

ity was still quite uneven within the region. As a result the proportion of the population 14 years and younger was slightly more than one fifth of the total population in Poland and Slovakia (25.3-25.5%), the same value in the Czech Republic was 21,7%, while in Hungary it was 20.5%. Nowadays the fertility differences are much smaller. The proportion of the young in the countries of the Visegrad region in 2010 ranged only within the domain of 14.2-15.3%.

Besides the proportion of the elderly population, other frequently used indi-cators are the old-age dependency ratio and the ageing index. The dependency

ratio is the proportion of the elderly (65 years and over) to the population of working age (15-64 years), while the ageing index shows the proportion of the elderly to the population 14 years and younger (Figure 2)1.

1 Thanks to the expansion of education, besides the threshold of 15 years, it is in cases also drawn at 18 and 20 years, and it follows that the lower limit of the population of working age is adjusted accordingly.

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Figure 1 :: Proportion of the population 65 years and over in the Visegrad countries, the European Union and Austria between 1990 and 2010, %

Source: Eurostat (demo_pjanbroad), authors’ own compilation

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Figure 2 :: The old-age dependency ratio in the Visegrad countries, the European Union and Austria 1990-2010, %

Source: Eurostat (demo_pjanbroad), authors’ own compilation


However, all the Visegrad countries had a rate lower than the average for the European Union. The trends in the old-age dependency ratio within the region reflect different rates of increase. Among the countries of the region Slovakia had the lowest ratio of elderly to persons of working age. The Slovak time series has been very stable over the past two decades. Between 1990 and 2010 the dependency ratio increased by barely one percentage point. In contrast the increase in Hungary and Poland was 4.2 and 3.6 percentage points respectively. Despite the more substantial increase, the Polish dependency rate continued to be lower than the figure for the Czech Republic where it was really only after 2005 that the trend began to accelerate. Hungary differs considerably from each of the other Visegrad countries, both in the year of the change of system and at the present time. And the differences at present are greater than they were two decades ago.

Similar tendencies can be read from the ageing index (Figure 3). As a result of the radical decline in the number of children born, the ageing index of 45.6% in 1990 rose to 94.8% percent by 2010 among the Visegrad countries. The balance in the numbers of the elderly and the young has shifted towards the old in the Czech Republic and Hungary since 2006-2007. In these two countries there are 11 elderly for every 10 young persons. The same figure was 8 for Slovakia and 7 for Poland. Nevertheless, it is worth noting that the Czech (107%) and Hungarian (112.6%) values cor-respond to the EU average (111.2%).

1.2. Life expectancy of the elderly

The life expectancy of the population, the mortality rate can be calculated most precisely from the mortal-ity table that enables us to determine the life expect-ancy for any exact age or age interval. Continuing to apply the earlier defined age threshold of 65 years, let us examine life expectancy by gender and for the population as a whole.

Life expectancy at the age of 65 in 2010 in Austria was approximately 20 years, which proved to be slightly higher than for the EU as a whole. Within the Viseg-rad region the Poles could count on liv-ing a further 17.6 years and the Czechs 17.4 years at the level of mortality for the given year for the age group. The almost identical figures for the Hungarian and Slovak populations (16.5 and 16.3 years) show a lag not only behind the western mortality pattern but also compared to the other two countries of the region, al-though the differences are considerably less than they are for life expectancy at birth, that is, at age zero.

Life expectancy at birth for women in Hungary was 6.1 years lower than in Austria (80.8 years) in 2010. Slovakia lags

with 5.2 years, Poland with 4.1 years, and Czech Republic with 3.1 behind the Aus-

trian figures. Comparing the present situation to that of the early nineties, there has been an improvement in overall life expectancy everywhere with the most substantial improvement in the Czech Republic (3.7 years), and the most moderate (2 years) in Slovakia that separated from it. The unfavourable life expectancy of the Hungarian population within the Central East European region existed already before the societal transition (Bálint 2010:166-168, Vallin 2004). The lag

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Figure 3 :: The ageing index in the Visegrad countries, the European Union and Austria 1990-2010, %

Source: Eurostat (demo_pjanbroad)

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can be attributed to specific components of the mor-tality structure; primarily the outstandingly high risk of cardiovascular diseases and cancer, and digestive diseases among the middle-aged can be regarded as the dominant factor, and the role of factors related to health behaviour can be clearly associated with those risks (Kovács-Ôri 2009, Valkovics, 2001). The East-West di-vide in the life expectancy of the European population is not a new phenomenon. The recent history of general mortality in the East European and even more the East Central European region can be interpreted in the con-text of catching up to and falling behind the West. It is at the same time important to note that there have been more and less successful actors of this pulsating move-ment even within the same period. It should be stressed above all that life expectancy in old age has improved everywhere over the last two decades. In all countries this improvement could be described very precisely as a linear trend, but the rate of increase differed from country to country.2 The life expectancy for men and women at the age of 65 does not differ greatly from the above. The figures for Austria representing the Western mortality pattern indicate lasting growth in spite of starting from a higher basis. The same is true, although to a lesser extent, for the Visegrad countries. After the

2 Oeppen and Vaupel (2002) claim that the linear trends of life prospects in the countries with the highest life expectancies can be well described and predicted. Bongaarts examined the long-term trends (1850-2000) in the mortality of different age groups and predicted a slowdown in improvement compared to the scenario of Oeppen and Vaupel (Bongaarts 2006).

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Figure 4 :: Trend in life expectancy at 65 in the Visegrad countries and in Austria, 1990-2010, years

Source: Eurostat Database (demo_mlifetable)


change of system a very small degree of catching up occurred among Czech men, while the lag of the other three members of the Visegrad Four grew appreci-ably. In the case of Polish men it grew by close to one year (0.82), among Hungarian men by a year and a half (1.43), and in the case of the Slovaks by close to two years (1.81) compared to 1990! The divergence was less char-acteristic in the case of women, because Czech and Polish women were able to achieve an improvement in life expectancy similar to or even better than that of the Austrians (3.3 years). In contrast life expectancy at 65 for Hungarian and even more for Slovak women improved to a much more modest extent (the former from 15.4 to 18.2 years, the latter from 16 to 18 years).

1.3. Regional demographic differences in the Visegrad countries

NUTS2-level regional data will be used here to il-lustrate the regional inequalities. There are 35 regions within the Visegrad countries, each with a population of approximately 1-2 million, although there are a few

with well below a million (Bratislavský kraj) and Polish regions with a population exceeding three million (Malopolskie, Slaskie, Wielkopolskie, Mazowieckie).

The indicators of ageing revealed quite similar regional characteristics, whichever one we select we find the same regional structure. It can be said in general on the basis of the regional pattern that the differences within the countries on the whole proved to be less than those between the countries. This is also indicated by the fact that the values within a country generally fall between two points. The proportion of the elderly within the Visegrad region was the highest in Hungary, and all the Hungarian regions were char-

acterised by ageing. At the other end of the spectrum we find the Slovak regions with a low ageing population. At the macro level there was only a slight difference between the Czech and the Polish figures. On the basis of extent the differences between the Polish regions were greater, with a clear South-west-North-east divide within the country.

The picture regarding life expectancy at 65 was relatively uniform. There was no regional pattern of difference between the genders. Here too the differences appeared mainly between the

countries, while differences within the country were relatively slight. The regions of Hungary and Slovakia showing demographic behaviour departing from the Visegrad region generally figured among the last. Even the central regions of the two countries (Bratislavský kraj, Közép-Magyarország) produced life expectancy less favourable than for the Visegrad region as a whole. Higher values can be observed in the North-east and Eastern regions of Poland, life chances in old age are less favourable in the central part of the country, while the likewise homogeneous western part of the country represented a transition between the two. The highest differences of around 2-2.1 years were found in the

Old-age dependency ratio, %

15,6 - 17,517,6 - 19,419,5 - 21,121,2 - 23,023,1 - 25,8

Ageing index, %

61,5 - 82,182,2 - 92,993,0 - 102,3102,4 - 112,0112,1 - 129,5

Old-age dependency ratio, %

15,6 - 17,517,6 - 19,419,5 - 21,121,2 - 23,023,1 - 25,8

Ageing index, %

61,5 - 82,182,2 - 92,993,0 - 102,3102,4 - 112,0112,1 - 129,5

11,1 - 12,612,7 - 13,813,9 - 15,015,1 - 16,116,2 - 17,6

Proportion of elderly, %

Figure 5 :: Indicators of ageing in the NUTS2 regions of the Visegrad countries, 2010

Source: Eurostat Database (demo_mlifetable)

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Czech regions regardless of gender. However, this was due to the markedly high values for the region of the Czech capital (Praha).

2. Sociological aspects

From the middle of the last century in the wake of the comprehensive expansion of the welfare state, the three-fold division of the life course became institu-tionalised (Kohli 2007). While the expansion of educa-tion marked the borderline between childhood and adulthood universally, the expansion and universality

of the pension systems made “retirement” a marker of old age, and statutory retirement age the age line between middle course and old age. At the turn of the millennium, following new waves of modernisation and individualisation, the earlier borderlines marking both the attainment of adulthood and the beginning of ageing are becoming increasingly blurred. As regards the third stage of the life course, the change of roles and status once assumed to occur at the same age have become separated (Moen 2006). A key role in this separation has been played by the “freezing” of the retirement age and indeed its gradual creeping down to an ever lower age, and by the steady growth

in life expectancy as a result of which the period spent in good health after retirement is becoming longer. Numerous further factors are making the lives of those aged between 50 and 70 years increasingly ‘pluralised’: it is sufficient to think of the appearance and extension of early retirement, the questioning of traditional occu-pational careers organised on the basis of seniority, or of “secondary” and voluntary employment after retire-ment (Moen 2006, Anxo et al. 2010, Spéder et al. 2010). At the same time there is also a general improvement in people’s health, and life expectancy is increasing. The phases of the family cycle earlier regarded as “clas-sical” are also undergoing change. While earlier the life of the elderly after their last child had left home was characterised by the elderly couple with an “empty nest”, followed by a solitary life after one of the couple died, today there is a rise in divorces in old age increas-ingly followed by new partnerships. It is not possible here to examine all the status-changes alongside the life course3 but the processes to be presented in the following clearly show that we need to have a much more differentiated picture of ageing, of the last third of the life course.

3 In an earlier study we attempted to give a brief but comprehen-sive picture of life course transitions in the changing Hungarian institutional environment (Spéder, Kapitány, Naumann 2010).

Men

13,213,3 - 14,114,2 - 14,514,6 - 15,215,3 - 16,5

17,5 - 18,118,2 - 18,618,7 - 19,119,2 - 19,619,7 - 20,2

WomenMen

13,213,3 - 14,114,2 - 14,514,6 - 15,215,3 - 16,5

17,5 - 18,118,2 - 18,618,7 - 19,119,2 - 19,619,7 - 20,2

Women Total

15,7 - 16,416,5 - 17,317,2 - 17,417,5 - 17,817,9 - 18,5

Figure 6 :: Life expectancy at 65 in the NUTS2 regions of the Visegrad countries in 2010, years

Source: Eurostat Regional Statistics Database (demo_r_mlifexp), authors’ own compilation


2.1. Changes in the life course4

2.1.1. Trends in the health status

of the elderly

It is a commonplace that everyone’s health deteriorates with advancing age, and there is an increase in illnesses (that become chronic), visits to the doctor, and the use of medicines. This gradual deterioration in the health is shown in our figure, where the trend in the observed or subjective health status can be seen with advancing age. (Figure 7) (In this case the subjects were asked to indicate their satisfaction with their health on a scale of 0-10.) Although we are aware of the weaknesses of

4 This chapter uses the figures and interpretations of our earlier study (Bálint-Spéder 2012).

this variable, countless analyses confirm the strong correlation between the so-called subjective or perceived health status of the individual and the (objec-tive) health status as determined by a specialist (doctor). Although in reality individuals either have an illness (blood pressure problem, gastric disorder, spinal problem, etc.) or they do not, so we cannot speak of degrees but rather of binary situations (ill/not ill), the human body does gradually wear out and vari-ous signs of disease accumulate. This is manifested in the gradual deterioration of the health visible in the diagram. In other words, it is not possible to identify a specific age before which people can be regarded as healthy and after which as ill or suffer-ing from disorders of old age.

There is no essential difference between the gen-ders in proportion: the slightly greater deterioration in the health of women can also be attributed to the selection effect of (male) mortality.

The trend in another variable measuring the health status and quality of life – the proportion of those “restricted in everyday life by illness” – shows a similar picture as the percentage of those who are restricted grows steadily. The change of pace with the growth of problems as age advances is reflected in this

variable, as well as differences between the genders. Although the proportion of those who are restricted is high even among those in their early 60s (approx. 40 %), it is only after the age of 70 that a serious deterioration, a stronger growth in the percentage of those restricted occurs. Only barely more than one third of the very old are not restricted in their everyday lives. This means that in Hungary a substantial deterioration in the qual-ity of life can be expected around the age of 70. The lower level of restriction in the case of men may be the result of selection, their higher mortality rate.

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Figure 7 :: Satisfaction with health on a scale of 0-10 (0 = not at all satisfied, 10 = fully satisfied)

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Figure 8 :: Impeded in everyday activity by health problem, illness, disability

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2.1.2. Changes in family structure;

family relations and loneliness

It often escapes our attention that changes in family structure are also frequent among the elderly, although of course they are (basically) shaped by processes and events of a different nature from those that lead to changes in the case of the young or middle-aged. Chil-dren moving away from home, death of the spouse, later moving in with children are the main forces shaping the family structure in old age, but it should not be for-gotten that divorce (separation) and new partnerships are becoming increasingly frequent among the elderly too, and that these events are no longer the “privileges” characteristic of the young or the middle-aged. In Hungary for example, there has been a substantial increase in the proportion of divorces after 20 years of marriage, and the possibility of new partnerships being formed in old age cannot be excluded. Finally, a new family role as grandparent can fill the entire period of old age, although this can now generally be interpreted as part of the wider family system. The family structure measured at a given point in time can be interpreted as a congruences these interrelated processes. The data available for Hungary give an insight into the changes in family structure that occur with ageing and our figure showing the Visegrad countries together allows us to make comparisons for different age groups within the elderly.

The process of children moving away begins and reaches its peak among the middle-aged, but in part also extends into young old age. While more than half (55 %) of those aged 45-49 years live as a married couple with their children, this family structure is found in only a third (33.5 %) of the somewhat older cohort. The consequence of these changes is known as the “empty nest”, a household consisting of a married couple. Two-person households with (only) a spouse or partner are thus not only and not primarily characteristic of the young, but also of the elderly. According to the data recorded in 2008 in the Turning Points of the Life Course5 research pro-gramme, in Hungary more than a third of those aged 65-69 years (36.0 %) and just under a quarter of those 75-79 (22.9 %) live this way (see Figure 9). The disrupting effect on the family of loss of a spouse is also strongly felt by those still in their sixties as a consequence of the

5 The Turning Points of the Life Course research programme is a longitudinal data survey examining demographic behaviour, in which we question the population aged 18-74 years every three years from 2000/2001. In 2008 this population was already 24-82 years old. The research is part of the Generation and Gender Program (GGP). In 2000 we questioned slightly more than 16,000 persons and in 2008 the number of respondents was still over 10,000. More details on the data collection are available at www.demografia.hu/en.

relatively poor Hungarian mortality rates. A quarter of the 65-69 years group (24.1 %) live alone as widows; they represent half of the elderly in the 75-79 years age group (45.0 %). Although as we have seen, there is an increase in the rate of divorces among those married for over twenty years, the decisive reason for living alone in old age is still widowhood. A gradually spreading event of late old age is for parents and one of their children to begin living together again: while barely more than a tenth of those in their late seventies

100

90

80

70

60

50

40

30

20

10

0

%

60-64 65-69 70-74 75-79 80-82

Married couple

Alone Alone, widowed Alone with child Alone with other

Married couple with child Married couple with other

Figure 9 :: Distribution of different age groups of the elderly population by household types, 2008

Source: authors’ own calculations, NKI, Turning Points 2008/9 wave


(10.4 %) live with their children, by the time they reach eighty this proportion rises to one fifth (20.9 %).6

Due to the lower life expectancy for men there are substantially more women in one-person households as a consequence of loss of the spouse and living to-gether with their children (again) in late old age is also more characteristic of women (24.6 %). However, the most widespread partnership among elderly men is a married couple: 57.5 % of those aged 70-74 years live in such households (these data are not shown in the figure).

The 2001 census data enable us to compare the fam-ily structure of the elderly in the Visegrad countries. In comparing those aged 65-69 years taking two aspects into account (whether the person lives alone or with a spouse/partner, or with children), we distinguished four family types. (Germany served as a reference of the Western countries for this comparison.)

The majority of the elderly aged 65-69 years live alone or with a spouse/partner, indeed the proportion of married couple households is clearly the highest (see table). The differences by gender are also “uniform”: the women more often live alone, mainly as a conse-quence of the higher mortality among men. The differ-ence between the Visegrad countries and Germany is

6 Of course, among the very old living together with children is not always the result of moving in together: while they may be few in number, there are people who never move away from their children.

mainly found in that the elderly in the postcommunist countries more often live with their children. This is especially characteristic in the case of elderly men, with strikingly high proportions for Poland. At the turn of the millennium in Poland more than one quarter of men and women aged 65-69 years lived together with their children.

It is worth making a short detour in the interpreta-tion of the family structure situation to consider the perspective of those approaches that regard ageing as

the process of loss of status (S. Molnár 2004). The “empty nest” mentioned earlier can be interpreted as the end of the parental roles and thus acquires a certain negative connotation. But it is also possible to interpret it in a way that regards this period of young old age more positively. The departure of the children quite clearly brings an improvement in the financial situation (Spéder 2000, Stanovnik et al. 2000), and this means an increase in the available resources and the expansion of available options for action. We have to agree with the ideas of de Jong Gierveld, that in harmony with the growth of freedom the young old are also characterised by the individualisa-tion processes, and the vehicles of this process are most likely to be persons in their sixties living in a partnership or liv-ing alone in a transitional age. When the

child or children leave the parental home, the parent/parents become the (similar) independent personali-ties living alone or in a partnership as the (still) child-less members of the young generation. This can also be promoted by prolongation of the period of economic activity. Entering retirement around the age of 65 also makes it natural for the environment that the older men and women free themselves of family obligations and strive to attain their own goals in life. From this viewpoint it is worth considering the ideas of Verdon

Table 1 :: Distribution of women and men aged 65-69 years by selected household types, 2000/2001

Source: authors’ own calculations based on 2000/2001 European census data, Eurostat data

Countries Lives alone Lives with spouse only

Lives alone, without

partner with child

Lives with spouse/

partner with child

FemalesGermany 31.2 64.7 3.2 0.8

Poland 29.4 44.4 13.4 12.8

Czech Republic 35.6 50.4 7.5 6.5

Hungary 37.5 49.6 7.4 5.5

Slovakia 40.3 41.0 9.7 8.9

MalesGermany 13.2 82.0 0.9 3.7

Poland 11.8 60.1 3.2 24.9

Czech Republic 14.4 68.6 2.1 14.8

Hungary 12.5 72.0 2.0 13.6

Slovakia 14.2 62.5 2.7 20.7

26

Less than monthly

Monthly

Twice monthly

Weekly

Twice weekly

Several times weekly

105

5,6

8,9

20,0

13,1

13,1

Source: Turning Points , 3rd wave, 2008, authors’ own calculation

Figure 10 :: Connection between parents living separately and their children (frequency of meeting)

and de Jong Giervald who regard the coexistence of the elderly and their children as a kind of constraint (Jong Giervald, 2003). (Either because the child is un-able to move out, or because the parent is not capable of living alone, mainly due to his or her state of health.) Seen in this way, the high proportion of coexistence with children that characterises the Visegrad countries can be interpreted as a kind of “situation of constraint”, as an obstacle in the process of separating from the parental home.

When examining the family relations of the elderly it is worth devoting attention not only to the spouses and to children living together with the parents but also to the children living separately, to the relation-

ship between these children and the parents since the majority of children do not live with the elderly. Seen from the angle of the elderly, it can be said on the basis of the Turning Points survey by questionnaire in 2008 that over nine-tenths (91.6%) of the persons over 60 in the sample had a child and 85.2% had a child living separately. The majority of the elderly, 68.1%, had only a child or children living separately, 17.1% had both a child living separately and a child living with them, and the minority 6.4% had only children living with them.

Although the connection between parents and children can be evaluated from many angles, the data collected in the Hungarian Turning Points (GGS) survey allowed us to “measure” systematically two considera-tions; the frequency of personal meetings, and the de-gree of satisfaction (measured on an 11-point scale) with the relationship with the child. The latter is difficult to analyse in more detail as the over 60s rated very highly the quality of their relationship with their children living apart: the average satisfaction rating was 9.1 out of a possible 10. This means that practically everyone chose one of the three highest values (8-9-10) indicating that they were ‘very satisfied’ with the relationship with their child. There was a substantive difference between the genders: the men were more dissatisfied than the women with their children living separately. We know consider-ably more about the relationship between the child living separately and the elderly parent from the other variable.

One third of the parents (29%) meet their children daily, one quarter (26.1%) meet them if not daily but often every week. One tenth of the parents meet their

children very rarely (less than monthly). On the whole, more than half of the parents living separately from their children have almost daily personal contact with one of their children, and we can say of 15% of the parents that they meet their children living separately very rarely (monthly, or more rarely). It is basically proximity that determines personal contact with the parents; if the parent and child live in the same locality it helps frequent contact.

Family relations, the immediate and wider family undoubtedly plays a key role in the well-being, the mental and physical state of the older age groups and in the self-esteem of the elderly. The family relations can be clearly seen if we compare them to the indicators for loneliness. A relatively simple indicator – agreement with the statement: I felt lonely last week – is a good characterisation of the situation of those concerned.

Overall barely more than a tenth of those over 65 feel lonely often or always. As expected, the number of lonely increases with age (cf. Figure 11). Close to twice as many were lonely among those aged 80-82 compared to the 60-64 years age group. But family relations explain the loneliness of the ageing popula-tion much more than age. While the elderly live with a spouse or partner the proportion of those struggling to cope with loneliness is tiny (3%). It is not surprising that the lonely are to be sought among those without partners. To what extent is living together with children (moving back, moving together), or frequent personal contact with the children able to fill the


vacuum left after the death of a partner? The brief answer is: hardly at all. Although there is a difference between the feeling of loneliness of those who live with their children and those who live far from their children and have very rare personal contact, it is less than (perhaps) expected.

It can be clearly seen that those who live with chil-dren are less lonely than those who live separately but there are no big differences according to the frequency of contact with their children. Of course, further investigation would be required taking other factors

into account, but it can definitely be stated that being together with children is only able to offset to a small extent the loneliness arising from the loss of a partner.

2.2. Age and age group identity, the borderlines of old age

It is quite clear from the previous chapter that it is not easy to define an age at which a person becomes old (in contrast to the age of 18 after which young people acquire countless rights and are definitely in

a qualitatively new situation). In other words, becoming old can be interpreted as a process, and one that is being increasingly extended, in which the variability of role and style changes grows (cf. Moen 2006).

The question then is how ten-able is the age of 65 currently used by demographers as the border-line of old age? It must be noted in advance here that the rightful response of demographers to this question is that from a certain viewpoint where we set the bor-derline of old age is indifferent as regards the future ageing of the population: whatever age above

60 is selected, the increase in the number of elderly is unequivocal and unstoppable. A slight difference can be found only in the degree of ageing but not in the basic trends.

In order to assert the sociological viewpoint it is worth comparing the average age of the role changes in old age with the subjective perception of becoming old (2 indicators each), and the age of 65 used in demog-raphy with the indicator of average life expectancy at birth. All six indicators are available only for Hungary.

Demographically oldBecoming a grandparent

Life expectancyIdeal age for retirement

RetirementAverage age of becoming old

80

75

70

65

60

55

50

42

40 Women

Year

65,0

77,8

57,3

47,3

55,1

60,8

65,0

69,2

58,9

49,6

59,3

63,1

Men

Source: authors’ own calculations based on demographic data and the 2006 and 2008 ESS survey

Figure 12 :: The borderlines of old age (the average age of becoming old) for women and men according to different criteria

Lives with spouse

Lives with child

Lives without a spouse/partner and meets child daily

Meets child weekly

Rarely meets child

Has no child

Total

0 5 10 15 20 25 30 35

2,9

18,7

27,9

28,7

32

27,9

12,7Lonely

Source: authors’ own calculations, Turning Points, NKI, 2008/9

Figure 11 :: The loneliness of the population over 65 living in different family relations according to a simple loneliness measure (The ratio of perceived lonely), Hungary, 2008/2009

28

In Hungary in 2006 the population put the average age of entering old age at 60.8 years for women and 63.1 years for men. These two ages are higher than the age of becoming a grandparent and the average actual age of becoming a pensioner, and are close to the bor-derline of 65 years at present applied in demography. In the past decades people in Hungary generally still became grandparents before reaching old age, as the former occurred in the case of both men and women before reaching the age of 50. Before the change of system it was the general practice to have children early, the great majority of young people had their first child before the age of 25. As a consequence of postponing having children, the age of becoming a grandparent will shift towards 60. The average age of retirement

is also below the demographic threshold of 65 years, and even precedes the subjective age of becoming old. Those who become pensioners are not regarded as old by society and as the figure below shows, those concerned do not regard themselves as old either.

We examined in detail whether persons belonging to different cohorts regard themselves as middle-aged or old. The gradual change in self-evaluation can be clearly seen (Figure 13) in that ageing is not a transition that occurs from one day to the next but a process: for ex-ample, half of those aged 60-64 years regard themselves as middle-aged and the other half as old. Indeed, more

than a third of the 65-69-year-olds also consider them-selves to be middle-aged, and it is only among the over 70s that we can speak of a population with a uniform awareness of old age (Figure 13). It can be seen that the awareness of old age emerges after the old-age border-lines mentioned earlier. It is first in the 65-69 years age group that those regarding themselves as old are in the majority and only in the case of the over 70s can we state that the whole of this population regard themselves as old. It is worth pointing out that at the average actual age of retirement the great majority of those concerned consider themselves to be middle-aged.

The old age identity of the Hungarian population, that is very similar in profile to that of people in the other Visegrad countries, differs from the European average: although in both Europe and in Hungary the group of those who regard themselves as old can first be observed among those in their late 50s, in Europe this process culminates at a later age, indeed the spread of old age identity does not become all-inclusive. In the European population a quarter of those aged 70-74 years still regard themselves as middle-aged (Figure 14).

If in the case of the European countries we ex-amine the life expectancy and the estimated average age of becoming old, we find a significant correlation between the two. We have argued in more detail elsewhere that the higher the life expectancy in the given country, the later the age of becoming old in that country.

%

Europe – middle-agedEurope – old

Hungary – middle-agedHungary – old

100

90

80

70

60

50

40

30

20

10

0

– 19

20–2

4

25–2

9

30–3

4

35–3

9

40–4

4

45–4

9

50–5

4

55–5

9

60–6

4

65–6

9

70–7

4

75–8

0

81–

Age group

Source: authors’ own calculations based on the ESS 2008 survey

Figure 14 :: Self-evaluation of different cohorts (the percentage regarding themselves as old or middle-aged) in Europe (by population weight) and in Hungary

Age groups

%

Middle-aged menMiddle-aged womenOld menOld women

100

90

80

70

60

50

40

30

20

10

0

– 19

20–2

4

25–2

9

30–3

4

35–3

9

40–4

4

45–4

9

50–5

4

55–5

9

60–6

4

65–6

9

70–7

4

75–8

0

81–


Figure 13 :: Self-evaluation of different cohorts (the percentage regarding themselves as old or middle-aged) by gender


2.3. Public assessment of the societal standing of the elderly

The picture we form of the different social catego-ries – including of the elderly – becomes part of our everyday actions and decisions, and thereby actively contributes to shaping the situation of the given social group. According to earlier analyses there has been a slight improvement in the social assessment of the elderly (Dobossy et al 2003). Here we will focus now on the characteristics of the assessment of the elderly in the Visegrad countries in international comparison. One of the questions asked in the 2008 ESS survey was how the respondents rank the status of persons in their 70s on a scale of 0 to 10 (cf. Abrams et al. 2009). (The answers given to this question simultaneously measure the objective circumstances of the elderly (e.g. mate-rial situation) and judgement of them (e.g. their pres-tige)). For the sake of clarity we have selected the data for the population of seven countries, and arranged them in rising order of the assessed social status of the elderly (see Figure 15). The social ranking of the elderly appears to be the most favourable in Southern Europe (Greece), and in Western Europe (Germany), it is most unfavourable in the former socialist countries, particularly in Slovakia and Poland. But in considering the judgement of the elderly in society it is worth also taking into account the social positioning of the young (those in their 20s) and the mature (in their 40s): both how the assessment of the young and the old relates, and what is their average level in the status hierarchy.

In all countries the status of the middle-aged is considered to be the best, and in general that of the elderly the lowest. This is characteristic of all Visegrad countries, but there is a substantial deviation in the perception of the difference between the social status of the young and the old. While in Poland and Slovakia the situation of the young is perceived to be much better than that of the elderly, in the Czech Republic and Hungary there appears to be hardly any differ-ence. In the western countries the public assessment of status differences between the young and the old varies. While in Sweden the young are considered to be in a

more advantageous situation, in Greece the elderly are considered to be in a better position, and in Germany there is no substantial difference in the perception of the situation of the two generations. The differences in Western Europe are almost properly related to the welfare regimes, as their profile differs considerably regarding the generational risks. On the basis of the above it can be said that the perception of the social status of the old in the Visegrad countries is not worse than in the western countries as the judgement of the situation of the old within the given society is worse in Sweden than it is in the Czech Republic or Hungary.

4. Summing up

In our study focusing on the Visegrad countries we have examined a few characteristics of the universal process of ageing. We were able to make comprehen-sive comparisons only in our demographic analyses. They revealed that the Visegrad countries are in a very similar position in the universal process of social ageing, the differences between them being due to the fertility dynamics and the different rate of change in life expectancy. After making regional analyses we were able to conclude that the differences within the individual countries are less than those between the countries.

8

7

6

5

4

3

2

1

0

Average

Slovakia Poland Czech Republic Hungary Sweden Germany Greece

Young Middle-aged Old


Figure 15 :: Assessment of the societal standing of persons in their 20s, 40s and 70s in the Visegrad countries and selected countries of the EU15, 2008

30

With the help of sociological analy ses, for which data were available gene rally only in the case of Hun-gary, we were able to establish that it is increasingly important not to regard old age as a homogenous life stage because, although the situation of the elderly is in many respects identical, we can also find substan-tive differentiation among them. We have shown that the health status deteriorates steadily with advancing age, that the elderly live in widely differing family structures and family relations, and that children are able to “compensate” for loss of the spouse or partner to only a very limited extent. The comparison revealed that more elderly persons in the Visegrad countries live together with their children, but at the same time we were able to conclude that this is more the result of constraint than of choice.

We pointed out that the borderlines of ageing are increasingly blurred, the possible markers of becom-ing old are becoming more widely spaced and as a result the process of becoming old is being gradually prolonged. Finally, we very briefly examined the public assessment of the societal standing of the elderly. We concluded that it is not possible to determine that this assessment is unequivocally worse in the Visegrad countries than in western countries.

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KEY WORDS: POPULATION AGEING, CENTRAL AND EASTERN EUROPEAN COUNTRIES, RETIREMENT, CARE, OLDER WORKERS


1. Introduction

For many countries in Central and Eastern Europe (CEE) population ageing and an ageing workforce seems to be – or even better to say – should be a real challenge in the next decades. As demographers (e.g. Schoenmaeckers, 2009) indicate, this process is the result of the low fertility rates observed in these countries in the last decades, in-creasing longevity and last but not least, emigration which especially has had an impact on demographic changes in CEE countries after they joined the EU.

In this paper, I will discuss some possible socio-economic consequences of population ageing in CEE countries by examining and comparing countries which joined the EU after 2004 (Poland, Czech Re-public, Slovakia, Hungary, Lithuania, Estonia, Latvia) and after 2007 (Bulgaria and Romania). The selected countries could be treated as those which had been clustered in the same group dependent on the Soviet Union, in contrast with other countries that joined the EU with them in 2004, Cyprus, Malta or even Slovenia.

2. Population ageingand consequences

By population ageing we mean the increasing share of population aged 65+ and/or the increasing median age of the population. According to Kinsella and Velkoff (Kinsella and Velkoff 2001; Gavrilova, Gavrilov, 2009) the share of 65+ population is approximately eight percent to ten percent of the total population. Ac-cording to different institutions (UN, Eurostat and independent demographers (e.g. Lutz, Scherbov, 2003; Lutz, Sanderson, Scherbov, 2004) there is a common agreement that already “relatively young” countries of Central and Eastern Europe compared to Western European countries, have also “aged” in regard to their

workforce (Botev, 2012). Looking at the figure below, we see the changes in the share of older people in the total population based on data from Eurostat (2009).

An analysis of the population structure by age also reveals an alarming picture. These results confirm that we are already experiencing, and in the future will increasingly experience the effects of a shrinking and ageing workforce (fewer people working and an increase in the average age of employees).

However it has to be emphasized that all these indicators show only a national perspective. The more relevant information is that within each country there are differences not only in the factors leading to population ageing (such as differences in fertility rates,

Some Socio-economic Consequences of Population Ageing in Selected Central and Eastern European Countries1 JOLANTA PEREK-BIAŁAS

1 This paper was originally prepared on the basis of the extensive work under the Author’s Fellowship of the Program “Generations in Dialogue” of the ERSTE Foundation, Vienna, Austria in 2008-2011 at the Warsaw School of Economics. In this text, only a few issues are discussed.

21%20%19%18%17%16%15%14%13%12%11%10%

Bulgaria

Czech Republic

Estonia

Latvia

Lithuania

Hungary

Poland

Romania

Slovakia

2008 2010 2015 2020

65+

Figure 1 :: Changes in the share of people aged 65+ in a total population – present and future

Source: based on Eurostat database, 2010.

34

increasing life expectancy, migration) but even in the share of people of retire-ment age. Data available confirm that in 2009 alone Bulgaria, Latvia and Estonia already had the highest proportion of people over 65 among the countries se-lected for analysis, while Poland (some regions like Małopolska, on the border with Slovakia) and Slovakia had regions with the lowest number of people over 65 (Eurostat, 2012). However, these two countries still have over 10 % of 65+ in the total population.

Based on UN data, in 2005 Bulgaria and Latvia – with respectively 23% and 22% of the total population – had the highest proportions of 60 and older population. In 2050, based on the UN projections, Bulgaria followed by Po-land (with 23% and 38% respectively) will be among the countries with the highest percentages in this age group. The pressure of population ageing on the economy can be described by the old-age dependency ratio (Figure 3). The changes in old-age dependency ratios reflect a rapid process of popula-tion ageing, which is related to the increase in the financial burden for the working age population (see more

details for Poland in Matysiak, Nowok, 2007). As the figure shows, in the countries analyzed we are already facing population ageing and so a shrinking and ageing workforce.

Consequences

Social and economic consequences of population age-ing are known (see Schulz, 1995; Clark et al., 2004; Gavrilova, Gavrilov 2009) but it is more crucial to indicate where and why some of these consequences

– particularly in Central and Eastern Europe – can create problems/conflicts. It is not possible to present all economic and social consequences here but I would like to indicate some of them, showing current differ-ences and similarities among the countries analyzed. The last part of the paper also focuses on showing the dilem mas people face between a decision to work or retire and what expectations there are regarding care for the elderly which influence the decision on retire-ment. At the end of the paper, some recommendations will be briefly discussed.

Different sources of data were used for this paper. First of all, the Eurostat databases were explored extensively (in particular demographic, labour market and other indicators related to the topic for selected countries). Secondly, I used the data of the European Social Survey (ESS1) (different rounds), and also Gen-

1 European Social Survey, www.europeansocialsurvey.org

100 %

90%

80%

70%

60%

50%

40%

30%

20%

10%

0% PL BG CZ EE LV LT HU RO SK

Less than 15 years Between 15 and 64 years 65+

15% 15% 15% 15% 15% 15%

71%

13% 17% 17% 17% 16% 16% 12%

69% 69%68% 69% 69% 70% 72%

13% 14% 14%

71%

15% 15%


Figure 2 :: Population structure by age – 2009

Bulgaria

Czech Republic

Estonia

Latvia

Lithuania

Hungary

Poland

Romania

Slovakia

27,0

25,0

23,0

21,0

19,0

17,0

15,02000 2001 2002 2003 2004 2005 2006 2007 2008 2009


Figure 3 :: Old-age dependency ratios over time


der and Generations Programme (GGP2). I also made use of the unique survey of Health and Long-term Care in the European Union, Special Eurobarometer 283/ Wave 67.3 – TNS Opinion & Social, 2007.

3. Current situation as a way to understand possible future consequences

3.1. Labour market

There is a general consensus that the employment rate of older workers should be increased as a goal of the European Union (an employment rate of 50% for older workers was a target in the Lisbon Strat-egy). There could even be some incentives in national labour market policy: without a change in attitudes and behaviours of older generations towards staying or leaving the labour market, and without a change in attitude and concrete actions from employers and different stakeholders, it will be difficult to convince people in CEE countries to work longer and postpone retirement as long as possible.

The situation of workers aged 50+ in 2010 in the labour market varies in the countries examined. As shown in Figure 4 the employment rate of workers aged 55-64 in a country such as Estonia was over 50%, and in some like the Czech Republic, Lithuania, Slo-

2 http://www.unece.org/pau/ggp/Welcome.html

vakia it was over 50% for men, but in other countries (especially Poland and Hungary) the employment rates for both men and women were very low. In Slovakia, the difference in employment was quite substantial when we compare women and men. In general, lower

employment rates for people over 50 could be found for women. This applies not only to CEE countries but to all European countries.

However, analysis of the overall employment rate should be controlled by education level. As shown in Figure 5, we can conclude that those who have a higher level of education (level 5 and 6 ISCED) have higher

employment rates. Analysis for 2008 alone shows that for the younger generation (25-64 for all countries) we see that this employment rate was more than 60% (Figure 5). People with the lowest level of education (0-2) were in the worst situation. For the 50-64 age

group, none of the countries analyzed reaches the employment level of 50% and in some countries the trend is just as serious because the same low level of employment was found for the age group 25-64 (Slovakia).

Another trend could be seen in this figure, as the older generations with the same education level had a lower employment rate than the younger generations. There may be a smaller difference between these two (young-old) generations in the Czech Republic, Estonia and Latvia but in other countries, the differences are much bigger (see Hungary and Poland). It appears that the human capital/skills

and competences which the older generation acquired in the past (under the centrally planned economy) are no longer valid or needed by employers (see e.g. some analysis for Poland in Perek-Białas, Ruzik, 2005, Perek-Białas, Turek, 2010).

One explanation is that now the economies of these analysed countries are market-oriented and require

BG CZ EE LV LT HU PL RO SK

Female

Male

70

60

50

40

30

20

10

0


Figure 4 :: Employment rate of workers 55-64 (in %) in 2010

36

workers with modern economy skills, like ICT skills and knowledge of foreign languages etc. However, why is the difference smaller in some CEE countries and in others bigger in such international comparisons? One

possible answer is that it is due to differences in the human capital of these societies. Another explanation could be that in some CEE countries the education/teaching system – including for older citizens – is much better matched with the requirements and demand of the labour market.

To better understand this data, it is also important to mention that in some occupations such as manual

ones (like construction, road works, cleaning) we see quite a high employment rate for all countries (Euro-stat database, 2009). But in some countries – for men as well as for women – we see very low employment

rates (for example in the service sector, e.g. in shops). In an analysis of the labour market situa-tion of older workers, not only the education level is crucial but also the type of job. More skilled professions need higher levels of education which usually is more evident for younger generations.

The obvious question to ask is what are people over 50 doing if they are not working? The easy answer, although it

is a very important one, is to say that the majority is in retirement (especially between the ages of 55-65) which will be discussed later in a bit more detail. It is interesting to look at the main reasons for not seeking employment among inactive people aged 50+. This data is courtesy of the Labour Force Survey (LFS), harmonized by the Eurostat and shown above. Here, we see (Figure 6) that in most countries the age group of particular interest for this paper (inactive 50+) is

retired but some of them are not able to work because of health reasons (especially men in Estonia, Lithuania, and Poland). The case of Hungary shows that the ma-jority – almost 80% of inactive 50+ women and 75% of

such men – were in retirement in 2009. The former low retirement age could be an explanatory factor here, as in Hungary it was 55 till 19983. However, there are still some who claim that work is not available for them or they have to look after children or incapacitated adults.

3 See more in Gál Robert Ivan, Iwasaka Ichiro, Széman Zsuzsa (eds.) Assessing Intergenerational Equity. An Interdisciplinary Study of Ageing and Pension Reform in Hungary. Budapest: Akadémiai Kiadó, 2008.


100

90

80

70

60

50

40

30

20

10

0

25-49 ISCED 0-225-49 ISCED 3-425-49 ISCED 5-650-64 ISCED 0-250-64 ISCED 3-450-64 ISCED 5-6


Figure 5 :: Employment rate by age groups and education level in 2008 (%)

Think no work is available

Retired

Other reasons

Awaiting recall to work (on lay-o�)

In education or training

Own illness or disability

Other family or personalresponsibilities

Looking after children orincapacitated adults

F M F M F M F M F M F M F M F M F M


100 %

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

12 1515

25 2315 16

1614

3 39 19

19

1930

1120

78 7595 95

81 82 7878

7179 75

65 60

41 49

8677

69


Figure 6 :: Main reasons for not seeking employment among inactive people aged 50+


The same could be found in some other countries like Bulgaria, Romania and Poland, where women (about 5% to 8%) are not seeking a job because they are look-ing after children or have other family responsibilities. However, here we have to be careful about some data. For example, the results for Romania, where both men and women who are not seeking a job because of other reasons, differ from the main list. Instead, it suggests a methodological problem in the comparative analysis by country and it is important to notice and acknowledge this. Perhaps migration could give some more explana-tion but this is beyond the scope of this paper.

3.2. Retirement behaviour

There are various methods for checking what citizens think about a certain age for staying in or leaving the labour market but quite often public opinion polls are used to find answers on questions such as: 1): In your opinion, what is the ideal age for a man/a woman to retire permanently? (and then missing values include answers: Don’t know, No ideal age, Should never retire permanently, Should never be in paid work, or 2): And before what age would you say a man/a woman is generally too young to retire permanently? and then missing values include answers: Don’t know, No ideal age, Should never retire permanently, Should never be in paid work. Analysis based on ESS, Round 3 2006 clearly shows that the trend in all these countries is the same. The median ideal retirement age for men in all countries is 60 while the median ideal retirement age

for women in all countries is 55, with the exception of Estonia (58). In Poland, the average ideal age of retire-ment was the lowest and for women it was 53.2. In the

analysis of the age when someone is too young to retire this is not surprising because this minimum retirement age (calculated on median) for Bulgaria and Estonia is 55 for men and for the other countries only 50, while for women the median minimum retirement age is 50. Again in Poland, the averages of all answers for

these questions of when someone is too young to retire are the lowest among all countries for both men and women. The average retirement ages are approximately

49 years for men and approximately 46 years for women. If attitudes are compared with retirement behaviour, Table 1 shows average effective ages of retirement in selected coun-tries of this part of the Europe. The effective average age of retirement is higher than that based on just opinions of respondents but in most countries it is still lower or equal, with the exception of Estonia where – due to the design of the pension system – people have incentives to work longer than the official eli-gible retirement age, as they can then receive higher pension benefits.

As it was mentioned above the need to increase the retirement age is one of the remedies for the shrinking and ageing work-force for countries examined in this paper. Already we see above that these results are not optimistic as they are much lower than is already implemented by law (eligible retire-ment age). Such attitudes should be changed

as it is needed at least to accept the already existing eligible retirement age but also to bring citizens to understand the need to increase the retirement age as an effective way of dealing with population ageing. To make clear and more understandable what kind of regulations exist in each of the countries analyzed

Source: OECD estimates derived from the European and national labour force surveys.

Table 1 :: Average effective age of retirement versus the official age, 2004-2009(a)

a) The average effective age of retirement is defined as the average age of exit from the labour force during a 5-year period. Labour force (net) exits are estimated by taking the difference in the participation rate for each 5-year age group (40 and over) at the beginning of the period and the rate for the cor-responding age group aged 5 years older at the end of the period. The official age corresponds to the age at which a pension can be received irrespective of whether a worker has a long insurance record of years of contributions.b) Official retirement age is shown for 2010.

Men Women

Effective Official(b) Effective Official(b)

CZ 62.0 62 59.0 59

EE 66.2 63 63.4 61

HU* 60.0 62 58.9 62

PL 61.7 65 58.5 60

SK 59.9 62 56.2 62

38

(see e.g. about the relevant issues in analysis of pension systems in Central and Eastern Europe, Holzmann 2009; Holzmann, Ufuk, 2009) we also need to look at the criteria of eligibility for retirement (early re-tirement), but that is beyond the scope of this paper. However, it is important to notice that regulations are changing in recent years. For example, the official retirement age in Hungary has been now gradually introduced up to 65 years. For cohorts born in 1952 e.g. the official retirement age is currently 62.5 years. The regulation has just been changed in Poland as well where not only the increase of retirement age was voted in the Parliament and accepted by the President (already up to 67 years old) but also the new change makes the retirement age equal for both men and women (see differences in Table 1).

Political decisions against raising the retirement age can also slow down the growth in the proportion of the ageing workforce. In summer 2012 in Hungary, for example, the g o v e r n m e n t wished to introduce com-pulsory retire-ment at 62 for public service workers which

would have the effect of advancing the exit of the 1952 cohort from the labour market. Decision-makers justified this proposal as a cost-saving measure and did not take into account other processes the measure would induce, e.g. the compulsory exit of older health workers would cause difficulties in certain special areas and would leave some regions without services.4

The increasing retirement age is needed from the perspective of the macro level and the economy but

4 There was a protest against this change however at the time of writing the study it was not known which areas of public service would be exempt from compulsory retirement

not from the point of view of the individual. Citizens take into account: the poor state of health which can lead to the risk of disability and not being able to be as productive as in a younger age, the fear of becoming unemployed and together with the shrinking social

Source: ESS Round 3, 2006.Note: does not include missing values such as: refusals, not applicable, don’t know, no answer

Table 2 :: Worried about not being able to retire at the age one would like to (%)

Source: ESS Round 2, 2004Note: Question: Did you want to retire then or would you have preferred to continue in paid work?

Table 3 :: Willingness to retire at the age of retirement by gender (% of all retired)

Not wor-

ried at all

1 2 3 4 5 6 7 8 9Ex-

tremely worried

Total

BG 27% 6% 3% 3% 3% 8% 4% 5% 7% 6% 30% 100%

EE 20% 14% 12% 9% 5% 10% 6% 8% 6% 3% 6% 100%

HU 24% 6% 5% 5% 3% 7% 6% 7% 8% 7% 22% 100%

PL 11% 5% 5% 6% 4% 13% 6% 11% 14% 9% 15% 100%

SK 8% 8% 9% 7% 4% 16% 11% 14% 10% 6% 7% 100% Country Male Female Total

Czech Republic Wanted to retire 73.2 69.8 71.3

Preferred to continue paid work

26.8 30.2 28.7

Estonia Wanted to retire 56.5 61.2 59.7


43.5 38.8 40.3

Hungary Wanted to retire 58.3 56.0 57.0


41.7 44.0 43.0

Poland Wanted to retire 54.5 71.2 63.2


45.5 28.8 36.8

Slovakia Wanted to retire 58.3 67.5 63.5


41.7 32.5 36.5


safety net and the diminishing possibility of finding a new job, this could also lead to a negative change in attitudes.

The attitude of ‘retirement as soon as possible’ probably comes from worries about not being able to retire at the age one would like to, as shown in Table 2 (see for more explanations for Poland e.g. Perek-Białas, Worek, 2005, Perek-Białas, Rószkiewicz, 2011). Quite interestingly, there are some countries which are more or less in the same range of responses compared to those countries who are not worried at all or extremely worried about such a situation (BG, HU, PL, SK even with lower numbers). Here, the exception is Estonia where the majority of the population is not worried at all about retirement at the age they would like to. However, this information was published before the economic crisis and it also relates to the discussion about the need to increase the retirement age.

This last result should be read with a look at the willingness to retire or preference to continue in paid work at the moment when someone becomes retired. In all countries the retired preferred to retire rather than continue in paid work, but in the Czech Republic 71.3% of eligible persons wanted to retire, while in Hungary and in Estonia, less than 60% of eligible persons wanted to retire. By gender we see that there is a group of men (45.5% in Poland, 43.5% in Estonia, 41,7% in Slovakia) who would like to work longer – beyond the eligible re-tirement age. Women in Poland (almost 72%) definitely prefer to retire when they are eligible.

3.3. Work or care vs. work and care

Additionally, in order to show a more complex picture of dealing with a shrinking and ageing workforce, we cannot forget that the number of people who will be dependent because of age will increase and the care system has to be not only improved but also expanded

and adjusted to the needs of older people. In some countries of Central and Eastern Europe the role of the family in dealing with care tasks (not only for the elderly, but as well including children, grandchildren) is strong and perceived as adequate.

In countries like Bulgaria, Slovakia, Poland and Hungary5 more than 80% consider that dependent elderly people have to rely on their relatives, while in Lithuania and Romania more than 70% agree with such a statement (Health and Long-term Care in the European Union, Special Eurobarometer 283/Wave 67.3 – TNS Opinion & Social, 2007).

Figure 7 shows that especially in Bulgaria, Romania and Poland more than 50% accept that older persons should live with their children in order to provide the necessary care and help for their parents.

However, traditional family struc-tures with two or three generations living together and other relatives living nearby are increasingly becoming less common. Taking into account the need to reach the Lisbon Treaty goals of in-creasing employment rates (for women as well as for older workers), societies of these countries have in mind the cur-rent situation in the labour market, with preferences to retire earlier rather than

continue in paid work, with mixed and short-sighted attitudes of employers.

5 In Hungary for example, the new Constitution (2011) declaring eldercare to be a family task ignores the problem of work and care and this can cause a new challenge.

They should live with one oftheir children

Public or private serviceproviders should visit theirhome and provide them withappropriate help and care

One of their children shouldregularly visit their home, inorder to provide them with thenecessary care

They should move to anursing home

EU27 EE CZ HU LV LT SK BG RO PL

70

60

50

40

30

20

10

0

Source: Health and Long-term Care in the European Union, Special Eurobarometer 283/Wave 67.3 – TNS Opinion & Social, 2007 (selected countries).

Figure 7 :: Attitudes regarding care for the elderly %

40

Moreover, information contained in the research of the Generations and Gender Program (First Wave, available for Bulgaria, Romania and Hungary) shows that in Hungary for example about 50% of those sur-veyed think that children should adjust their working lives to take care of the needs of their parents.

And, as predicted, women tend to shoulder the most responsibility of caring for family members. Therefore, it is the reconciliation of working and caring duties (not only for elderly parents but also for grand-children especially when there is limited or not enough support in child care in some countries for children up to three years old or older, as is the case of Poland) that is becoming a key issue for the ageing workforce.

In some countries in Central and Eastern Europe we still do not see real policy actions to help citizens deal with reconciliation of work and care. The econom-ic and social factors are related to the labour market, to retirement behaviour and to care. It is necessary to change the current option of “work OR care” for “work AND care” in order to provide sustainable strategies to deal with the consequences of population ageing. However, it has to be planned carefully and solutions implemented not only as proposed by governments and experts, but with a real understanding and support of employers taking into account various values, cultural, ethnic and religious differences.

4. Some conclusions

In the coming years the issue of population ageing and its consequences cannot be only an academic topic in these countries as it is creating more challenges for policy makers and politicians to be able to tackle the impacts of this issue which concern all areas of a na-tional economy. It is important to focus on the issues at all levels including at the national level, regional level and even local level.

The consequences of the ageing workforce in CEE countries is already being noticed but this topic is still not a priority in the public debate6. We need a greater national or even multi-regional investigation into the socio-economic consequences of population ageing and the issues of an ageing workforce (as the example the OECD efforts could be mentioned here7). This is especially important in CEE countries as they cannot be treated as one homogenous group of countries with similar challenges. The heterogeneity is found not only in official and available statistical and demographic indicators, but is revealed by surveys and studies, as

6 The analysis of active ageing policy in Poland and in the Czech Republic can be found in Perek-Białas, Ruzik and Vidovic´ová (2006). However, the EY 2012 on Active Ageing and Solidarity Between Generations could bring some changes but the national governments also have to be ‘active’ in making and implementing an adequate policy.

7 The project OECD/LEED Programme on Demographic Change and Local Development in three regions of Poland is currently be-ing carried out (2012).

well as cultural and public policy differences between these countries. All these factors should be taken into account.

We need to elaborate a comprehensive strategic perspective that coordinates the different processes without contradictions in order to think about and plan for real actions regarding the issue of population ageing because the demographic change calls for a broader look at consequences, and not only economic ones. The countries should be able to use the potential of an ageing workforce (at the individual, societal and state level); and last but not least, there should be a political will and the resources to deal effectively and over the long term with this demographic challenge.

Companies and businesses can do this by promot-ing the idea of working longer and by using different measures which can help in maintaining the productiv-ity of older workers on a desired level. This could be done by creating possibilities to work for older workers, but also supporting employees who would like to re-main working longer than the current eligible retire-ment age, finding ways for the possible combination of work and care if this latter is a reason for retirement, especially for women.

And so as a last point – as some statistics showed – not only to concentrate on one indicator, namely the employment rate of older workers but also to think about and take action on how to prepare different


actors, different spheres of social policy (including besides the labour market and pension system, also the health, long-term care sectors) over the long term for an ageing and shrinking workforce.

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KEY WORDS: POPULATION AGEING CONSEQUENCES AND CHALLENGES; CONSEQUENCES ON MACRO-ECONOMIC SPHERE, LABOUR MARKET, NEEDS IN HEALTH AND SOCIAL SERVICES; PARTICULAR MEASURES ADOPTED IN THE WAY THESE CHALLENGES ARE FACED IN SLOVAKIA.

44

Introduction

The latest figures for the Slovak Repub-lic show that the population has been ageing. The long-term decline in the birth rate and relatively stable death rate together with the longer contempo-rary life span are leading to an increase in both the number and proportion of older persons in the country. This development has many consequences for the macro-economic sphere, labour market and for demands made on the health and social services. These changes are great challenges for policy-makers, employers, individuals and families, creating the need for new programs and strategies able to face those challenges.

This paper presents the facts about population age-ing in Slovakia and shows some particular measures which Slovakia has adopted to face these challenges. It briefly presents some demographic figures that de-scribe this process, reforms made in the pension system and their impacts on the increasing employment rate of older workers. The paper is based on official statistical data as well as on the results of sociological surveys carried out in the Slovak Republic in recent years.

high birth rate of the post-war baby boom. In the next period the increase in population slowed down. The main reasons for this were the continuous decline in the birth rate, and the relatively stable death rate (that had fluctuated slightly in the post-war period) (see Table 1).

Migration, regarded as the third demographic proc-ess which affects development of the population – has had relatively little significance in Slovakia. The coun-try had closed borders before 1989. The emigration was mostly illegal and the Czech and Slovak Federal Republic was not attractive for potential immigrants. The largest portion of migration movement was ac-counted for by internal migration between the Czech

Slovak population in figures

In 1950 Slovakia was characterised by a “healthy” age pyramid with the following figures: 0-14 years 28.8%; 15-64 years 64.0%; 65 years and over 6.7%; and those not specified according to age 0.5%. From 1950 to 2010 the total population increased by 58% (1 994 568) but this increase was unevenly divided among the age groups.

By 2010 the demographic age pyramid changed dramatically. The number of children in the total population decreased by 16.6%, and the number of people aged 65 and over increased by 193.0%. The number of people of economically active age (15-64) rose by 77.7%. In 2010 the proportion of the different age groups was: 0-14 years 15.2%; 15-64 years 72.5%; 65 years and over 12.3%.

The intercensal period 1950-1961 showed the larg-est increases and this is attributed to the significantly

Population Ageing – Impacts and Challenges in the Slovak RepublicBERNARDINA BODNÁROVÁ

Source: www.infostat.sk/vdc/sk/index.php?option=com_content

Table 1 :: Selected data on basic demographic processes in the Slovak Republic, 1950–2010

Year Number of live births

Number of deaths

Natural increase

Total population

Per 1000 inhabitants

1950 28.8 11.5 17.3 3 463 446

1960 22.1 7.9 14.2 3 994 270

1970 17.8 9.3 8.5 4 528 459

1980 19.1 10.2 8.9 4 984 331

1990 15.1 10.3 4.8 5 297 774

2000 10.2 9.8 0.4 5 400 679

2010 11.1 9.8 1.3 5 435 273


and Slovak Republics. Since 1993, after the split of the Czechoslovak Federal Republic, the Slovak Republic has had a positive balance of migration. E.g. in 1993 Slovakia had a net migration of 1 751 persons (0.03% of total population), in 1994 it was even 4 768 persons (0.08%). Then the balance of migration slowed until 2002 when Slovakia received only 901 persons (0.08% of the total population). Since then net migration has again increased: in 2009 the net migration balance for Slovakia reached 4 367 persons (0.08%), in 2011 it was 4 485 (0.08%). www.portal.statistics.sk/files/scheme/sek_600/

demographie/obyvateľstvo

In 2009 822 persons applied for asylum in Slovakia but in the same year Slovakia granted asylum to only 14 persons. (Štatistická ročenka, 2010)

These demographic trends resulted in changes in the age structure of the Slovak population between 1950 and 2010 (see Figure 1). They are characterised by a diminishing share of children (with the exception of 1960 which is the result of the huge birth rate in the 1950s), a growing proportion within the total popula-tion of people aged 65 years and over and an increasing proportion of those in the 15-64 years age group.

The fastest increase in the popula-tion has been in the 65 and over age group. In addition to the increase in size (in absolute and relative numbers) within the total population, this group has also changed according to other characteristics. While in 1950 the proportion of women aged 65 plus was 42.9% compared to 57.1% for men, in 2010 these figures were 51.4% and 48.6%. The feminization of ageing is a result of the longer life of women com-pared to men. In the period between 1950 and 2010 the number of men aged 65 and over increased by 148.1% while in the case of women this increase was much higher, 218.3%.

The proportion of persons 80 years and over showed a big increase too. While in the year 1950 people aged 80 years and over represented 13.6% of those 65 and over, in 2010 their proportion was 23.4%.

This development has resulted in changes in other characteristics of the Slovak population. Average life expectancy at birth, considered by experts to be one of the most important indicators, reached 71.6 years for men and 78.8 for women in 2010. Between 1950 and 2010 the average life expectancy in Slovakia increased by 12.62 years for men and 16.84 years for women. But the gap in life expectancy for men and women continues to widen. While in 1950 women lived 3 years longer than men, in 2010 this gap reached 7.22 years in favour of women. Despite the longer life expectancy in Slovakia, statistical data showed it was shorter than the figure for two other Visegrád countries: compared to 70.4 years for men in Slovakia, it was 72.6 years in the Czech Republic and 70.6 years in Poland. Life expectancy for men was lower in Hungary where it was 68.7 years. A similar situation was found in the female population. While the life expectancy for women in Slovakia was 78.0 years, in the Czech Republic it was 79.2, in Poland 79.1 and in Hungary 77.1 years. http://

www.infostat.sk/vdc/sk/index.php?option=com_content&task=vie

w&id=67&Itemid=37

Other indicators, including the average age of the population and the index of ageing, also increased their values in Slovakia between 1950 and 2010. The only

100 %

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%1950 1960 1970 1980 1990 2000 2010

0-14 15-64 65+ undetected

28,8 31,5 27,9 26,1 2518,7

15,3

62,6 63,4 64,6 69,9 72,4

9,5 10,4 10,3 11,4 12,3

0,1 0,1

61,4

70 0 00 9

64

6,70,5

Source: Historická ročenka ČSSR (do roku 1980), Federální statistický úřad. Praha

1985. SNTL – Nakladatelství technické literatúry a ALFA – Vydavateľstvo technickej a ekonomickej literatúry. http://portal.statistics.sk/files/Sekcie/sek_600/Demografia/Obyvatelstvo/vyvoj_oby-vatelstva_sr/vyvoj_2010_tabulky_n.pdf

Figure 1 :: Population by age group in Slovakia, 1950 – 2010 (%)

46

index with a positive value is the economic dependency ratio, but this index is expected to change in the op-posite direction.

The growth of the population of working age has already been slowing down and in the coming years this trend will continue even faster. According to a Eurostat prognosis, in 2030 in Slovakia there will be 19.4% (164 500) less children and 10.0% (389 600) less people in the 15-64 years age group, while the popu-lation 65 and over will increase by 75.3% (487 000) compared to 2008. It is expected that the proportion

of people aged 65 and over will increase to 21.27% of the total population in Slovakia by 2030.

Changes in the pension system in Slovakia

Reform of the pension systems in the developed countries is considered to be one of the ways to face the challenges of ageing populations. In the Slovak Re-public such a reform started in 2004 and continued in 2005. The new pension system was built on three pil-lars: social insurance (pay-as-you-go system), personal

savings (which was originally indicated as the key change in the transformation of the pen-sion system) and supplementary pension scheme. The three pil-lars were thought to establish a modern, multi-source financed system.

The first pillar (pay-as-you-go) was launched after Law No. 413/2003 on Social Insur-ance took effect. The new law strengthened the merit principle within the system by establish-ing closer ties between pension contributions paid to the system and pension benefits disbursed from the system. The other

changes the law brought in the system were: increasing the pension age to 62 years (for both men and women), obligatory insurance for at least 10 years (later it was extended to at least 15 years), introducing the early retirement old-age pension, changed formula for the calculation of pension benefits, elimination of the partial disability pension and minimum and maximum pension limits. People are allowed to apply for early re-tirement 2 years before the official pension age, if they have been insured for at least 15 years, the amount of early retirement benefit would be 1.2 times higher than the subsistence minimum for one adult person in the given year. However, their pension will be reduced by 0.5% for each month before reaching the regular retirement age. Insurees in this pillar are eligible to the following pensions: old-age pension, premature old-age pension, disability pension, widow’s pension, widower’s pension and orphan pension.

The second pillar or savings for old age was a completely new element in the Slovak system. It was launched in January 2005, after Law No. 43/2004 on Pension Scheme. Originally it was included in the system as a compulsory pillar and entry into the system of old-age pension savings was made mandatory for all individuals who, before January 2005, had not been insured for the purpose of pension by Social Insurance. Those who had been insured for pension purposes before that date by Social Insurance had 18 months (from 1 January to 30 June 2006) to decide whether they would join the old-age savings scheme or remain

Source: www.infostat.sk/vdc/sk/index.php?option=com_content* average from data received in 1949-1951. ** data for 1 July of the year The age dependency ratios are used as indicators of the level of support of the young (0-14 years) or the old (65 years and over) by the working age population (conventionally aged 15-64).Source: www.infostat.sk/vdc/sk/index.php?option=com_content

Table 2 :: Selected characteristics of the population in the Slovak Republic, 1950 – 2010

Year Number of inhabit-

ants SR**

Average life expect-ancy at birth

Average age

Ageing index

Depend-ency ratio

male female

1950 3463446 59.00* 62.* 30.20 23.04 55.43

1960 3994270 67.70 72.47 30.35 22.05 62.83

1970 4528459 66.73 72.92 32.02 33.59 57.43

1980 4984331 66.75 74.25 32.55 39.74 57.39

1990 5297774 66.64 75.44 33.56 41.44 54.89

2000 5400679 69.17 77.22 35.97 59.78 44.20

2010 5435273 71.62 78.84 38.7 81.01 38.23


only in the pay-as-you-go system. The amount of the contribution for the old-age pension savings was set at 9% of the assessment base. In the short history of the second pillar a few important changes were made. One of the most important allowed people who had joined the second pillar to leave it and as a result the second pillar ceased to be mandatory during the whole period of paying contributions in the pension system. Under the latest amendment to the law on pension savings, an individual who participates in the retirement pen-sion saving scheme for the first time is insured in both pillars. If persons insured for old age in the second pillar decide to terminate participation in pension savings, they have to announce this decision to Social Insurance. Such a decision can be made within 730 days from the date of first participation on the pension insurance and this announcement has to be officially certified or a declaration signed in the presence of an employee of Social Insurance Agency.

The current situation gives future retirees two pos-sibilities: to be insured only in the pay-as-you-go system and in this case the total volume of their contribution is paid and administered by Social Insurance Agency and the future pension will be paid only from this source. Those who decide to be insured in two pillars pay their contribution in two pillars. Along with the contribution to the first pillar, the second contribution is paid to Social Insurance Agency which subsequently redirects half of the amount paid to the pension asset management company chosen by the future pensioners.

The third pillar (supplementary pension scheme) is funded on a voluntary basis. In Slovakia the predeces-sor of this model of creating pension funds was sup-plementary pension insurance introduced in 1996, but this pillar changed after introduction of the above laws.

The original idea of introducing a three-pillar pension system was evaluated as very good by experts. The problem was that the reform of the pension system was introduced only on the basis of political consen-sus and did not have the support of the whole so-ciety. Subsequently, each new government made changes to the original pension system. Some of the amendments were made to correct minor errors but others resulted in deep changes in the system. Most of these changes concerned the second pillar and as a result the originally compulsory insurance has been made voluntary. There were also other amendments in the pension system and it is expected that the changes will continue. Currently, reduction of the volume of the contribution paid in the second pillar and its redirec-tion to the first pillar is under discussion. The proposed

reduction in contributions to the second pillar and their redirection to the first pillar would reduce the long-term resources deficit in the first pillar. Changes in the val-orisation system in the pay-as-you-go schedule are also expected.

In 2011 the average statutory old-age pension was 362 EUR and the early retirement pension 357 EUR. The average old-age pension was 45.84% of the average wage in the country, which is less than in 1993 when it was 53.71%. The proportion of early retirement old-age pensions is low, 3.2% (32 130 persons) of all persons receiving old-age pension benefits (989 763). (http://www.

socpoist.sk/pocet-vyplacanych-dochodkov--v-mesiacoch-/3150s)

malefemale

70000

60000

50000

40000

30000

20000

10000

0

do 7

6

85,1-

95

110,

1-12

0

130,

1-14

0

185,

1-17

0

185,

1-20

0

225,

1-24

0

255,

1-26

5

290,

1-30

5

325,

1-35

0

365,

1-38

5

415,

1-42

5

445,

1-46

5

485,

1-51

5

565,

1-58

5

606,

1-63

0

645,

1-66

5

685,

1-70

5

730,

1-75

5

780,

1-80

0

830.

1-85

5

875,

1-90

0

925,

1-94

5

965,

1-99

6

1000

.1+

Source: www.socialnapoistovna

Figure 2 :: Old-age pensions (as the only pension received) by gender in EUR (21 Dec. 2011)

48

There are still great differences between the pen-sions of men and women. The cumulative amount paid for old-age pensions in 2010 amounted to 3 758 182 000 EUR which represents 5.8% of GDP. 7.7% of per-sons aged 65 and over were at risk of poverty. The worst situation is in the female population – 10.1% were at risk compared to 3.9 % of men (EU-SILC 2010).

Living longer – working longer?

Experts say one of the possibilities for alleviating the consequences of demographic ageing is prolongation of the working life. It is a good idea but care is needed with its implementation. The fact that people do not live their whole lives in good health must be taken into consideration when talking about extending the work-ing life. The average healthy life expectancy at birth (HALE) in Slovakia was 63 years for men and 69 years for women (the corresponding figures for the Visegrád countries are: Poland 63 years for men, 68 years for women; Hungary 62 years and 68 years; Czech Repub-lic 66 years and 71 years, WHO 2003).

In 2005 in Slovakia the chance to live a healthy life without disability and any functional limitation was 78.3% of their life for the male population and 72.2% for the female population. This indicates that the health condition of the elderly has to be taken into account when considering prolongation of the working life. As Juhani Ilmarinen said “…objectives must be set

in such a manner that they can be achieved also with decreased functional capacity or deteriorated health” (Ilmarinen, 2008, 113). Statistical data show more people at a higher age have some health problems (of

course there are younger people in bad health as well), and some of these problems are the causes of limitation in working and personal life which can be overcome by adjustments to the working place, the use of appropri-ate work equipment, flexible working time and so on.

Subjective indicators of the health condition show that elderly people more often evaluate their health in general as “rather bad” and “very bad” than the younger population. While 3.2% of the whole popula-

tion over the age of 15 years evaluated their general health as “very bad”, in the population aged 55-64 the share of such answers was 4.8% and in the 65-74 years age group it was 8.6%.

9.0% of the total population evalu-ated their health condition as “rather bad”, but this figure was 13.5% for the 55-64 years age group and 31.2% for those aged 65-74 years (EHIS, 2009).

The official age for retirement in Slovakia is 62 years for both men and women. In the case of women this age is being approached gradually and still takes into consideration the number of children that was considered under the former law. Slovakia still belongs to the countries with both a lower pension age and employment rate of older workers. What do the data on the employment

rate of older workers say after reform of the pension system in Slovakia?

Statistical data in Figure 3 show that the employ-ment rate in Slovakia varies by age within the working life and by gender. The highest employment rate is achieved by both men and women between the ages of 40 to 54 years. The employment rate by gender is very different in the population aged under 40 years and 54 years and over. Women in the younger and the older

1009080706050403020100

15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65+

male female

Source: Labour force sample survey results in the Slovak Republic for the 1st quarter. ŠÚ SR. Bratislava 2011. Data on population as of 1 January 2011.

Figure 3 :: Employment rate by age in Slovakia in Q1 2011 (%)


age groups have significantly lower employment rates than men in the same age group, but the reasons for this situation are different. While younger women take

up their roles as mothers resulting in a lower employ-ment rate, the older women have a lower employment rate due to earlier exit from the labour market. Though the new pension law equalized the retirement age for both genders, women who were insured according to the former law are gradually approaching this age.

In general, statistical data show that postponing retirement age had a positive impact on increasing the

employment rate among older workers in Slovakia. As data in Figure 4 show, the employment rate for men aged 55-64 years increased by 18.8% percentage points

between 2000 and 2009. When this data is compared with those for the EU-27, the employment rate for older men is still lower but it is approaching the EU level. Comparing the data on the employment rate of older men in the Visegrád countries in 2000 and 2009, the strongest increase is found in Slovakia (18.8%), followed by Poland (7.9%), the Czech Republic (6.8%) and the lowest increase Hungary (6.6 %).

The employment rate in the female population in Slovakia is lower than that for men in the 55-64 years age group. When the trend in the employment rate in

the group of older women is compared within the four Visegrád countries, a different situation is found. In Slovakia and the Czech Republic there was a continuous increase in the employ-ment rate of older women, but the starting position in 2000 was different in these countries. The employment rate in this group was lower in Slo-vakia (10.2%) than in the Czech Republic (22.1%). This increase between 2000 and 2009 in Slova-kia reached 15.9% and in

the Czech Republic 12.9%. Data on the development in Hungary showed an increase between 2000 and 2006 followed by relative stability. A different situation again was found in Poland where the employment rate of older women was relatively stable throughout the period measured.

Postponing retirement was only one of the factors causing a rising employment rate of older men and

80

70

60

50

40

30

20

10

0SK CZ HU PL FR DK EU27

2000 2006 2009

35,2

51,6

59,3

58,4

33

41,4

39,6

37,4

38,4

45,332,9

40,1

42,1

61,9

67,1

62,7

46,9

52,6

54,6

49,9

54

2000 2006 200960

50

40

30

20

10

0SK CZ HU PL FR DK EU27

10,2

22,1

32,135

13

27,1 27

21,9 19 21,926,1

35,236,6

46,2

54,350,9

27,4

34,8

37,8

16,9

26,1

Source: Eurostat (online data code: lfsi emp.s. Statistics in focus - 30/2011

Figure 4 :: Employment rate of men aged 55-64 years in selected countries in 2000, 2006 and 2009 (%)

Source: Eurostat (online data code: lfsi emp.s. Statistics in focus - 30/2011

Figure 5 :: The employment rate of women aged 55-64 years in selected countries in 2000, 2006 and 2009 (%)

50

women in Slovakia. Other supportive measures were also introduced that helped to increase the employ-ment rate of older workers. Among these measures we can mention introduction of an anti-discrimination law that prohibits direct and indirect age discrimination of older workers; positive bonuses for those who continue to work beyond retirement age (this bonus increases the future pension benefit by 0.5% monthly); pensioners who continue to work are allowed to receive pay and pension concurrently without any reduction. After 2004 a number of new working places were created mostly as a result of new investors’ activities in the country. Empirical data from the sociological survey of employers1 showed that in the years between 2006 and 2008 66.2% of employers filled a vacancy with a person 50 years or over despite preferring younger employees. Emp loyers said that they most valued loyalty to wards the enterprise (90.4%), indispensability in certain professions and the better working discipline of older employees (Kostolná, 2008, 22 and 26).

1 The empirical sociological survey “Aktívne starnutie v kontexte trhu práce SR” (Active ageing in the context of labour market in Slovakia) was carried out as quota sample survey in 2008. The sample was representative for size of enterprises, sectoral and regional structure of enterprises. The sample comprised 260 employers, and data were acquired through standardized face-to-face interviews. Submitted questions were answered by enterprise owners, human relations officers or authorised employees.

Labour market – pension reform –pro and contra

According to statistical scenarios the population ageing will continue to speed up causing increased costs of health and social care services for the elderly, and of course, it will influence the labour market. Slovakia has introduced a few measures that will help to ease the situation.

One of the most important measures that could help to relieve public finances for an ageing society was the reform of the pension system started in 2004, including the increase of the retirement age. As a consequence, exit from the labour market increased as well. In 2005 the retirement age was 57.5 years for old-age pensioners and 56.8 years for early retirees. In 2009 the average age of those who become old-age pensioners was 59.1 years (an increase of 1.6 years) and 58.6 years for old-age beneficiaries (1.7 years higher) (Štatistická ročenka 2010).

The new system which is based on three pillars on the one side creates better conditions for multi-sources of pension income but on the other side postponing and equalizing the retirement age for both sexes was not welcomed by the public. According to the findings of a representative sociological survey on gender equality and the labour market in Slovakia, 45.5% of respond-ents “definitely did not agree” and 31.5% “somewhat disagreed” with the unification of the retirement age

for both sexes. Negative attitudes towards equalizing the retirement age were expressed more often by women than by men (57.6% of women and 33.2% of men definitely disagreed and 27.4% women and 35.8% men somewhat disagreed) (Bahna, 2006, 64). The results from another sociological survey2 showed that people still consider different levels of retirement age for men and for women as optimal. The optimal retire-ment age according to results from the sociological survey “Plus for women 45 years and more” carried out by the Institute for Public Affairs in Bratislava in the period 2005-2008 and later published are 59.3 years for men and 55.4 years for women (Bútorová et al., 2008, 94). Those limits are closer to the former official pension age for both men and women than the current age and in the case of women the reason may be the different family tasks, especially eldercare (as well as other care tasks) they have traditionally been responsible for. Even younger people reject the idea of working longer after reaching the retirement age, even if they are in good health. A positive answer for willingness to work longer than the retirement age was received from 27.0% of young people aged 20-35 years (Bodnárová. 2006).

In the second quarter of 2006 the ad hoc module on transition from work to retirement (by labour force

2 The survey “Slovakia on the way to gender equality” was con-ducted in a representative sample in 2006. The sample comprised 2 521 respondents and data were acquired through standardized face-to-face interviews.


survey) was carried out in Slovakia. The survey cov-ered 795 400 persons aged 50-69 years who worked and 413 800 persons of the same age who did not work. Respondents from the first group were asked which factors from a list of possibilities would influence their decision to work longer.

The responses showed that the possibility of flex-ible working time would contribute to the decision to stay longer at work for 11.2% of individuals (12.3% of men and 10.4% of women), for the rest this possibility would not be important. More opportunities to update their skills would influence the decision to stay longer in work for 6.0% of respondents (7.2% of men and 5.1% of women), the others would not take it into considera-tion when making their decision on leaving the labour market. Better health conditions or safety at the work-place would influence the decision on retirement for 7.6% of respondents (9.1% of men and 6.4% of women), for the rest this possibility would not be important.

Respondents from the second group were asked which factors from a list of possibilities influenced their decision to retire or to retire early. The main reasons for retirement in their cases were: favourable financial arrangement for 12.4% respondents (13.5% of men and 11.9% of women); loss of job for 4.2% (4.3% of men and 4.2% of women); 3.8% of the respondents gave health problems or disability as the main reason for retiring (4.7% of men and 3.6% of women); a further 2.1% chose taking over care for children or other depend-

ent relatives as the main reason for retirement (0.1% of men and 3.4% of women). The largest group of re-spondents (75.2% in total; 74.7% of men and 75.1% of women) reported “other reasons” that influenced their decision (Štatistická ročenka 2007). The variety of reasons for older workers for leaving the labour market would require more attention. Their study could give a good base for removing obstacles that explain why older workers leave the labour market before reaching pension age or for creating conditions that would be an incentive for a longer working life.

As the data showed there were many reasons that are related to the working place and employer. They could help to form a climate free of discrimination against older workers, offering a variety of flexible work patterns to suit older workers, and jobs properly adjusted to suit them. Improving the qualifications for their older workers could also be effective. But there is also room for government action to help employers in their incentives to keep older workers in the working process.

Summary

The Slovak population has been ageing and this proc-ess has had many consequences that raise questions to be answered. Some of them are closely associated with public finances and some of them mostly with human issues. A few important measures have been

implemented in Slovakia in recent years but there are still a great number of questions to be answered.

The pension reform and working life prolongation is one of the measures that could help to stabilize the macroeconomic sphere and public finances in the country. Slovakia has taken the first steps including postponing the pension age and widening the space for working life prolongation. According to statistical data the average age of people who left the labour market and became pensioners has risen in recent years to 59.13 years (old-age pensioners) and 58.58 years (early retirees) in 2009.

Working life prolongation does not depend only on the official increase of the pension age. Very important factors in this process are the health condition of the population (not only the population of higher age) and enough available jobs for older persons.

A healthy population is a base for economic pros-perity – people in good health can work longer, pay taxes, pay contributions to pension funds and postpone withdrawing pension benefits from them. A healthy population also gives an important ground for saving financial resources on additional health and social services.

Besides improving health services, there is still a wide room for improving people’s lifestyle, which is estimated to influence 50-60% of good health (Hegyi

52

and Rovný, 2003). Lifestyle is the sum of activities that can affect human health in both negative and positive ways. The most frequently reported activities that affect health in a negative way are: smoking, alcohol, limited physical activity, unhealthy eating, stress and so on.

Working life prolongation will also require changes in the labour sphere. First of all a great number of available working places will be required for older people. They will have to be redesigned to the physical condition of older workers. There may be a need for special working equipment at working places, changes in working time organization, and more breaks during working time. The participation of older workers in the labour market will also require changes in the attitudes of individuals towards their own retraining, mastering new technologies, computer skills so that these people are able to remain competitive at work.

All the questions mentioned show the variety of issues the ageing society faces, and dealing with them definitely requires a comprehensive approach by the economic and political spheres, employers and individuals. Policy-makers should also be aware of the increasing participation of women in the labour market which has a positive effect on the economy and pension system on the one hand but at the same time decreases care resources taken free of charge by families and shifts the responsibility to the formal care system that consequently requires new financial sources.

References

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Bodnárová, Bernardína; Filadelfiová, Jarmila; Gerbery, Daniel. (2005) Výskum potrieb a poskytovania služieb pre rodiny zabezpečujúce starostlivosť o závislých členov. Bratislava: Inštitút pre výskum práce a rodiny. Accessed at: http://www.sspr.gov.sk/IVPR/images/IVPR/pdf/2005/rodina/Sluzby.pdf

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Filadelfiová, Jarmila. (2007) Ženy, muži a vek v štatistikách trhu práce. Bratislava: Inštitút pre verejné otázky. ISBN 978-80-88 935-91-9.

Giannakouris, Konstantinos. (2009) Ageing characterises the demographic perspectives of the European societies. Accessed at: http://epp.eurostat.ec.europa.eu/cache/ITY_OFFPUB/KS-SF-08-072/EN/KS-SF-08-072-EN.PDF

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Historická statistická ročenka ČSSR. (1985) Praha: Federální statistický úřad, SNTL –Nakladatelství technické literatúry a ALFA – Vydavateľstvo technickej a ekonomickej literatúry.

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http://www.sspr.gov.sk/IVPR/images/IVPR/pdf/2005/rodina/Sluzby.pdf

http://portal.statistics.sk/files/Sekcie/sek_600/Socialne_statistiky/Socialne_statistiky/EHIS_2009/ehis_2009_verzia_pre_portal-su-sr.pd




http://portal.statistics.sk/files/silc_2010.pdf

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Ilmarinen, Juhani. (2008) Ako si predĺžiť aktívny život. Starnutie a kvalita pracovného života v EU. Bratislava: Klub strieborných hláv a Príroda. Living longer, living better. Addressing the challenge of an aging workforce. IBM Global Social Segment and Lisbon Council. September 2007. ISBN 978-80-07-01658-3.

Kostolná, Zuzana. (2008) Aktívne starnutie v kontexte trhu práce SR. Záverečná správa z výskumu. Bratislava: Inštitút pre výskum práce a rodiny. Accessed at: http://www.sspr.gov.sk/IVPR/images/IVPR/vyskum/2008/Kostolna/Kostolna.pdf

Labour force sample survey results in the Slovak republic for the 1st quarter. (2011) Bratislava: Štatistický úrad SR. Data on population as of 1 January 2011.

Perichtová, Beáta et al. (2008) Pracovné podmienky a rodová rovnosť. Bratislava: Inštitút pre výskum práce a rodiny. ISBN 978-80-7138-127-3.

Sigg, Roland. (2007) Extending Working Life: Evidences, Policy Callenges and Successful Responses. In: Marin, B. and Zaidi, A (Eds). 2007. Mainstreaming Ageing. Indicators to Monitor Sustainable Policies. Vienna: European Centre Vienna. Ashgate. ISBN 978-0-7546-7361-3.

Social protection and social inclusion 2008: EU indicators. Document drawn up on the basis of SEC(2008) 2260. (2009) Luxembourg: Office for Official Publications of the European Communities. ISBN 978-92-79-10155-7. Accessed at: www.ec.europa.eu/social/BlobServlet?docId=2553&langId=en

Štatistická ročenka Slovenskej republiky 2007. (2007) Bratislava: Štatistický úrad SR. ISBN 978-80-224-0990-2.

Štatistická ročenka Slovenskej republiky 2010. (2010) Bratislava: Štatistický úrad SR. ISBN 978-80-224-1163-9.

Výskum európskych hodnôt 2008. Slovensko. (2008) Bratislava: Sociologický ústav SAV a Iris. ISBN 978-80-85544-57-2.

Výsledky výberového zisťovania pracovných síl za 1. štvrťrok 2011. (2011) Bratislava: Štatistický úrad SR. Accessed at: http://portal.statistics.sk/files/vzps111_publikacia.pdf

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http://www.infostat.sk/vdc/sk/index.php?option=com_content&task=view&id=67&Itemid=37

www.socialnapoistovna


http://portal .statist ics.sk/fi les/Sekcie/sek_600/Demografia/Obyvatelstvo/vyvoj_obyvatelstva_sr/vyvoj_2010_tabulky_n.pdf

http://www.sspr.gov.sk/IVPR/images/IVPR/vyskum/2008/Kostolna/Kostolna.pdf



http://www.ec.europa.eu/social/BlobServlet?docId=2553&langId=en

http://www.ec.europa.eu/social/BlobServlet?docId=2553&langId=en

http://portal.statistics.sk/files/vzps111_publikacia.pdf

http://portal.statistics.sk/files/vzps111_publikacia.pdf

http://www.infostat.sk/vdc/sk/index.php?option=com_content

http://www.portal.statistics.sk/files/scheme/sek_600/demographie/obyvate<013E>stvo

http://www.portal.statistics.sk/files/scheme/sek_600/demographie/obyvate<013E>stvo



http://www.socialnapoistovna



http://portal.statistics.sk/files/Sekcie/sek_600/Demografia/Obyvatelstvo/vyvoj_obyvatelstva_sr/vyvoj_2010_tabulky_n.pdf



54

KEY WORDS: DISABILITY, EMPLOYMENT REHABILITATION, SHELTERED EMPLOYMENT, POLICY EVALUATION


There are large numbers of disability pensioners in Hungary and disabled job seekers often have difficulty in finding a job. According to comparable Eurostat statistics for the year 2002, disabled em-ployment ranged between 29% (Spain) and 74% (Sweden), while in the new member states the Hungarian figure was the lowest (at 12% in 2002) and the Czech figure was the highest (48%).

After a brief descrip-tion of the labour market participation of disabled workers, the paper briefly reviews the demographic factors in the background and then goes on to describe the evolution of the policy context in or-der to identify options for improvement. The last part of the paper sum-marises recent research results on the impact of rehabilitation services and based on that, makes some recommendations for redesigning the sys-tem of state subsidies.

Background

Prior to 1989, labour force participation and employ-ment were rather high in Hungary. During the transi-tion, employment dropped from over 71% in 1990 to below 55% by 1993 and has never since exceeded 58%. The adjustment of labour supply to the decline in la-bour demand caused by the transitional shock followed two channels. Beside the rise in unemployment, labour force participation fell significantly during the 1990s. Most people leaving the labour market became eligible for some social provision, such as old-age pension, disability pension, or maternity allowance. By 1995, the share of benefit recipients among the working age population reached 31% and was close to 30% even in 2005 (Duman and Scharle 2011).

In 2008, almost 14% of the active age population (aged 15-64) suffered from some sickness or disability which reduces their capacity to work.1 Around 75% of this group receive some welfare provision and only 23% worked. However, about 9% (150,000 persons) indicated that they would like to work but cannot find a job, while the current system of wage subsidies only provides subsidised employment to 30,000-40,000 disabled workers (Table 1).

1 Own calculations based on the Labour Force Survey data of the Central Statistical Office, 2008 4th quarter, which included sup-plementary questions on disability.

Integrated Employment and Rehabilitation Services: New Evidence from HungaryÁGOTA SCHARLE

Source: Own calculations based on the Labour Force Survey data of the Central Statistical Office, 2002, 2nd quarter and 2008, 4th quarter. For 2011, 2nd quarter Labour Force Survey data published by the CSO: http://www.ksh.hu/docs/hun/xftp/idoszaki/pdf/megvaltmunkakep.pdf

Table 1 :: Economic activity of able-bodied and disabled working age people in Hungary

Population aged 15-64 Long-term ill or disabled

2002 2008 2011 2002 2008 2011

Working age, thousands 6850.0 6789.8 6770.2 748.2 938.0 766.8

Of which: employed 3847.2 3850.7 3779.0 85.9 215.5 139.0

unemployed 229.2 340.0 467.6 9.9 42.5 45.9

Economically active, % 59.5 61.7 62.7 12.8 27.5 24.1

Employed, % 56.2 56.7 55.8 11.5 23.0 18.1

Unemployed, % 5.6 8.1 11.0 10.3 16.5 24.9

Inactive but would like to work, % of working age

6.6 4.8 5.8 14.4 9.4 n.a.

56

As Table 1 above shows, there was a considerable increase in the employment of the disabled population before the global financial crisis. Between 2002 and 2008, there was a two-fold increase in economic activ-ity and employment among people with reduced work capacity, while their unemployment rate increased by 60 per cent. The expansion in labour market participa-tion can be partly attributed to an increase in job search activity (and, to a lesser extent, in willingness to work); put differently, somewhat more people would like to work, and among those people significantly more are actively looking for work.

The low labour market participation of disabled people is explained by both supply and demand-side factors. On the supply side, the relatively easy access to disability pensions is the main cause2 while on the demand side, it is low levels of education and the dis-criminative hiring practices of employers. The above observed increase in activity can be related to changes in legislation, but also to higher education levels – so far as we know, there has been no research that has addressed this question to date.

Labour market discrimination against people with disabilities is hardly documented at all but, according to recent population surveys, the extent of discrimination is considerable (Lovász 2012). The recent rise in the un-

2 Own calculations based on the Labour Force Survey data of the Central Statistical Office, 2008 4th quarter, which included sup-plementary questions on disability.

employment rate of the disabled population, which was much steeper than for the non-disabled population, also seems to suggest that disabled workers are discriminated at the time of lay-offs. However, this cannot be verified on the basis of aggregate figures available for 2011, which may reflect the effects of discrimination as well as of demographic composition and other factors.

In general terms, the education level of the working-age population – particularly of women – has improved in the last 20 years. This is a result of the expansion of educa-tion in the 1960s that reached pre-retirement cohorts in the past few years: the number of people with a school leaving certificate has increased substantially among the over 50-year-olds. The improvement in education has affected the majority of disabled people as well, but primarily those who lost their full work capacity after ob-taining their education. While there has been some recent improvement in promoting the integrated education of children with learning or other disabilities, the availability of high quality integrated education has remained rather uneven across regions and across type of disability.

Lastly, it must be noted that the health status of the population has been gradually improving since the early to mid-1990s. Although mortality indicators only started to improve in 1993, the deterioration in health had been arrested earlier, according to Pauka and Tóth (2003). This is also reflected in life-expectancy trends: since its lowest level in the early 1990s, life expectancy at birth has increased by 4–6 years, and life expectancy

at the age of 60 has increased by 2–3 years. This im-proving trend might have contributed to the decline in disability pension claims (Scharle, 2008b).

Policies affecting the employment of disabled people

Apart from the decline in labour demand, the employ-ment prospects of disabled people have been largely determined by two main types of welfare provision: pensions and rehabilitation subsidies.

a) Disability pensions

Disability pensions3 had been available since before the Second World War, while disability benefit4 in its

3 Act II of 1975, currently in effect, states that people with a 67% reduction in their work capacity are entitled to disability pension provided that no improvement is expected in their condition within a year. The entitlement ceases if the claimant recovers and/or his or her income approaches the level at which it was before the onset of disability. The amount of pension is determined with reference to previous income, similarly to old-age pension: at 25 years of service, it equals the amount of old-age pension, with additional compensation for a total impairment of health. The entitlement to disability pension does not cease when retirement age is reached, the claimant continues to receive the disability pension.

4 Various benefits (labelled disability benefits in Table 3) are paid to claimants not satisfying either the service years or the loss of work capacity condition of the disability pension. The benefit is flat rate if service years are insufficient and wage-related if the claimant has sufficient work history but only between 40-67 % loss in their work capacity.


current form was introduced in 1983. Their eligibility rules remained unchanged during the transition, but – as in many other transition economies – the evaluation of claims was rather generous (Allison and Ringold 1996). As Vanhuysse (2004) argues, the lenient pension policy introduced in order to forestall social discontent or resistance at the time of the regime change was a rational political decision and social insurance institu-tions were therefore willing to co-operate in granting early pensions to workers facing insecure prospects of employment. As a result, the number of people under retirement age in receipt of disability pensions rose from 233,000 in 1990 to 352,000 by 1996 and doubled by 2003.

It must be noted that this process had started well before the regime change. However, the upsurge in disability pension claims starting in the mid-1960s was accompanied by a clear and substantial decline in the general health of the population. The situation was different in the late 1980s: the previous declining trend in health indicators seemed to be reversing. Based on multivariate analysis of county-level panel data, Scharle (2008a) showed that the rising incidence of disability pension receipt was largely a consequence of labour market tensions.

As public spending on pensions steadily increased while revenues remained low due to the low employ-ment rate, governments began to acknowledge the need for reform. Between 1998 and 2009, several

attempts were made to curb disability pension claims by tightening both the rules and the practice of evalu-ation committees, and wage subsidies and training programmes were gradually extended to cover disa-bled persons, low qualified workers and older workers. The boldest of such measures was the introduction of a rehabilitation allowance in 2008. This was granted to new claimants of the disability pension or disability benefit whose work capacity could be partially or fully rehabilitated (as assessed by a committee of health and employment experts). Recipients of the allowance must cooperate with the PES (Public Employment Service) and participate in trainings or other rehabilitation services as required by the PES.

In 2011, the newly elected conservative govern ment introduced a profound reform of disability pen sions and similar allowances, with the aim of significantly reducing the number of claimants. In a politically risky and much contested move, the government also launched a complete review of existing disability pen-sion claims (except for cases where the disability was permanent and implied the full loss of work capacity). The impact of these recent measures cannot be evalu-ated yet. There has been a noticeable drop in disability pension claims in recent years but there has been a parallel improvement in the educational composition of the cohorts nearing pensionable age. The respec-tive impact of these two factors has not been clearly separated yet.

b) Rehabilitation subsidies

Assistance in the labour market rehabilitation of un-employed people with reduced work capacity is mostly provided by the public employment services network in the form of advice and subsidies to employers and services to disabled job seekers.

Historically, state subsidies predominantly went to sheltered workshops and factories. Several expert reviews had uncovered inefficiencies in the subsidy system and an empirical study in 2004 found that the rehabilitation activities of firms providing sheltered employment tended to be firm-specific and training or services facilitating the return to the open labour market were rare (Krolify, 2004).

In the past five years, the system of rehabilitation subsidies was gradually revised partly to increase the social integration of disabled people and partly to curb growing public expenditures and improve efficiency. Since 2005, only accredited employers equipped to provide employment rehabilitation qua-li fy for wage subsidies. However, public funding has not been directly linked to rehabilitation outcomes so there is practically no incentive for firms to as-sist the transition of their workers to the regular labour market. In practice, though formally meeting the accreditation criteria, most firms still do not provide services that would support the transfer to unsubsidised jobs. Also, though accreditation rules

58

require that the share of disabled workers should be at least 40-50% in sheltered workshops, the share of disabled employees is typically much higher, between 60 to 100%. Thus, despite the clear intention of the government to increase labour market integration, a large share of state subsidies still goes to sustaining segregated employment.

The government decree of August 2007 on disabil-ity policy5 set the objective of developing rehabilitation services to facilitate open labour market participation by the end of 2009 and preparing job centre staff for performing associated tasks by the end of 2010. Serv-ice provision has developed in two strands. There is a non-governmental strand, in which NGOs (some set up in the early 1990s) offer services to clients on a first-come-first-served basis, using their own, rather varied methods. These NGOs received dedicated government funding first in pilot projects and later in annually launched competitive grant schemes. There is a public strand developed in the past five years mainly on the basis of EU funds. This is operated by local job centres, which provide some services by their own staff and some services by contracting non-profit organisations (that may be NGOs in the first strand). In both strands there is considerable variation in the quality and ef-ficiency of rehabilitation services and in availability across regions (Gere, 2000; OSI, 2005; FRSZ, 2006).

5 Government Decree 1062 of 2007 (August 7) on the preparations for the implementation of the new National Disability Programme for the period 2007-2010.

The development of NGO services is severely limited by the lack of stable government funding arrangements which increases financial insecurity (FRSZ, 2006).

The recent cuts in access to disability pensions have been accompanied by plans to develop services and restructure subsidies for sheltered employers. The exact details of these plans however have not been made public yet.

The policy challenge

The above review of the labour market situation and relevant policies leads to fairly clear policy conclusions. The task appears to be two-fold: on the one hand, the current system needs to be restructured in order to reduce incentives to leave the labour market perma-nently and on the other hand, effective and efficient policies must be developed to assist those with low chances of finding secure jobs in the regular labour market. A number of Western European governments have faced a similar problem and starting from the 1990s, some have implemented policy measures which proved to be viable (OECD 2008). British, Danish,

* Some respondents only provided data on their organisation (legal status, size, type of services offered, etc.) and some provided individual-level data on their employees or clients but with missing variables so that they had to be dropped from the individual-level analysis. ** Sheltered workshops are also accredited but are treated as a separate group as they qualify for higher subsidies. Accredited employers in the survey included only the so-called ‘priority’ group entitled to the highest level of subsidies. The two groups are legally distinct but otherwise rather similar – their differential treatment by the government mainly reflects the historical development of the subsidy system.

Table 2 :: Response rate and sample size

total stock(number of organisa-

tions)

responded response rate %

supplied individual-level data*

employees/clients

sample of or-ganisations

sample with individual

data

Sheltered workshops** 21 17 81 15 13710 13462

Accredited employers** 48 23 48 22 4895 4508

NGO service providers 37 29 78 11 4479 1148

Total 106 69 65 48 23084 19118


Dutch and Swedish experiences suggest that the solu-tion has three key components. The first two are aimed at reducing incentives: tighter regulations on eligibility conditions and a reduction in benefit amounts. The third component offers an alternative: effective ac-tive labour market policies or social services which enhance work capacity and employment prospects. Focusing on the third component, the next section reports the results of a recent survey that attempted to assess the performance of existing NGO rehabilitation services and compare it to the reemployment chances for workers in subsidised sheltered jobs.

The efficiency of rehabilitationservices – survey results

In 2010, the Budapest Institute conducted a three-phase survey of rehabilita-tion services provided by sheltered workshops and NGOs. In the first phase, administrative data on a sample of employees and clients were collected from all the main employers and service providers receiving a rehabilitation subsidy in 2009 (Table 2). In the second phase, a smaller sample

of high performing organisations was selected and a sample of their employees/clients were invited to fill in a questionnaire. The third phase examined the three best performing service providers to identify the organisational and other features that make their serv-ices successful. The summary below focuses mostly on the results of the first phase, which measured the reemployment chances of employees and clients in subsidised and regular jobs, controlling for age, work capacity, education and local unemployment (Table 2).

The administrative data collected in the first phase of the survey included demographic information, wage, working hours, the date of entering the organisation (as an employee in the case of sheltered workshops or as a client in the case of NGOs) and the date and direction of exit from the organisation. Using this data, the probability of exit to an unsubsidised job (or to any job) is estimated, given the type of organisation, tenure, age, work capacity, and education of the individual and the local unemployment rate. This estimate was then used to predict hypothetical employment probabilities for each observed individual, using the true values of demographic variables but varying the dummies indi-cating the type of organisation. The resulting average probabilities are presented in Table 3.

The above results clearly show that employment in sheltered workshops or accredited firms contributes very little to the chances of a disabled worker to trans-fer to the regular labour market. Even if considering exits to any job (rather than only unsubsidised jobs), less than 1% of workers would exit to other employ-ment within 6-23 months of entering the firm. The reemployment chance of NGO clients is 30 to 50 times higher compared to disabled workers in a sheltered workshop, controlling for individual characteristics and the local labour market.6 The best service provi-

6 The gap is larger if only exits to unsubsidised jobs are considered, but may be biased by missing information: most firms had no information on whether the new job of their former employee was subsidised.

* By design, the regression sample included only individuals with no missing explanatory variables. ** See note for Table 2 above

Table 3 :: Average observed and predicted reemployment outcome by type of organisation

(1) type of organisa-

tion

(2) observed

(3) N

(4) observed

(5) predicted

(shel-tered)

(6) predicted

(NGO)

(7) N

entered between Aug 2008 and Jan 2010

(total sample)

entered between Aug 2008 and Jan 2010

(regression sample)*

Sheltered workshops**

3.1 2064 0.6 0.6 21.2 1236

Accredited employers**

15.5 862 5.7 0.5 18.9 280

NGO service providers

38.6 516 38.9 1.4 38.9 499

Total 11.5 3442 10.8 0.8 25.3 2015

60

ders can place 33-49 % of their clients in unsubsidised jobs in the regular labour market.

Policy implications

The full social integration of disabled people clearly requires further reform: a gradual reduction of employ-ment subsidies, an expansion of rehabilitation services and better-designed incentives for all actors. The system of subsidies should make all actors interested in plac-ing disabled workers in integrated jobs in the regular labour market. On the basis of a detailed review of the current Hungarian subsidy system and international best practice, incentives could be strengthened by:

• a gradual shift in quality assurance towards perform-ance measurement and performance-based financing and away from administrative requirements and accreditation certificates;

• an increase in the stability of financing rehabilitation schemes;

• an increase in state expenditures on effective reha-bilitation services at the expense of wage subsidies for accredited employers;

• requiring all accredited employers and service pro-viders receiving a rehabilitation subsidy to place a certain proportion (adjusted to work capacity) of their disabled workers or clients in the regular la-bour market;

• expanding the capacity of rehabilitation service providers and ensuring access to services across the country;

• establishing a monitoring system that provides infor-mation on the labour market performance of disabled workers employed in subsidised jobs or receiving NGO services.

Based on the estimates presented above, a realloca-tion of a fifth of current wage subsidies for disabled workers to NGO-provided rehabilitation services would increase the disabled employment rate by over 2 percentage points and would become self-financing within four years through the social security contribu-tions and income tax paid by disabled workers placed in regular jobs.

References

Allison, C., Ringold, D. (1996) Labour markets in transition in Central and Eastern Europe 1989-1995, World Bank Technical Paper, No. 352.

Duman, A., Scharle, Á. (2011) Hungary: fiscal pressures and a rising resentment against the (idle) poor. In: Clasen and Clegg (eds.) Regulating the Risk of Unemployment, Oxford University Press, 2011.

FRSZ (2006): Hungarian Research report on people with disability and employees with changed capacity for work. October 16, 2006. Foglalkozási Rehabilitációs Szolgálat, Szombathely.

Gere, Ilona (2000): A megváltozott munkaképességû emberek bekapcsolása a munka világába [The integration of people with changed work capacity into the labour market]. Szociális és Családügyi Minsztérium, manuscript.

Krolify (2004): A célszervezetek körében készült kérdôíves felmérés eredményei. Empirikus elemzés az Országos Foglalkoztatási Közalapítvány megbízásából [Results of a survey by questionnaire among the target organisations. Empirical analysis for the National Employment Foundation]. Krolify Vélemény- és Szervezetkutató intézet, October 2004.

http://www.budapestinstitute.eu/uploads/chap12_Hungary.pdf

http://www.budapestinstitute.eu/uploads/chap12_Hungary.pdf


Lovász, Anna (2012): Labour market discrimination. In: Fazekas and Scharle (eds.): From pensions to public works. Hungarian employment policy from 1990 to 2010. Budapest Institute and IE-HAS.

OECD (2008): Modernising sickness and disability policy: OECD Thematic Review on Sickness, Disability and Work: Emerging Issues and Information Request for the Synthesis Report. DELSA/ELSA(2008)2, March 2008.

OSI (2005): Rights of People with Intellectual Disabilities. Access to Education and Employment, Monitoring Report: Hungary, Open Society Institute, Budapest.

Pauka, T., Tóth, I. (2003): A magyar népesség egészségi állapotának változásai 1979 és 2001 között a morbiditási adatok tükrében [Changes in the health status of the Hungarian population between 1979 and 2001 in the light of morbidity data]. Central Statistical Office (KSH), Budapest.

Scharle, Á (2008a): A labour market explanation for the rise in disability claims. In: The Hungarian Labour Market, Institute of Economics, Budapest.

Scharle, Á (2008b): Korai nyugdíjba vonulás [Early retirement]. In: Nagy, Gyula (ed.): Jóléti ellátások, szakképzés és munkakínálat. IE-HAS, Budapest, pp. 81-103.

Scharle, Á (2012): Pensions and unemployment benefits. In: Fazekas and Scharle (eds.): From pensions to public works. Hungarian employment policy from 1990 to 2010. Budapest Institute and IE-HAS.

Vanhuysse, P. (2004): The pensioner booms in post-communist Hungary and Poland: political sociology perspectives, International Journal of Sociology and Social Policy, 24(1-2).

http://www.budapestinstitute.eu/uploads/emp_pol20_hu.pdf






62

KEY WORDS: INTIMATE PARTNER VIOLENCE, OLDER FEMALES, SOCIAL INSTITUTIONS


1. The transnational cooperation. Partners and countries involved

IPVoW1 was carried out by 7 research institutions from Austria, Hungary, the UK, Poland, Germany and Portugal2.

Given the fact that the type of welfare regime is strongly connected to the way gender hierarchies are organised in the countries, participants were included from liberal welfare regimes (United Kingdom), cor-porate welfare regimes (Austria, Germany), Eastern European welfare regimes (Hungary, Poland), and Southern European welfare regimes (Portugal).

The decision on the methodological approach was guided by research interest on the one hand and

1 Intimate Partner Violence against Older Women’ research supported by European Commission. Final Report available at website: www.ipvow.org

2 The following organisations and individuals took part in the study: Germany - German Police University (DHPol), Muenster: Thomas Goergen and Birgit Winkelsett (coordination); Austria – IKF (Institute of Conflict Research), Vienna: Birgitt Haller and Helga Amesberger; Germany - Zoom - Society for Prospective Developments e.V., Goettingen: Barbara Naegele, Urte Boehm and Nils Pagels; Hungary - Academy of Science, Budapest: Olga Toth and Katalin Robert; Poland - University of Bialystok: Jerzy Halicki, Malgorzata Halicka, Emilia Kramkowska and Cesary Zuk; Portu-gal – CESIS – Centre for Studies for Social Intervention, Lisbon: Heloisa Perista, Alexandra Silva and Vanda Neves; UK - University of Sheffield: Bridget Penhale and Jenny Porritt

Research aims were first of all to gain insight into cases of intimate partner violence against older women in general, and secondly to gather information on institutional knowledge of cases and ways of dealing with the phenomenon.

The project design included the following components: (1) Review of existing institutional data on intimate

partner violence against older women(2) Institutional survey(3) Staff interviews (4) Victim interviews(5) National expert networks In this paper I present some data coming from

institutional survey.

2. Methodology of the institutional survey. Survey aims and design

Institutional knowledge about cases of intimate part-ner violence against older women was a crucial com-ponent of research in the frame of the present study. Professionals working with older victims can provide information on phenomena of IPV in old age as well as on help-seeking behavior of older women, services offered, service usage, and case outcome. Since the study did not aim at representative data on prevalence and incidence but had its focus on older female victims’

known research limitations as regards this specific topic on the other. Prevalence data on the issue would have been highly interesting to the research team, but no empirical approach which could produce sound data was feasible or reasonable. Given the fact that only rather small numbers of older female victims of IPV have been identified in victimization surveys down to the present, any attempt to measure the extent would inevitably lead to a need for very large sample sizes and might still not result in sufficient case numbers to allow in-depth analysis. An additional problem which was identified was that victimization surveys aiming at prevalence data are of very limited value as regards victimization in the “fourth age” because the most vulnerable older women (e.g. women with dementia) are also the least accessible to research. With these limitations in mind the research team decided to put a special focus on help-seeking and service usage by older victims of intimate partner violence and on qualitative data on cases of IPV against older women.

Intimate Partner Violence Against Older WomenOLGA TÓTH

64

needs, help-seeking and service usage, institutions and professionals within these institutions were a primary source of information.

In selecting institutions, we made an effort that they should cover the full scope of entities that profes-sionally deal with older people. Questionnaires were sent to all state and non-governmental organizations that provide help for the victims of violence. The first group of institutions (which we called, by a general term, domestic violence service group) included crisis centers, shelters, victim help institutions, telephone aid lines and non-governmental organizations dealing with violence within the family. The next group under the name law enforcement includes all the institutions that deal with enforcing, causing to enforce rules of law related to violence. In Hungary, they are the police, the public prosecutor’s office and courts. Health serv-ice organizations include various institutions of health care, in our sample, primarily family doctors and medical and psychiatric wards of hospitals. The group called general social service includes family helpers as institutions with the most overall scope of duties in social care. All the institutions that provide basic social care for the older (feeding, giving help at home, village caretaker service) were classified into this group. The service for older institution group includes day and residential care centers for the older, aid lines and advisory services set up for the older. Finally, the other institution group includes entities that deal with more overall interest protection, older affairs issues or

are related to the topic in other forms (e.g., self-help/mutual help groups).

3. Respondents

In several cases, respondents did not answer even the simplest, socio-demographic questions either. This indicates that they are disinterested in the topic. This is also implied by the fact that we find no connection at all between the respondent having provided its personal data or not and having had or not having had cases in the past years. In lot of cases, respondents were driven by the motivation to get the task that they did not like done as soon as possible. Only in 48 cases from among the 79 questionnaires returned did we learn of data on the identity of the respondent.

The 48 respondents included 42 female and 6 male persons, which other-wise indicates the gender composition of the experts who deal with the topic. Ap-prox. half of the 48 respondents (47,9 %) have higher education qualification in social care/work. 29 % merely indicated that they have higher education qualifi-cation but did not specify their special subject. In some cases, there were respondents with law, police, health and secondary education qualification. In terms of interpretation of data, it is

a good sign that we had respondents from all sorts of position levels; therefore, the questionnaires aggregate diverse experience.

4. Results

How many victims were there?

Let us look at how many older female IPV victims in total the 33 institutions contacted in the period 2006-2008. As it can be seen in the rest of the analysis, the number of victims will be different regarding each question. There are several reasons for that. If the staff member of an institution completed the short questionnaire, s/he did not answer certain questions. Also, it occurred that certain institutions had only aggregated data that

Total number of victims (Q2)

First contact (Q12)

From where organization knows(Q11)

Victim’s features (Q8)

Forms of violence (Q7) Service provided (Q13)

Circumstances (Q10)

Age (Q3)

Perpetrator (Q9)500400300200100 0

Diagram 1 :: Number of cases based on various questions 2006–2008 (institution N=33)


did not contain certain material splitting of the data. In such cases they did not answer the given question and, unfortunately, did not give an estimate figure either. In other cases staff members of the institutions completed the questionnaire superficially. They did not spend enough time on searching for and finding information regarding the question or thinking about it deeper. As they did not undertake to give an estimate at least, they did not answer the given question. Finally, we believe, it might have also occurred that they misunderstood a given question; so, sometimes inconsistent responses were produced (Diagram 1).

Experts were able or willing to give information on older female IPV victims to a different extent. If we consider the answer given to question 2 the basis, accordingly, during the 3 years under review the 33 institutions met with a total of 465 cases. It is senseless to calculate the average per one institution because, as most of the institutions knew about 1-5 victims, the relatively high case number is produced by the data of a few national or county organizations. We can learn of the most information on the perpetrator (441 cases). We are provided with definitely less information on the age of victims, the circumstances of committing the act and the service provided. It is unfortunate that very few responses were received on both the forms of violence and the characteristic features of the victim. And even less on establishing contact and flow of infor-mation. Consequently, general statements can be made only precariously.

What forms of violence have occurred?

As we have indicated in the previous sections, a part of the institutions gave rather incomplete responses on the details of violence and the relation between the victim and the perpetrator. 33 institutions met with older female victims during the period under review; at the same time, only 18 institutions gave a survey on what forms of violence occurred. Consequently, we received no more than 214 interpretable responses to this question. If we accept as a starting-point that the institutions met with a total of 465 victims, then, even if we calculate with one kind of violence, we do not get any information on half of the victims regarding this question. What is more, there seems to be an agreement in literature that various forms of violence occur usually in a combined form. It is very rare that a person becomes the victim of one type of violence

only. Our data supported the above; victims suffered 3-4 kinds of violence. So, it can be stated that regard-ing a significant part of the victims who were noticed by the institutions not even basic information on what form of violence victims suffered was revealed (Table 1).

Each of the institutions that answered the question met with physical violence in the scope of older female IPV victims. In most cases, this involved verbal/spir-itual violence (83.3 %) and financial exploitation (72.2 %). These are the forms of violence that most typically go together. The number and rate of sexual and neglect type violence is relatively low. We presume that victims conceal sexual violence even more than other types of violence. And tasks of care are carried out less by the intimate partner, much rather by adult children or professional care personnel. So, in the aggregate, it was

63 victims con-cerning whom we learned of what kind of violence they suffered. There is no significant difference be-tween specific institution types in terms of what type of violence they give an ac-count of.

Table 1 :: Forms of violence (N=18)

N of organizations percent of organizations N of victims

physical 18 100 63

sexual 4 22,2 9

verbal 15 83,3 65

financial 13 72,2 43

neglect 7 38,9 7

sexual harassment 4 22,2 6

stalking 5 27,7 21

total 18 214

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Who was the perpetrator?

In the following table we present what relation was maintained between the perpetrator and their older female IPV victim in the cases that the institutions learned of (Table 2).

It is noteworthy that most information is avail-able to institutions on the perpetrator. With regard to almost all perpetrators we learned of what relation of kinship they maintained with the victim. As a matter of fact, categories might somewhat overlap since the part-ner can be at the same time caregiver or care recipient.

Furthermore, after a divorce or a break a cohabiting partner can transform into a former partner.

Nevertheless, we consider it notable that it is former part-ners who commit IPV against older women to the greatest extent. The interviews made with victims support both the fact that the violence is often con-tinued after divorce or break and that in specific cases the violence will become more serious when the woman wants to dis-continue cohabitation maintained until then. This result can be

advanced also by the fact that it is easier for victims to speak about the abusing conduct of the former partner than about the currently existing partner, who might continue to live together with the victim.

Circumstances of committing the act

Furthermore, it is worth looking at what information came to the knowledge of organizations regarding the circumstances of violence. Specific factors listed in the questionnaire set in pairs exclude each other; so, we can also observe that to the best knowledge of experts how characteristic it is that victims, as we presume, suffer mostly unilateral violence (Table 3).

The data of the table clearly show that whenever an institution gets in contact with an older female IPV victim, the victim will be characterized at a higher rate by permanent, unilateral, frequent violence rather than by rare, mutual, short term violence of lower weight. As a matter of fact, due to lack of representa-tivity, generalisations cannot be made from these data to the extent that the violence that takes place was by all means characterized by the above too. Another explanation is also possible: by the time various helping experts learn of specific cases, the relevant case will have become more serious. Our interviews also sup-port that a part of the experts are not sensitive enough

Table 2 :: Were there cases in the practice of the institution (N=33) when the perpetrator

Perpetrator was… N of organizations

percent of organizations N of victims %

Cohabiting partner 33 100 168 38,1

Partner not cohabiting 15 50 56 12,7

Former partner 11 33,3 177 40,1

Caregiver of victim 10 30,3 38 8,6

Care recipient 2 6,1 2 0,5

Total 33 441 100

Table 3 :: Number of victims in terms of the circumstances of committing the act

N of insti-tutions

N of vic-tims

N of insti-tutions

N of vic-tims

One-way violence 12 41 Mutual violence 2 2

Frequent 13 33 Infrequent 7 30

Lasted longer than 1 year

10 36 Lasted less than 1 year

6 13

Started before 60 10 60 Started after 60 10 28

Total 170 73


to this important problem; consequently, they do not notice “milder” cases of violence or cases of violence commencing in old age to a sufficient extent. So, in terms of prevention it would be important to make experts sensitive to this issue.

Perception of the problem of IPV against older women

In our research we often meet with the opinion that IPV against older women is not a really important prob-lem. It was due to this argument that a part of experts did not complete and return the questionnaire. They believed – as we shall present it in the part covering the analysis of the interviews – that violence would not probably commence in old age and violence lasting for decades would in some form end by the time of reaching old age. Accordingly, in the questionnaire we put some opinion questions that tested this topic. Respondents answered to attitude questions on a scale of 6 grades where answer 1 represented the opinion strongly disagree and answer 6 the opinion strongly agree.

In evaluating the results, we need to take into ac-count that questions were answered by the 79 experts who dedicated time and energy to completing the questionnaire. So, they are committed to the issue to some extent even if they had not met with any cases in their practice. Those who do not consider the issue important expressed their opinion by the sheer fact of

not completing the questionnaire. Subsequently, it can be made probable that in a more extensive scope of the profession an opinion different from the results set out below, deeming the problem less important, would develop.

In terms of our topic, the most overall opinion question inquired whether old age rules out that a woman can become the victim of IPV. The statement ran as follows: ”Women in all stages of life are threat-ened by IPV – women in later life are not exempted from this.” Experts agreed with this statement at a high rate (5.3 on average). Consequently, whereas this is an unimportant social problem in common talk and to a part of experts too, another group of experts do consider it very important. This record calls our atten-tion to the need to make the public more aware of the topic—we must make it known in a much wider scope.

Importance of the topic

The next group of attitude questions concerns the social importance and negligence of the problem. The point that older female IPV victims would need to get more help than is given at present (”Older female victims of IPV need more support than is provided up to now.”) is a more or less accepted standpoint among experts since the average of the responses was 4.9. However, the point to what extent this field is not properly addressed in general (“The importance of the problem of IPV against older women is underestimated

up to now”), and to what extent the number of such victims will grow in the future (“The number of older female victims of IPV will grow in the future.”) divided respondents more. Experts, while they would like to provide older victims with more – and as we shall see below – better quality care, do not consider the field very underestimated (average 4.1). It is possible that the thought behind this opinion is that in general IPV is an underestimated topic not handled as an issue of great importance in Hungary. Consequently, the situation of older victims is not significantly different from that of younger victims. Yet, it is also possible that a part of respondents – as we have referred to it earlier – do not consider IPV a widespread phenomenon among older couples. This latter point is implied also by the fact that respondents do not foresee any rise in the number of victims in the future (average 3.1). So, whereas the number and rate of older people in our society grows, respondent experts are uncertain about the question if more and more violence cases were identified in the future.

Denying the topic

Thereby we have arrived at a third group of opinion questions. There is a specifically identifiable group of respondents who do not consider the issue important. In close connection with that, they do not foresee any rise in the number of older female victims, and think that in the case of older couples IPV cannot be a very widespread phenomenon. There is a strong significant

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correlation between the opinions that assert that there are few older victims, older women will not become IPV victims and the number of victims will not grow in the future are closely correlated. At the other pole, a group of opinions can be identified that considers the field neglected, thinks that the importance of the issue is underestimated at present and foresees a significant rise in the number of victims in the future.

We analyzed these opinion questions by cluster analysis too. Based on the cluster analysis, opinions were classified into two clearly separable groups. Members of one of the groups (N=57 persons, 72.2 % of respondents) typically consider the topic important, deem the situation of older female IPV victims pecu-liar and point out that more victims can be foreseen in the future. Members of the other group (N=22 persons, 27.8 % of respondents) do not consider the topic especially important, deem that violence of older women by their partner is not a very widespread phe-nomenon among older women, so they do not foresee any considerable change. It is noteworthy that there is no significant difference between institutions that have and institutions that do not have knowledge of cases in terms of what opinion group the respondent was ranked. So, knowledge of cases does not change judgment of the topic. However, we found significant difference (at .05 levels) between the opinions of ex-perts of various institutions. At a rate much higher than at other institutions, workers of law enforcement insti-tutions were classified into the group that consider the

topic an issue of low importance. This institution type contained the police, public prosecutor’s offices and courts. Within the group, specific institutions cannot be separated from one another due to the low number of elements. However, our professional information support the fact that shift in attitude to and growth of knowledge about IPV victims of the police has significantly improved in the past years; therefore, we presume, indifference to the topic can be typical of the workers of other law enforcement institutions rather than the police.

Latency

In the last group of opinion questions, we asked that in the experts’ view how many percent of victims aged 20-40 and 60+ seek help. Actually, this ques-tion group provides a kind of estimate on latency in the scope of young and older victims. Experts responded to this question at a high rate, the number of respondents was 69-74 (number of total questionnaires = 79). The following table shows the average of the opinion of total respondents (Diagram 2).

In general, respondents judged that victims aged 20-40 seek help at a higher rate than victims over 60. Only concern-

ing help from the church was the figure of older people higher. Experts held the view that victims of violence mostly turn to a physician: every fourth-fifth in the young age group and every seventh-eighth among the older. Definitely less victims report the case to the po-lice (16.3 % of young victims, and merely 6.3 % of the older). In the opinion of respondents both the rate of using external help is low and, unfortunately, the rate of victims who turn to family members, friends is very low (12.5 % and 9.2 % respectively). All this implies that in our society IPV is still considered a topic that victims find difficult to talk about and regarding which they get help with difficulties. As a matter of fact, these opinion questions are not suitable for measuring real

seeking other help

seeking other by the

clergy

seeking psycho-

social assistance

seeking medical

help

pressing criminal

charges

0,0 5,0 10,0 15,0 20,0 25,0

60+ years old20-40 years old

16,36,3

21,313,4

14,34,7

10,013,6

12,59,2

Diagram 2 :: In your opinion how many % of IPV victims aged 20-40 and 60+ seek help?


latency. They provide a kind of estimate from the aspect of those who might meet or, for that matter, not meet with such cases.

Summary

This part of the project, the experts’ questionnaire can be just partly called successful in Hungary. It has been again proved what other sociological research studies have demonstrated that use of self-completion ques-tionnaires in Hungary is not expedient. Completing a questionnaire independently causes difficulties to and by all means evokes antipathy in many people. There-fore, if a similar kind of investigation is made in the future, it must be prepared more profoundly, possibly by involving the supervisory authorities of institutions.

It was also due to low degree of sensitivity to the topic that only one-fourth of questionnaires sent out were returned. When we asked the institutions that had not returned the questionnaire for the second time to fill in at least the opinion questions and the questions regarding the institution even if they had no cases, we were often given the reply orally that they considered the topic uninteresting, unimportant. For this reason they feel the completion of the question-naire is a kind of waste of time. In better cases, they underlined another form of violence from their prac-tice as a more important subject more suitable for re-search (e.g. violence of older persons by their children,

grandchildren). In worse cases, they judged the entire topic of violence within the family unimportant.

Only 11 respondents indicated that the issue was important to them and they would undertake an interview too. This number is far from the figure we expected. Furthermore, not all respondents who un-dertook the interview had case experience, and many respondents with case knowledge did not undertake the interview. So, interest in the topic arises from the personal knowledge of the expert completing the questionnaire rather than from the experience of the institution. Therefore, generating sensitivity to the topic is one of the most important tasks in Hungary.

Based on the data available to us, the institutions – where it is documented – met mostly with cases where physical-mental-financial violence goes together. The overall majority of violence was unilateral, recurrent, long-lasting and commencing before the age of 60. Consequently, experts working in practice did not support the view extensively held in Hungary that IPV is a mutual, ad hoc and accidentally occurring form of family conflict, which affects men just as much as women.

Unfortunately, we have received little information as to how the institutions got into contact with victims and what services they provided for them. It was mostly domestic violence service type institutions that provided several kinds of services: primarily psycho-social sup-

port, legal advice and crisis intervention. Due to low-key information supplied on services, it would be difficult to make proposals on improving services. Yet, we can state that the experts of organizations dealing with violence are the most prepared and the most suitable for provid-ing help; therefore, improvement of these institutions and increasing the number of experts would be of key importance. Regarding the improvement of services, it is expedient for Hungary to use the experience of the other countries that take part in the project.

The group that considers the topic less important constituted a minority, yet appeared among the respondents (27.8 %). Presumably, this view is more widely held among those who have not returned the questionnaire. A part of the experts assert that relationships of the older do not contain any element of violence; others consider the abusive role of other family members more important. As our research was not a prevalence study, it would be difficult to convince those skeptical about the topic by data. Presentation of cases might have some kind of convincing force to them.

We think that sending out questionnaires and processing responses have brought some results. The most important is the fact that experts’ attention has been driven to this issue. It can be hoped that the institutions that have so far not dealt with this issue at all will pay somewhat more attention to this topic in the future.

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KEY WORDS: INTEGRATING HEALTH AND SOCIAL CARE; FORMAL AND INFORMAL CARE; LONG-TERM CARE, INNOVATION, PRACTICE EXAMPLES


1. Introduction The rising demand for long-term care (LTC) calls for policy approaches allow-ing for holistic and inclusive views that integrate the role of different public programmes, sectors of society, and private initiatives. The objective of the FP7 project ‘INTERLINKS – Health systems and long-term care for older people. Modelling the INTERfaces and LINKS between prevention and rehabilitation, quality of services and informal care’ has therefore been to construct and validate a general frame-work to describe and analyse LTC for older people from a European perspec-tive to illustrate the state of the art in 14 European countries. The particular aims of the project were to inspire and stimulate health and social care professionals as well as policy makers

• To work towards integrated systems of LTC;• To improve planning and delivery of services for frail

older people at the interfaces between formal and informal care, and between social and health care; and

• To integrate prevention, rehabilitation, quality man-agement, governance and finance in the toolbox to develop LTC systems.

While policies still rely more or less explicitly on informal family care, the preconditions for purely informal approaches tend to become unsustainable. Organisational structures are often patchy and un-equally distributed. Quality is mainly defined by mere structural quality indicators, and resources are lacking to coordinate existing services around the needs of users and their carers.

However, as all LTC systems are still ‘under con-struction’ there is a wealth of opportunities to learn from each other, in particular for developing welfare regimes like those of the Visegrad countries. Innova-tive examples for quality development, governance and for supporting informal carers will be presented, based on the INTERLINKS framework for LTC in Europe (http://interlinks.euro.centre.org).

With 16 university institutes and research agencies from Austria, Switzerland, Denmark, France, Finland, Germany, Greece, Spain, Italy, The Netherlands, the Slovak Republic, Slovenia, Sweden and the United Kingdom, INTERLINKS has been one of the largest projects focusing on ‘Health Systems and Long-term Care for Older People’ in the Seventh Framework Programme of the European Commission. 20 Euro-pean stakeholder organisations were represented in the ‘Sounding Board’ of INTERLINKS, providing feedback on interim results and specifying useful information for improvements. In all participating countries ‘National Expert Panels’ gave feedback on

This contribution will present results of INTER-LINKS by addressing problems and solutions of LTC for older people at the interfaces between formal and informal care as well as between health and social care systems. Indeed, all European countries are dealing with inconveniences and bottlenecks at these bounda-ries, but integrated approaches to long-term care are only emerging slowly. This can be shown in relation to policies, processes and pathways, organisational structures, management and leadership, resources and, in particular, an own identity for LTC.

Constructing Long-term Care Systems in Europe – Theoretical Conside-rations and Examples of Innovative PracticeKAI LEICHSENRING

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national reports and helped identify innovative prac-tice, policy developments and relevant documents.1

2. A common understandingof long-term care

The project started off with a collection of information about potential pathways, bottlenecks and solutions for two constructed cases (‘vignettes’) of older people needing long-term care in the participating countries. The related posters were describing the complexity of services and facilities, which ‘Mrs. L.T. Care’ after an acute stroke or ‘Mr. L.T.C. Dementia’ may need.2 Individual country contributions showed, whet her such services are in place, how they may be accessed and to what degree they provide smooth transitions at the interfaces between health and social care systems. This exercise helped gain a common understanding of what LTC meant in the different countries and provide insight into the huge differences within and between national systems. However, a common feature in all countries was the importance of informal and family care and the divide between this informal and the formal care systems. Within the latter, a second

1 All products and results of the project can be found and down-loaded from the project website http://interlinks.euro.centre.org. See also Leichsenring et al, 2013.

2 An ideal-type ‘story of Mrs. L.T. Care’ has eventually been translated into a flash-movie to provide a definition of LTC and an introduction to the INTERLINKS Framework.

divide can be identified between the health and social care systems. Furthermore, it became evident that LTC systems with an own identity, defined processes, organisational structures, management and leadership approaches or specific means and resources are only just emerging (see Figure 1). The ‘unstable equilib-rium’ of the current state of LTC in most European countries may be exemplified by the development of ‘grey’ or legally unregulated phenomena such as, for instance, the emergence of a market for ‘migrant car-ers’ (Bettio et al, 2006; Di Santo and Ceruzzi, 2010). Families, in particular women, who are providing the bulk of care work are increasingly overburdened or, e.g.

due to their participation in the labour market and boosted mobility, simply not present to care for their older parents. With the huge wage dif-ferentials between geo-graphically close Central and Eastern European countries, it has become a wide-spread practice, in particular in Austria, Germany, Italy, Spain or Greece, to compensate for the lack of services by employing domestic as-sistants from neighbour-ing or near-by countries.

With their pensions and cash-benefits older people and their families in Western Europe are hence able to pay monthly wages for 24-hours care which, in migrant carers’ countries of origin (Poland, the Czech Repub-lic, Hungary, Slovakia, but also Romania, Bulgaria or Ukraine), would hardly be attainable. Although some legal amendments and incentives have been intro-duced, e.g. in Austria and Italy, most migrant carers work without any labour contract, training or legal basis, and it is doubtful, whether these arrangements will be sustainable in the long-run.

Social caresystemServicesResidential careProvidersProfessionsMethodsLegal FrameworkPolicies

Health caresystem

Hospital - ServicesProviders - Professions

GPs - MethodsLegal Framework

Policies

The formal -informal divide

The health-social care divide

Identity - Policies - Structures -Functions - Processes -

resources/Funding

Long-term carelinked-in, co-ordinated

integrated?

Users

Informal carers:family, friends ... ’migrant carers’

Figure 1 :: Towards integrated long-term care systems?


3. Focusing on the governance of informal care, prevention and rehabilitation, quality assurance and quality management

The ensuing project phase consisted in research ad-dressing particular aspects of these emerging national models in Europe, namely to show how the links to health care services, the quality of LTC services, the incentives for prevention and rehabilitation, and the support for informal carers are being governed and fi-nanced to enhance structures, processes and outcomes of LTC systems. Altogether, 33 national reports and four European overview papers came, among many other things, to the following conclusions:

• The changing needs and perceptions of care call for the development of specific policies addressing the formal/informal care divide. Though caring will remain a family issue, we are confronted with differ-ent perspectives due to new intrafamilial dynamics, gender issues and the necessity to reconcile work and care.

• Informal carers are both co-producers of care and in need of support services – their specific needs are not always necessarily in line with the older care recipient’s needs.

• LTC policies have thus to be assessed in terms of their ability to provide specific and unspecific sup-port to informal carers, the degree to which they support families in fulfilling their responsibilities (e.g. services in cash and in kind; care leave and

other support to combine caring and working), and in how far they are sustainable. As a special case, for instance, the employment of migrant care work-ers (Italy, Greece, Austria, Spain) was specifically analysed as a solution invented by civil society to fill the gaps between supply and demand of formal care. Though some interesting support practices could be identified, the long-term sustainability and the broader social impact of these solutions are doubtful (Triantafillou et al, 2010).

• Another important issue for emerging LTC systems is the question in how far LTC needs can be decreased or prevented, and which incentives are needed to in-vest in rehabilitation and the promotion of autonomy in LTC. Respective literature reviews and national reports showed that prevention and rehabilitation within LTC, i.e. once a person has started to be in need of LTC, are relatively scarce. Tangible interventions focus at best on geriatric assessment and falls prevention, while the general governance approach promoting competition on quasi-markets often results in ‘care taylorism’ that impedes person-oriented care approaches across the ‘chain of care’.

• As a result, the political insight in the necessity of prevention and rehabilitation within LTC exceeds the political and financial investment by far. The topic is still in an initial state of research, policy and practice with remarkable differences between coun-tries. Besides explicit preventive and rehabilitative interventions it will mainly be necessary to develop organisational pathways and structures to promote

local and regional steering capacities at all stages of LTC to promote prevention and rehabilitation in terms of promoting self-determination, empower-ment and individual responsibilities (Kümpers et al, 2010).

• Also when it comes to quality assurance and quality management in LTC, specific tools, methods and practices are only just emerging, however at an in-creasing pace over the past decade. A general trend from inspection to quality management and external audits can be identified (AT, CH, NL) as well as a growing search for process and result-oriented qual-ity indicators, rather than the traditional definition of structural requirements only. However, quality assurance across the ‘chain of care’, benchmarking between organisations and public reporting are only at an initial stage – with respective restrictions and difficulties to prove evidence-based quality improve-ments. An important issue in this context is the search for indicators that consider users’ quality of life and related satisfaction surveys (Nies et al, 2010).

• A crucial aspect for improvements lies with appropri-ate governance and financing mechanisms that, over the past two decades, have mainly been inspired by New Public Management and market-orientation. INTERLINKS research related to these issues showed that, in spite of important improvements and investments, these approaches have not always been successful to promote inter-agency working, user-orientation, prevention and/or quality improvement across the ‘chain of care’. For instance, if financing

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of care home residents is dependent on their level of care needs, providers will lack incentives to invest in rehabilitation. Also, if providers are working as competitors, coordination and networking might be impeded, rather than encouraged (Allen et al, 2011).

4. Constructing a Framework for Long-term Care

Based on these findings, the consortium partners start-ed to construct a general INTERLINKS Framework for LTC defining themes, sub-themes and key-issues that have to be addressed to define and analyse LTC systems. This Framework was validated by National Expert Panels and the European Sounding Board dur-ing 2010/2011.

The six themes that constitute a LTC system include the identity of LTC, policy & governance, pathways & processes, management & leadership, organisational structures and means & resources. Each of these themes contains an introductory explanation of its purpose in the modelling process, and is further defined by 3 to 6 sub-themes that, again, are further specified by relevant key issues. The rationale for the construction of sub-themes and 2 to 8 key issues in each of the sub-themes was informed by the work undertaken within the first two project phases that resulted in European overview papers. Key issues also reflect the primary foci of INTERLINKS, namely

prevention and rehabilitation, informal care, quality development and governance and finance.

A specific challenge during this phase was to identify, describe and analyse practice examples in the participating countries to illustrate the 135 key-issues to be considered. About 100 practice examples were identified and peer-reviewed following a mutually agreed template. For instance, under the theme ‘or-ganisational structures’ with its subtheme ‘Formal care in the home and community’ the following key-issues were defined:

• access points (referral, counselling, one-stop-shops) • flexible and adaptable services to suit individual

needs and individual lifestyle• multi-professional teams (eg preventive/rehabilita-

tive measures)• structures that facilitate coordination and coopera-

tion with other formal and/or informal care (includ-ing mobility and transport)

• structures that facilitate communication, planning and care delivery with informal carers

• practitioners in independent practice as gate keepers and/or personal case and care managers

• diversity-friendliness: recognition of the specific care needs of hard-to-reach groups, especially their specific needs for information, coordination and support to access available services and benefits

With this Framework practitioners, policy-makers and all other stakeholders working in and with LTC

at organisational or at a systems level should thus be enabled and inspired in five steps to improve their practice by means of the interactive INTERLINKS website http://interlinks.euro.centre.org.

5. Identifying on-goinginnovation in long-term care

Among the about 100 practice examples that illustrate the INTERLINKS Framework for LTC a wide range of innovative approaches can be retrieved – always recalling the national differences for innovation de-pends on the specific context and pathways that have to be considered before transferring particular ways of working from one country to another.

In the following, we use the INTERLINKS tem-plate to describe and analyse practice examples that illustrate three selected key-issues:

• Organisational Structures – Formal care in the home and community: Structures that facilitate coordination and cooperation with other formal and/or informal care: Care in the neighbourhood (‘Buurtzorg’) is an example from the Netherlands that shows opportunities for a quick roll-out of new ideas if they prove to be client-oriented and cost-efficient (Huijbers, 2011).

• Policy – Opportunities in terms of linking social and health care: The ‘Reimbursement (fines) for delayed hospital discharges’ as applied in Sweden (and


Denmark) show a way how incentivising governance mechanisms may be applied (Emilsson, 2011)

• Identity/Concept of Long Term Care – Organisa-tions that explicitly address problems at the inter-faces between formal and informal care: R.O.S.A., a Network for Employment and Care Services (Italy) promotes the regulation of undeclared work and quality of care (Di Santo, 2011)

5.1. Care in the neighbourhood:Buurtzorg (The Netherlands)

Why was this example implemented?

Buurtzorg originated from noted gaps between clients’ needs and services delivered by traditional home care agencies, between competencies of staff and daily work routines, and between care delivered by home care agencies and support by other organisations and professionals. To deal with the first gap, Buurtzorg has built in a holistic assessment of client’s needs, which in-cludes medical needs, LTC needs and personal/social needs. Aside from primary nursing care, the individual care plan provides information that will support the client in his/her social roles and in taking up self-care and becoming more independent. The second gap seems to be bridged by self-managing teams, which al-low for a better use of staff ’s competence and for taking responsibility for a greater diversity of care tasks. To deal with the third gap, the network of informal care of the client is being mapped and involved. In addition,

other formal carers are identified and included. Finally, Buurtzorg has initiated new teams for social support (‘Buurtdiensten’), based on the same principles as its home care. In locations where such ‘sister-activities’ exist, it is possible to bridge the gap between various kinds of services more easily.

Description

The Buurtzorg model was designed by experienced district nurses who started an initiative group in 2006 with the objective to provide integrated home care, i.e. with connections to social services, general practition-ers, and other providers, for all persons who need care at home.

The organisational principle of Buurtzorg is to deliver care by small self-managing teams of 12 profes-sionals at a maximum, and to keep organisational costs as low as possible, partially by using ICT for the or-ganisation of care and a small but efficient centralised back-office.

The Buurtzorg method has six sequential compo-nents, which are delivered as a coherent package and cannot be delivered separately. The package includes assessment, mapping and involving the network of informal care as well as formal carers, care delivery, support of the client in his/her social roles and the promotion of self-care and independence.

The model was introduced on the strictly regulated quasi-market of Dutch home care in 2006, and from then it had to compete with usual home care for clients and contracts. By mid-2010, teams were active in 250 locations, with a total number of staff in these teams of 2,600 (amongst them 1,500 qualified district nurses) who serve about 30,000 clients annually. The growth rate of Buurtzorg has continued since with about 70 staff members in 5 to 10 teams per month. The cen-tralised back-office consists of about 30 professionals.

Apart from an initial subsidy in the framework of the Netherlands’ ‘Transition programme for long-term care’ (www.transitieprogramma.nl), costs are completely covered by regular sources from which usual home care organisations also draw their income, i.e. the Buurtzorg initiative is growing by virtue of the high engagement of professionals within the existing quasi-market of care in the Netherlands.

What are/were the effects?

So far no hard data are available for the evaluation of results or impact for clients. So the question about whether this novel method of working can effectively bridge gaps in LTC provision cannot yet be answered. There are, however, some indications about positive effects.

• Buurtzorg ranks number 1 amongst all home care organisations in user satisfaction according to results of the mandatory national quality of care

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assessment. This may reflect satisfaction about co-operation that addresses gaps between home care and informal and other formal care, and between expectations and care delivered.

• High satisfaction of GP’s and local authorities on the cooperation with Buurtzorg was shown by qualitative research.

• In 2011, Buurtzorg was awarded a prize as the best employer of the Netherlands in organisations with more than 1,000 employees. With now more than 4,000 employees Buurtzorg scored (on a scale from 1-10) 9.5 for involvement, 9.1 for low turnover of employees, and 8.7 for staff satisfaction.

• A significant result is the impressive decrease of cost: the consultancy agency Ernst and Young have calculated that Buurtzorg seems to be less than half as expensive as usual home care.

• Another indicator of success is duplication and imi-tation: Buurtzorg has been expanding from 2006 onwards, and its methods are being adopted by new Buurtzorg-like companies as well as by usual home care organisations.

Strengths

• Buurtzorg may be setting a new standard for home care in the Netherlands. Its main strength is to successfully bridge gaps in local level home care by having recognised what the problems are and then designing working methods that cope with the problems. Thus, it meets the needs of patients for integrated care.

• The Buurtzorg model has shown to be highly com-petitive: it is attractive to both patients and staff, and it can be easily introduced in almost every location even if usual home care is available in the area.

Weaknesses

• Demands on staff are very high because of self-managing teams.

• Activities have to be accomplished below or beyond those connected to professional education, and both within planned hours and unplanned in the middle of the night, as there is no night shift. For some staff, this is incompatible with other personal activities and interests at home, and they have to leave.

Opportunities

• International transferability of the Buurtzorg model is feasible only when the conditions of a free com-petition, free choice for users, motivated staff and self-management of teams are met.

Threats

• As other (usual) home care is adopting the Buurtzorg model (piecemeal, however), room for Buurtzorg ini-tiatives will shrink. However, from the perspective of integrated care, it is not important who supplies integrated home care, it is the model and delivery systems that count.

5.2. Reimbursement (fines) fordelayed hospital discharges (Sweden)


In 1992, when the Ädel reform was implemented in Sweden, municipalities were given the responsibility for social care of older people, housing, employment and support of people with psychiatric disabilities as well as for services for those whose medical treatment has been completed and who have been discharged from hospital care. Local authorities are also responsible for care in special housing (nursing homes) and primary home care in ordinary housing (in 50 percent of the counties). County councils are responsible for primary home care in ordinary housing (in the other 50 per cent of the counties), but in particular for hospitals (acute care) and primary care in medical centres (GPs). Be-fore the reform a major problem was that a significant number of patients were ‘blocking the beds’ in acute care causing long waiting lists for hospital treatment. To solve this problem municipalities were given the responsibility to run nursing homes (previously run by the county councils) for those people with both health and social care needs. In turn they were also made economically accountable for bed-blockers in hospitals by a system known as ‘reimbursement’ model that was implemented in 1992 and the ‘joint care planning model’ (implemented in 2006) to stress co-operation between the county councils and municipalities.


Description

With an ageing population, medical advances and changing public expectations, hospital beds are a scarce resource for which demand frequently outstrips supply. Furthermore there is a need for different organisations to cooperate in care for patients with multiple needs. Generally, there is a broad consensus that cooperation between county councils and municipalities is a neces-sity. However, to make this really happen, there need to be incentives for both sides – this was realised by the reimbursement system in combination with a joint care planning model. As soon as a patient is entering a hospital, the hospital doctor in charge writes a referral note to the municipal care service and the responsible GP to formally start the joint care planning model – and the respective reimbursement system:

Representatives from acute care and the munici-pality’s needs assessment unit meet with the patient and, if applicable, an informal carer, to plan rehabilita-tion and future care together, according to the patients needs. The results of this meeting are sent from the hospital to the municipal social services, including the potential date of discharge from hospital. It is then up to the municipalities to activate care services within five days after the defined ‘referral date’ (day of discharge). If the municipality is not able to provide a place in a care home or appropriate home care services, the municipality has to reimburse the county for hospi-tal costs of the patient.


The joint care plan model and especially the reimburse-ment system have been powerful incentives for munici-palities to provide appropriate services in terms of home care or in nursing homes. The Swedish National Board of Health and Welfare conducted follow-up studies on a cross-sectional sample at a specific day, regarding the number of ‘bed-blocker’. Between 1992 and 1999 there was a decrease from almost 2,500 patients to just above 1,000 patients who could be defined ‘bed-blockers’ within a cross-sectional sample on a specific day. Since 1999 their number has remained relatively stable, between 1,100 and 1,300 patients, although in 2007 a slight increase was noted – this was also due to major transitions of health policies at a general level, namely an important reduction of the number of beds in hos-pitals. However, health care consumption is increasing as well as social care. As a result, the ‘reimbursement and joint planning model’ did not solve the problem entirely, but the numbers of bed-blockers are lower and not fluctuating as much as without this mechanism.

What are the strengths and limitations?

In practice, the numbers of delayed discharges were reduced dramatically by the introduction of the ‘re-imbursement and joint planning’ model. Furthermore, the system strengthens communication between health and social care, and contributes to more transparency and defined responsibilities.

With a further decrease of the length of stay in hospitals, however, more pressure will be on local authorities, in particular those with a higher share of older people. In Sweden, this might lead to additional differences between municipalities in local taxes and in the long-run it might trigger debates about equity and national solidarity. In other countries, in particular those where municipalities are not able to levy local taxes, the system would have to be adapted, e.g. by including data about expenditures on social services in the respective distribution mechanisms of nationally levied taxes to regions and municipalities. In any case, more transparency concerning costs and responsibili-ties could be an important lever to fuel the expansion of social care services and to reduce expenditures for acute hospital care.

5.3. R.O.S.A. – A Network for Employment and Care Services (Italy)


In a context of scarce social services for older people and a ‘family-based’ welfare system, over the past 15 years Italian families have referred to a huge extent to ‘migrant carers’ to respond to rising demand of care in an ageing society. This gave rise to an influx of more than 700,000 migrants who are providing help with household chores and live-in care in Italian households, in more than 50 per cent of all cases without any legal basis. R.O.S.A., a network in the Region Puglia aims

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to improve the situation of both families and migrant care assistants by including the latter into local home care service networks and by guaranteeing adequate and appropriate professional solutions. This is also to support the strategic priorities of the Puglia Region in terms of improving social inclusion, the quality of care work, female labour market participation, promoting a better work/life balance and implementing home facilities for older people needing LTC.

Description

R.O.S.A. is an acronym standing for ‘Network for Employment and Care Services’ as it aims to establish a system to support people who need or provide care by matching supply and demand through a network linking different institutional bodies and social stake-holders. In particular, the objectives are

• To support families in finding qualified Italian and migrant care workers;

• To sustain the supply and demand of home care serv-ices by qualified and regular employment contracts;

• To provide private (Italian and migrant) care work-ers with continuing education in order to guarantee quality of care work;

• To improve knowledge about undeclared work in home care services in order to combat it;

• To create a system that allows working women to balance work and family life.

R.O.S.A. is an experimental project that started in 2008 and is still in progress, co-financed by Puglia Re-gion and the Italian Government. It has implemented several methods to improve care for older people in their own homes, and to promote an integrated system of home care services for older people needing LTC:

• A register of all Italian and migrant care workers offering private care in households by Province;

• Financial incentives have been designed to encour-age families to employ migrant care workers on the basis of regular contracts;

• Information and consultation points about employ-ment contracts in each local social district;

• Information campaigns involving trade unions providing administrative help with employment contracts at low cost or even free of charge.

In response to the large number of home care as-sistance requests in Puglia, the project aims to increase home care services by including migrant care workers into local formal home care services networks and by guaranteeing adequate and appropriate professional solutions.

The target group are therefore families of frail (older and/or disabled) people needing home care services, and qualified Italian and migrant care work-ers who offer home care services.

Puglia Region has defined and formally acknowl-edged private assistance by migrant care workers as a

profession by means of a specific regulation. Workers who have attended a special training course and whose competences have been certified by the Public Em-ployment Service, are enrolled in an official register of home care workers maintained by each Province.

Workers who do not have the necessary compe-tences for the certification of their professional qualifi-cations are put on a special list and take part in training activities provided by the R.O.S.A. Project. Once they have completed the training as a home helper (300 hours), they will be placed on the official register of home care workers.

Families who want to employ a qualified home care worker can apply to the Public Employment Service and search the list for the Italian/migrant care worker who meets their needs. Public Employment Service staff also offer consultancy and advice in recruitment.

In order to encourage the regulation of the em-ployment contracts for migrant care workers, Puglia Region provides a care voucher benefit, amounting to €2,500 per family (one-off payment). This benefit is a means-tested one-off payment.

The total cost of the R.O.S.A. Project was €1,740,000, of which €1,010,000 was financed by the Equal Opportunities and Rights Department of the Italian Government Council of Ministers.



The project is part of a wider re-organisation process of the whole integrated regional system for continuity of care in Puglia Region. Evaluation is still on-going, but two important results are already evident:

• Growth in occupation: Home care in Italy depends mainly on private and informal initiatives. Family care is traditionally down to women, who, because of the current negative trend, are less and less involved in the labour market and have fewer opportunities to attend training programmes. As a result of the ROSA project, by March 2010 about 2,000 people have been placed on the register of home care work-ers: 800 are fit to work and have been certified to do home care work and 1,200 are on the list to take part in training programmes provided by Puglia Region.

• Regularisation of undeclared work: Since the 1990s, for historical and geographical reasons, the Puglia Region has been an important centre of migration, with a high percentage of migrants finding jobs in private households. In most cases families do not set up a regular contract to avoid expenses for taxes and social security contributions. The project’s aim is to stabilise the employment of at least 800 migrant care workers and to support this effort by care vouchers to families. These should serve to partly cover expenditures for social security contributions and taxes linked to regular employment contracts. By March 2011, however, only 82 families had re-

quested such a voucher. Data on the number of total employment contracts that have been signed are not yet available because the project is still in progress. This low number is partly due to the insufficient incentive of the means-tested voucher but also to considerable resistance among families to set-up legal employment contracts as this would also imply to have to comply with legal conditions such as minimum wages and rest times. For this reason the project has an important additional impact in bringing about cultural change.

What are the strengths and limitations?Strengths

• the project promotes improved quality in migrant carers’ services for frail people needing LTC by matching supply and demand, the regulation of undeclared work and female employment

• it supports informal carers by employing migrant care workers and promotes work and family life balance

Weaknesses

• There are no municipal mechanisms to support the services, such as monitoring and home tutoring, respite services, emergency care, etc.

• The amount of the care voucher may not affect the regulation process because it only partially covers costs needed to regularise migrant care workers.

• Older people and informal carers are not used to choosing migrant care workers or other kinds of services through a ‘special register’. The registers

need to be designed more user-friendly to inform not only older people and families, but also all other people who might play a functional role in the relationship between the user and the migrant care workers.

• The time allocated to migrant care workers to take care of themselves is limited to a few hours per week: lots of migrant care workers do not give any priority to their own healthcare; some health care services are completely unknown to them.

Opportunities

• The project integrates private care work by migrant care workers into the formal network of social services which could be an opportunity for a better sustainability of migrant carers’ work in Italy.

Risks

• Italian/Migrant care workers continue to be placed through other channels such as word-of-mouth recommendations among neighbours, friends, acquaintances and parish members, rather than by means of the official register.

• Qualifications that have been attained by migrant women in their countries of origin, in particular social and health qualifications, continue to be not easily acknowledged in Italy.

• Initiatives to integrate migrant care workers in the LTC system are just a first step on a very long pathway of reforms. However, this care ‘model’ may also be a barrier to social policy innovation.

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This project, while having positive effects for families in terms of tailored care and immediate access to services, will have to face a wide range of issues concerning long-term sustainability, in terms of both demand and supply of care work. In a context of progressive regulation, some families will be increas-ingly unable to afford family assistance. Additionally, it should not be taken for granted that the future supply of migrant care workers will remain stable, as the countries of origin, in particular Eastern Europe, are trying to stop women’s emigration.

6. Conclusions

The aim of this contribution was to show results from INTERLINKS and the necessity to develop an own identity of LTC systems at the interfaces between health and social care as well as between formal and informal care. First indicators for such a development can already be identified in different parts of Europe

– though at different pace, at diverse levels and with various intensities.

The INTERLINKS Framework for LTC provides a wide range of inspirations and examples to improve long-term care in Europe (see the website http://inter-links.euro.centre.org) and facilitates the involvement of experts and policy-makers. The INTERLINKS Framework for LTC can serve as an interactive plat-form for further exchange, for boosting new ideas and for enhancing the bases of prevention & rehabilitation, quality management, governance and a better integra-tion of health and social care as well as of informal care.

LTC is under construction in ALL parts of Europe, but we can learn from each other at different levels by reflecting upon alternatives from other countries before planning an individual service or facility, and by adapting innovations from abroad to the local or regional context.

References

Allen K, Bednárik R, Campbell L, Dieterich A, Hirsch Durrett E, Emilsson T, Glasby J, Gobet P, Kagialaris G, Klavus J, Kümpers S, Leichsenring K, Ljunggren G, Mastroyiannakis T, Meriläinen S, Naiditch M, Nies H, Repetti M, Repkova K, Rodrigues R, Stiehr K, van der Veen R, Wagner L & Weigl B. Governance and finance of long-term care across Europe. Overview report. Birmingham/Vienna: University of Birmingham/European Centre for Social Welfare Policy and Research (INTERLINKS Report #4 – http://interlinks.euro.centre.org).

Bettio, F., A. Simonazzi and Villa, P. (2006) Change in care regimes and female migration: the ‘care drain’ in the Mediterranean, Journal of European Social Policy, 16(3), 271-285.

Di Santo, P. and Ceruzzi, F. (2010) Migrant care workers in Italy. A Case Study. Rome/Vienna: Studio Come/European Centre (INTERLINKS Report #5 – http://interlinks.euro.centre.org/project/reports).

Huijbers P (2011) Neighbourhood care: better home care at reduced cost, http://interlinks.euro.centre.org.

http://interlinks.euro.centre.org


Kümpers S, Allen K, Campbell L, Dieterich A, Glasby J, Kagialaris G, Mastroyiannakis T, Pokrajac T, Ruppe G, Turk E, van der Veen R & Wagner L. Prevention and rehabilitation within long-term care across Europe

- European Overview Paper. Berlin/Vienna 2010: Social Science Research Centre/European Centre for Social Welfare Policy and Research (INTERLINKS Report #1 – http://interlinks.euro.centre.org/project/reports).

Leichsenring K, Billings J and H Nies (eds) Long-term care in Europe - Improving policy and practice. Basingstoke 2013: Palgrave Macmillan.

Nies H, Leichsenring K, van der Veen R, Rodrigues R, Gobet P, Holdsworth L, Mak S, Hirsch Durrett E, Repetti M, Naiditch M, Hammar T, Mikkola H, Finne-Soveri H, Hujanen T, Carretero S, Cordero L, Ferrando M, Emilsson T, Ljunggren G, Di Santo P, Ceruzzi F & Turk, E. Quality Management and Quality Assurance in Long-Term Care - European Overview Paper. Utrecht/Vienna 2010: Stichting Vilans/European Centre for Social Welfare Policy and Research (INTERLINKS Report #2 – http://interlinks.euro.centre.org/project/reports).

Triantafillou J, Naiditch M, Repkova K, Stiehr K, Carretero S, Emilsson T, Di Santo P, Bednarik R, Brichtova L, Ceruzzi F, Cordero L, Mastroyiannakis T, Ferrando M, Mingot K, Ritter J & Vlantoni D. Informal care in the long-term care system – European overview paper. Athens/Vienna 2010: CMT Prooptiki ltd./European Centre for Social Welfare Policy and Research (INTERLINKS Report #3 – http://interlinks.euro.centre.org/project/reports).

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KEY WORDS: LONG TERM CARE, MIGRANT WOMEN, INVISIBLE WORK, INFORMAL LABOUR MARKET


Introduction

The literature on the migrant care work topic locates the phenomenon at the intersection of different social problems. According to Helma Lutz the adequate analytical focus is the intersection of three different ‘regimes’: the gender regime, the care regime and the mi-gration regime (Lutz 2008). Parreñas prefers to reflect on the intersection of race, class, gender and foreign status (Parreñas 2001. 30). Dawn Lyon focuses on the intersections between work and non-work, and locates care work at the interface of relations of affection and/or obligation, work, reciprocity and financial exchange (Lyon 2009). Ungerson builds up a theory on two axes: regulation/non-regulation and paid/not paid work (Ungerson 2004). Litwin and Attias-Donfut analyse care work as the issue of the inter-relationship between formal and informal care, they conclude that “complementarity is a common outcome of the co-existence of formal and informal care”, and they discuss the phenomena as a mixed provision (Litwin & Attias-Donfut 2009).

The present paper focuses on the interplay between the family employers and the migrant care workers. The employment of migrants as live-in care workers is a recent phenomenon in Central Europe. It is a strategy applied by the population as an answer to

is, the employer families/individuals try to escape from the burden they have to face caused by family duties, a sandwich situation, career and care responsibility towards the elder members of the family. This need seems to be transformed into a work opportunity for women coming from countries with a lower economic position. The employee families/individuals try to escape from the burden they have to face caused by limited income sources, social constraints, individual aspirations for personal or professional satisfaction, higher expectation for themselves and the other family members. This need seems to be transformed into a care source for families living in countries with a higher economic position. Thus the global and local systems enter into interaction and fill in the gaps occurring on the different sides more or less successfully, resulting in both advantages and disadvantages.

The core question of this paper therefore is: how do migrant eldercare workers fit into the formal and informal eldercare system, and how is the care work formed at the interface of the employer and employee? Specifically, what kind of care work is provided by the employees, and what are the background dynamisms of the care work? The paper explores the responses of the migrants at a subject level to the challenges stem-ming from the macro and mezzo level.

the shortcomings of the formal eldercare system and the long-term care burdens. The whole process built up around this increasing need lacks regularisation, formalisation, professional control, and remains spon-taneous, fitting the actual conditions in a very flexible way. Moreover, in major part this type of care work remains in the black sector, as the migrants perform their activity without a legal contract. The shortage in the care system and the insufficiency of the family institution on the one side and the social and economic constraints of the sending communities on the other side lead to the formation of a very special base for the care market. The two poles of the migrant care work can meet each other thanks to the condition that the needs on the one side are considered to be opportunities on the other side, and vice versa. That

What is a Migrant Care Worker? Being at the Crossroads of Servant, Family Member and Nurse StatusTÜNDE TURAI

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Methods and data

The research has been examining migrant women com-ing to Hungary from Romania and Ukraine (neighbour-ing countries; the majority of them are from the Hun-garian ethnic minority), carers from Hungary going to work abroad, and the families employing migrants. It is based on two years of work using a qualitative method.1

A total of 85 open-ended, semi-structured interviews were conducted, all except two of them tape-recorded. In addition ethnographic fieldwork was carried out in both the sending and receiving communities in order to understand the care drain in its complexity. The re-gions covered by the fieldwork are extensive: 3 regions in Romania (as it is the most important care source for Hungary), 1 region in Ukraine, 4 regions in Hungary, and 1 region in Austria (neighbouring country as well).

The corpus of the interviews is built up of 13 inter-views conducted with families employing care workers, 29 interviews with migrant carers working in Hungary, 12 interviews with migrant carers leaving Hungary to work in Austria, Germany, Switzerland, Israel, USA and Finland, and 34 interviews focusing on the context of the care migration conducted with heads of private employment bureaus, bus drivers involved in the trans-portation of the migrant care workers, the head of an NGO dealing with the training of social workers, the head of a public hospital highly affected by the care

1 OTKA, no K 76236. The research was conducted with Zsuzsa Széman.

drain, public opinion leaders from the sending com-munities and other migrant domestic workers. Among the mentioned interviews there are three which fit into two categories (e.g. employer and opinion leader), employer and employee), thus these were mentioned in both categories.

The sample of the migrant care workers consists of women who are mostly unskilled in the care domain (only one is a social worker, one is a nurse and three are nursing assistants), in total just 6 of them have a higher education diploma (in addition, there are three more women who are in training to earn a diploma). The type of work they did in 37 cases was live-in care work, 2 mentioned part-time work (additional work above a full-time job), 1 occasional care work, and 1 worked in care for 8 hours a day as live-out care worker. Regarding the relationship with the labour market, one interviewee reported fully legal work (Finland), 2 women mentioned that during their careers as carer they were employed at least once legally for a limited period (Switzerland, Hungary), the others did the care work in the black market. Language skills are strongly related to the ethnic origin. Migrant carers in Hun-gary are from the Hungarian minority of Romania and Ukraine (EH – ethnic Hungarians), so they speak Hungarian as mother tongue – there is just one excep-tion, a Ukrainian woman whose husband is a Hungar-ian speaker, so she has no communication difficulties in Hungarian. The situation is rather different in the case of care workers leaving Hungary in order to work

in Western countries or Israel (NH – national Hungar-ians). Those who complete the care activity in the USA, Israel and Burgenland (region of Austria close to the Hungarian border) do not need any language knowl-edge as they work for Hungarian families (in the USA and Israel there are Hungarians who immigrated after the Second World War and 1956, in Burgenland there is a Hungarian ethnic minority). Those who work in inner Austria, Germany and Switzerland need at least a basic knowledge of German. However there are just a few who have a communication level at their arrival, many of them arrive without any preparation and try to manage somehow in this disadvantaged situation.

Some more demographical data: they are mostly middle-aged (between 40 and 60); a numerous group has a partner (13 are married, 2 cohabit), 13 are wid-ows, 2 became widows during the care worker period, 8 are divorced or separated, and 3 are unmarried; 35 of them have one or more children, among these mi-nors were mentioned in 4 cases and one of the women took her minor son with her.

Migrants in the care system

The migrant care workers perform their activity at the interface of the explicit and implicit expectations expressed by and attributed to the employers on the one side, and on the other side the norms acquired in the sending community which is in the majority of cases more traditional than the receiving country.


According to the care givers the expected capacities and the tasks they consider the care work to contain are the following:

• in general: attentiveness, supervision, responsiveness, housework, company, fulfilment of personal wishes, personal care for the elderly,

• rarely: management of the health and social services for the elderly, management of the household (e.g. paying the bills), garden work, management of social and family relations / tensions of the person cared for.

Undoubtedly, the enumerated duties contribute much more to the construction of a familialistic care work than to any professional protocol. It is important to mention too, that it seems that the negotiation of the work tasks at the beginning is neither strict, nor orderly, but general and open to flexible solutions and changing conditions. Thus the concept of what care work com-prises is revealed during the activity itself. This affects the care workers in two ways: on the one hand they have a certain freedom in performing their care activ-ity, and on the other hand they are at the mercy of the changing situations and demands. The attributed and imagined duties of the nurses have less terrain, as the personal or health care of the elderly is just one small part of the numerous tasks. However it must not be underestimated. Two factors are of importance in this respect. First, the structural position of the care work-ers is partially the gap left by the social security system, forming the niche of the structural context. Second, the monetary value of the care work has an impact

on the shift of the migrant care workers towards the professional nurses at a certain level. Moreover, the monetary remuneration together with the lack of any formal frame has another impact on the care workers’ status: it might move their position towards servant status.

The research shows that the live-in care work does not mean professional work either for the employers, or for the employees. The very immediate fact that the majority of the migrant care workers do not have the training required for the care duties shows that being skilled or unskilled in care work has no relevance in the selection mechanisms – either from the point of view of the employers’ selection, or from the point of view of the women in the decision to enter the care domain. While neglecting the formal connection to the care system, the personal experiences in care duties within their own family network seem to play a much more import role. Moreover, it should be noted that this is not the key element, but rather the capacities which build up the familialistic models and norms.

It seems that the residential care work performed by the migrant care workers outside of the formal system is at the intersection of familialistic work, professional job and servant service. There are no clear borders among them, and the relationship between them is not clear. There is a constant interplay among these plastic and potential positions, and the status of the care worker is the outcome of the ever moving social and

cognitive interplay. The background dynamism is built up on several other ambivalences, such as: work/non work, emotion/profession, moral/obligation, love/salary, right/deference, independence/dependence, sharing/withdrawing, family member/servant/employee. In the following, the analysis reveals the background dy-namism of these ambivalences in order to understand how the different statuses of the migrant care workers are built up, and to get an in-depth view of what makes the difference between the statuses.

The first very important statement is that the status of the care workers does not depend directly on the work itself. The same complex of tasks might result in different positions. It seems that the subjective interpretations of the work they perform have a greater impact on the relationship among the actors and the attitudes towards the care work.

Second, the interviews reflect that the status reported by the care workers does not depend for the most part on structural characteristics like age, education, social class, family background, religion, and interestingly not on the legal or illegal form of the employment either.

There is one factor among the structural charac-teristics, the membership of the same ethnic group, which has importance, but not necessarily. There exists a positive discrimination towards the coun-terparts of the same ethnicity. Moreover, there is an

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extra value attributed to the counterparts coming from the Eastern regions as they are considered to be more traditional and morally purer. The collaboration between: (1) Hungarians and Transylvanians (region of Romania with a Hungarian minority); (2) Hungarians and Subcarpathians (region of Ukraine with a Hungar-ian minority); (3) inhabitants of Burgenland (region of Austria with a Hungarian minority) and Hungarians, and (4) Croatians (minority) in Austria and Croatians (minority) from Hungary echoed the positive ethnic extra value. It is important to emphasize that this is not a general rule, just a potential impact. The interview-ees reported very different situations, too.

The region of origin and the host community might also have some impact. The Hungarians seem to reject mostly the attributes of the servant category as it is considered to be too stigmatized:

“…servantship? This is a very subordinate position in my opinion, with a servant they commit a lot of atrocities, so I’m not one.” (NH, 44 years old, Hungary, works in Germany)

It is the women from the Subcarpathians (rural region with feudalistic historical antecedents) who more often locate their work at that position. Moreover they even used the term maid:

“So, I am… the one who always feel herself like a maid, um, yes, I put it like that. It isn’t like that?! Well um, anyone who does that kind of work has to adapt

a lot for everything to be good. Isn’t that so?” (EH, 55 years old, Ukraine, works in Hungary)

Regarding the host community, the Hungarian women perceived their German employers cold, and this resulted in a formal rather than spontaneous rela-tions.

Besides these, there are two axes which have a big influence on the background dynamics.

On the one hand, the location of domestic and care work at the bottom of the labour hierarchy; the similarities between the activity they perform in their own households and families due to the gender based division of labour and the work they do under the label of care work; the lack of standard and formal frame and the defencelessness in face of the informal employer without any legal protection pushes towards the underappreciation of the carer’s status.2

“Interviewer: Why did you feel badly at the begin-ning?

Interviewee: At the beginning because I thought: My God, I graduated from the university, I studied, I had a good job, I had everything, and at the end I have to do this work, I have to care for somebody. I don’t have to, of course. I didn’t have to care for my mother, or for my father, because they died, they didn’t need to be cared for, and now I have to care for a complete

2 This finding partially echoes Parreñas’s conclusion that the struc-tural location of migrant domestic workers in global restructuring propels the emergence of similarities; globalisation and its cor-responding macroprocesses initiate the emergence of parallel lives in different settings. Parreñas 2001. 247.

stranger! Perhaps this is why I felt so badly or I don’t know.” (EH, 57 years old, Ukraine, works in Hungary)

“Interviewer: And then what did you have to do?Interviewee: So, what you do at home, and I do,

too. I’m always asked: what do you do? What I do at home.” (EH, 57 years old, unskilled, Ukraine, works in Hungary)

“You have to accept what fate gives you there. And many people don’t have this capacity to compromise. You have to be able to compromise. You can’t protest, you have to do everything you are asked to do.” (NH, 70 years old, Hungary, works in the USA)

“You have to adapt to everybody. And mostly, you have to be silent. So, you have to put up with a lot.” (EH, woman in her 50s, Romania, works in Hungary)3

On the other hand, the structurally low position is counterbalanced by the moral value of the care work, the feeling of usefulness, the gravity of the burden they take from the cared person’s family members, and the value of the salary in terms of its transformation into social and material success in the sending community. These lead to the creation of the positive dimension of the care work. In general, the interviews reflect a

3 The data are not always precise. The interviewees preferred to protect themselves by not revealing the specific personal informa-tion because they work in the black market.


mixture of these, as well as the instability and the often changing dominance of the one or the other side.

“So, I have the mission in myself, I prepared my-self for this, irrespectively of the fact that I couldn’t continue my studies after ’98. It was in me that I’ ll do that, I was just searching for the solution, for how I could do this.” (NH, 30 years old, Hungary, works in Israel)

“For me this work means that I can offer something for humanity. Even if not in the form of inventing something that will be named after me, a building, or becoming a big inventor. But there are some people in whose eyes I see the joy. For me it is that I can offer something emotionally from myself. I always have a thought in my mind, that… that I … sure, that it will happen in my life… I don’t know, but otherwise I wouldn’t always have this thought … that I want to save somebody’s life very much, somebody’s. So, that I save somebody’s life with my own.” (EH, 46 years old, Ukraine, works in Hungary)

“And she [the daughter of the person cared for] goes somewhere for two weeks, and this is good for her too, that she knows that she has left her mother in se-cure conditions, day and night, always. She knew that everything was cared for, the flowers were watered as they should be, so she could go with her mind at rest. And this is a very important thing!” (EH, 60 years old, Romania, works in Hungary)

“You know how things are. As I’ve already said: 2 diplomas [of her daughters], then there was also the renovation of the flat, and these ate up all the savings. Then the wedding, not to mention all the rest. [All these were paid for from the care wage.] And then I say that I need to put a little bit aside, just a very little, not to be rich, just to replace what I had saved up.” (EH, 50 years old, Romania, works in Hungary)

In order to understand better the dynamism among the statuses of family membership, professional employee and servant status, some more factors need to be taken into consideration. The interviews report the following viewpoints as core elements in forming the differences: the quality of relationships among the actors, the place of the care stage in the personal career and life expec-tations, and the monetary value of the care work.

The quality of the relationship between the care worker, the person cared for and his/her family mem-bers makes a clear division between servant status and family membership, but its border role is not evident in the case of employee status.

The feeling of family membership is built up in the narratives by the following aspects: mutual trust, kind-ness, attentiveness, expression of emotions, respect for the personal needs or wishes, participation at family events, shared space and time, common meals, and presents as the material demonstration of the emotions above the monetary wage.

The components of the feeling of being a servant are: the control, the bad manners of the employers or the person cared for, the official character of the rela-tionship, the great quantity of work, tensions related to the appreciation of the work realised.

Let's take the example of two women at the same age (both are in their early 30s), who perceived very differently their role and status. One expressed posi-tive emotions:

“… the sick person is part of my life, I can’t forget about her/him. So, I call them even when I am at home, I get information, so I wonder every day about what’s happening there. It’s not possible to keep it within borders, I can’t do it (...) I can’t imagine caring for anybody with more devotion than I do now. I do eve-rything I can even now.” (NH, 34 years old, Hungary, works in Switzerland)

The other reported “I think, I don’t love this old man. I can respect

him. (…) But I say that you don’t ask yourself whether you love your boss or not, when you go to the office for 8 hours. Nobody is expected to love the boss. Then why would it be expected from me?” (NH, 31 years old, Hungary, works in Austria)

The place of the care stage in the personal career is a very subjective viewpoint, however it seems to have one of the most important impacts. The feeling of sat-

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isfaction, the positive meanings attributed to the care work, the potential perspectives related to this period and experiences directly influence the interpretation and through this the attitudes, too. The extra feeling of emotional self-realisation (in the sense of usefulness or gender) and/or cognitive development (namely, care and health knowledge) moves the status of the care worker towards professional worker or family member. The absence of these pushes the position down.

The monetary value of the care work plays a role much more in forming the professional or servant char-acter of the work.4 In the case of the family membership feeling, the money element remains in the background and the expression of love, enthusiasm and devotion are emphasized. For the description of the care work the terms of formal employment are used: the work is profession, the employer is called boss, the alternate migrant care worker is called colleague, the duration of each period of work is defined as a shift, the house of the person cared for is said to be the workplace. The above cited young woman reports:

“I don’t know, for me it’s difficult to reconcile the fact that he would like me to be like a family member, but at the same time I get money for my work. For me this is a contradiction, and I can’t resolve this. So for

4 Grootegoed, Knijn and Roit report that even in the case of rela-tives the mone tary value has an impact on the interpretation of the care work in the dichotomy of love and work. Grootegoed, Knijn & Roit 2010.

me it is easier and it also fits my character better to say: yes, this is my job, I do it, and above all I try, as much as I can, to be patient, and to listen to him.” (NH, 31 years old, Hungary, works in Austria)

In the absence of the profession-like interpretation the monetary element pushes the status towards serv-ant status:

“the money obliges you to be servile, to be atten-tive, to be polite, to give respect, because otherwise this doesn’t work.” (EH, 53 years old, Ukraine, works in Hungary)

In sum, it must be emphasized that the ambivalences never disappear. Clear positions were never reported by the care workers, there are many overlapping terrains. Migrant care workers shift between family membership and professional job, and between family membership and servant status. This might easily hap-pen, because the familialistic norms are always present in the work even if in different measures. But there are never overlaps between professional worker and servant position.

Conclusions

The work performed by the migrant women entering the care system is based on familialistic norms. This conception and practice fits well with the expectations of the employer families and the migrant care worker’s own socialization stemming from the familialistic cultural background of the sending communities. Thus, the emotions, morality, love, deference, dependence and the non-work characteristic of care work acquires a higher importance than professional attitude, obligation, salary, rights, independence and the job characteristics. Because the care work is performed in another family than their own, it enters into a different context that affects it in many ways, and locates the care work on the interface of familialistic work, profes-sional job and servant service. The main principles that shift the care work performed by the migrant women are less the structural factors, and much more the subjective elements. Among the structural factors, being not 'otherized' in ethnic terms plays a relevant role. The interviews emphasize the following as core elements: the quality of relationships among the actors, the place of the care stage in the personal career and life expectations, and the monetary value of the care work. However, the ambivalences never disappear, and the care work performed by migrant women shifts back and forth on this plastic and dynamic interface.


References

Grootegoed, Ellen; Knijn, Trudie; da Roit, Barbara. (2010) “Relatives as paid care-givers: how family carers experience payment for care”. Ageing & Society. 30: 467-489.

Litwin, Howard; Attias-Donfut, Claudine. (2009) “The inter-relationship between formal and informal care: a study in France and Israel.” Ageing & Society. 29: 71-91.

Lutz, Helma. (2008) “Introduction: Migrant domestic workers in Europe.” Pp. 1-10. In (ed.): Lutz, Helma (2008). Migration and Care Work. A European Perspective on a Global Theme. Frankfurt: J.W. Geothe University.

Lyon, Dawn. (2009) “Intersections and boundaries of work and non-work. The case of eldercare in European perspective.” European Societies. 12(2): 163-185.

Parreñas, Rhacel Salazar. (2001) Servants of Globalization. Women, Migration, and Domestic Work. Stanford: Stanford University Press.

Ungerson, Clare. (2004) “Whose empowerment and independence? A cross-national perspective on ‘cash for care’ schemes.” Ageing & Society. 24: 189-212.

Utasi, Ágnes. (2002) A bizalom hálója. Mikro-társadalmi kapcsolatok, szolidaritás [The trust network. The micro-social solidarity]. Budapest: Új Mandátum.

Yeates, Nicola. (2009) Globalizing Care Economies and Migrant Workers. Explorations in Global Care Chain. New York: Palgrave Macmilian.

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KEY WORDS: LONG-TERM CARE SYSTEM (DETERMINANTS, REFORM, DEVELOPMENT), HEALTHY AGEING, LONGEVITY, SOCIAL POLICY, CZECH REPUBLIC


Introduction1

The health and social systems have undergone important changes in the Czech Republic since the Velvet Revolu-tion and the fall of communism in 1989 and the dissolution of Czechoslovakia into the Czech and Slovak Republics in 1993. In our article we focus on a discussion of the definition and model of long-term care, factors contributing to the demand for long-term care for seniors, challenges and opportunities for integrated provision of LTC services and description and development of the long-term care system in the Czech Republic.

Understanding the role and position of long-term care within the social and health systems

There are different approaches to understanding the role, scope and goals of the long-term care system. Dis-cussion around long-term care shows that long-term care may be seen as an emerging concept or model of

1 This article has been written as part of the project “Long-term care for seniors: quality of care in institutions, organizational cul-ture and support for dignity of frail patients”, supported by grant No. NT11325 of the Ministry of Health of the Czech Republic.

cultural traditions, as well as the position of geriatrics within health systems and the level of development of long-term care in the respective countries.

Based upon those differences in health and wel-fare systems, long-term care can be conceived either as an integral part of health services or, in a rather narrow perspective, as mainly a social service. It may be considered either as a universal public service or as a last resort or residual service in terms of citizens’ access and entitlement. It can also differ in whether it involves prevention or only post-acute care such as rehabilitation and nursing.

A long-term care system represents a continuum of services for persons who live with or are at risk of reduced self-care capability, mainly due to a chronic condition and frailty. Long-term care includes a “range of services” provided in different contexts and settings, coordination and fragmentation thus being a major challenge.

In our understanding, a long-term care system should be an integral part of the health care system. The scope of long-term care cannot be limited to help with ADL activities or “personal care” as persons with a chronic condition and frailty need a range of health services and interventions in some stage of their condi-tion, among them for example those enumerated in the OECD definition: wound dressing, pain management, medication, health monitoring, prevention, rehabilita-tion or services of palliative care (OECD, 2011).

services or as a relatively new social protection scheme addressing growing risks of long-term care for the individual, family and society as a whole.

In a rather narrow perspective, long-term care may be seen as a professional service provided to frail seniors compensating for loss of functional independ-ence and ensuring help with basic activities of daily life. In a broader sense, the long-term care system includes prevention, geriatric services, age-friendly design and policies as well as protection of the income and well-being of informal carers.

Different approaches to long-term care reflect the variety and diversity of social and health systems in European countries and around the world, their

Opportunities and Challenges for Integrated Provision of Long-term Care Services in the Czech RepublicIVA HOLMEROVÁ, HANA VANKOVÁ, PETR WIJA

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Long-term care focuses on the special segment of frail seniors and people with disabilities with a pro-gressive condition, instability in health status and thus dynamic changes in their needs. The diversity of needs, of people and of situations makes it difficult to develop a comprehensive system of support and care which respects this diversity. Long-term care includes a special sector of professional health and social services provided in different settings (in the home, institution, special housing) and support of informal care as well as protection of carers.

An important aspect of long-term care is the length of time during which care is needed or provided. Duration of disease is an important factor for the or-ganization and financing of services and has a different impact on the life and social situation of both carers and persons in need of care. There is no precise defini-tion, however, of how long is long-term care. OECD definitions speak about an “extended period of time” (OECD, 2005, 2011) in relation to long-term care. Care provided for a period longer than 3 months is usually considered as long-term care within the Czech health system, though it is more important whether the patient is on an acute or long-term care bed. Such time limits and borders are however more important for insurance companies, financing and management of care rather than for the person in need of care and the carers. In any case, there is a need to differentiate between long-term care for frail seniors and persons with permanent physical, mental or sensory disability. Long-term care

services are targeted at those who require support and care due to worsening health, chronic condition and frailty which usually lasts months or years in contrast to life-long disability.

The role of LTC systems, however, is not only to provide services to persons with loss or decrease in self-care capacity, but also to address other risks and needs related to long-term care and functional decline and growing dependence on a supportive environment and the help of others. Among such risks and functions of a long-term care system we can mention protection against costs of care (ability to pay for professional long-term care), protection against financial consequences for the carer (income protection and support during and after provision of care), protection against social exclusion of carers from the labour market, social exclusion of both persons providing and receiving care from social participation, protection of rights, dignity and freedoms of people dependent on long-term care, their protection against abuse, etc.

The situation of long-term care often affects sev-eral generations which are usually in different phases of their life-course, e.g. senior living on a pension and carer in a later stage of their career and still dependent on paid employment. The risks to be covered by the long-term system thus should include the well-being of the informal carer (spouse, partner, adult children, etc.), specifically of the health and income of the full-time or part-time carer, their access to employment

and training, respite care, information and counselling, etc. The main instruments to fulfil these functions are provision of services, in-cash benefits and other measures in support of carers. Being fully or partially out of paid employment creates challenges for the carer and society as employment activity is often a necessary precondition for entitlement to participation in some welfare programmes.

Factors contributing to change in demand for long-term care

There is a range of factors contributing to the variation in demand for formal long-term care services, demo-graphic development being only one of them and not the most important one. Among the range of factors which have contributed to the increasing importance of long-term care as a distinctive area of social protec-tion, we can mention several long-term as well as more recent societal changes.

A rise in life expectancy and longevity translates into rising numbers of old and very old seniors. The risk of disability and frailty increases with individual and population ageing. Demographic development and its perception (demographic alarmism and fear of the economic impact of further structural ageing, fear of an ageing explosion and a “seniors’ wave”) is an important factor for politics and policy in long-term care. Nevertheless, decisive factors for explanation of


the paradigmatic shift in long-term care are probably to be found outside demographics.

Demographic ageing and fear of its consequences in developed countries appears together with other social changes in their health systems and society as a whole. Among many such changes we can mention early and better diagnosis, which improves survival and prolongs length of disease and potentially increases overall costs of care, and rising costs of acute care, mainly due to expensive technologies and pharmaceuticals.

Improved and more costly hospital care creates pressure to shorten hospital stays (McKee, 2002), which requires re-defining of boundaries between hos-pital care covered from health insurance and care to be covered from other sources (social insurance, state or municipal budget, etc.). Change in the definition of acute and post-acute care thus implies change in enti-tlements in terms of what conditions should be covered from health insurance. Hospitals in many industrial-ized countries have already transferred the long-term care of dependent older people out of hospitals into residential care and nursing homes. Thus, much of the cost has already been shifted from the health care budget to the social care budget (McKee, 2002).

Another factor contributing to the growing sig-nificance of long-term care is a rising specialization in medicine, which leaves more patients with chronic disease and frailty requiring non-medical or post-acute

care such as rehabilitation out of the competencies of any specialty, acute geriatrics being largely underdevel-oped in the Czech Republic and other countries as well.

Among factors influencing demand for profes-sional LTC services is the changing role of the family. Together with the above-mentioned trends in health care and demographic developments there has been a rise in neoliberal orthodoxy and neoliberalization in recent decades (Harvey, 2005) with growing emphasis on market ethics, family values and morality. This shift in emphasis between the roles of the individual, family, community and society came at the same time as rising expectations towards public services, etc.

Availability of informal care depends on various cultural, social and demographic factors, including migration, urbanization, female employment, level of support to informal carers, access to public services (transport), etc. Moreover, shifts in emphasis on the family, family ties and values often come together with

“verticalization” of the family and individualization of housing.

Much in the centre of the debate on long-term care lies concern about the future sustainability of long-term care as well as of health and pension systems. Future projections in some cases are based on a simpli-fied presumption of constant costs and constant share of people depending on LTC within a given population and age structure.

The share of GDP spent on LTC services may be interpreted as a sign of development of the serv-ices and government priority, rather than as a level of dependence in an older population and demographic ageing. Moreover, very different traditions and forms of support in the situation of long-term care make it difficult to reliably compare countries with different social and health systems.

Similarly, it is difficult to interpret information about the percentage of older population living in various institutions as level of “institutionalization”. Institutional care can be defined as “long-term care provided in an institution, which at the same time serves as residence of the care recipient” (OECD, 2005). Information about the share of older persons in institutions does not say much about the level of disability. Cultural differences and different quality of residential care within the EU are more relevant factors for assessment of the situation in different countries. Whether people are cared for in families or an institution largely depends on culture, tradition, and the development and supply of social services. Between 2 and 5 per cent of elderly people were cared for in nursing homes in a study of 10 high-income countries (Ribbe et al. 1997). These differences can be attributed to policy decisions (with intended or unintended consequences) rather than to the charac-teristics of older populations or demographics in the respective countries.

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The myth of escalating health care costs with ageing and blaming population ageing and the seniors boom for increasing costs of health and long-term care has been challenged and debunked by several authors and institutions (Friedland, Summer 1999; Gee, 2000; Mullan, 2002), although this myth is still uncritically ac-cepted especially by some politicians and media. More recently, the myth of an extensive rise in health care costs in consequence of population ageing has been the subject of the ILC Policy Report called “Myths of the High Medical Cost of Old Age and Dying” which focused on the situation in the US. Rising health care costs are driven mainly by supply-side changes such as new and expensive pharmaceuticals and technology and their fast development rather than by demand-side factors such as demographics or patterns of disease. Among demand-side factors driving the increase in costs of health care, physician and patient expectations play a role (McKee, 2002).

As a recent OECD (Colombo, 2011) study on long-term care states, the most obvious way to reduce cost in long-term care systems would be to reduce potential dependency in later life through lifelong health pro-motion. And prevention is reflected in long-term care systems in some countries through financial incentives and benefits. In the case of Japan a community-based, prevention-oriented LTC benefit targeted at low-care-need seniors was introduced in 2006. In Germany the government introduced “carrot-and-stick financial incentives to sickness funds that are successful at

rehabilitation and moving LTC users from institutions to lower-care settings” (Colombo, 2011).

Healthy ageing, effective hospital and ambula-tory geriatric services, the responsiveness and age-friendliness of the health system as a whole, including age-friendly primary health care (WHO, 2004) are key factors for reduction in demand for long-term care services. Pushing frail seniors out of the competence of the health care system and labelling them as “social” can be interpreted as a sign of age discrimination and unresponsiveness within the health care system.

As an approach promoted by WHO shows, the delay of disability should be a central part of any strategy for healthy and successful ageing (and thus long-term management of demand for LTC). The effort to increase positive health and health potential across the life course, reaching the maximum level of health and staying above the “disability threshold” as long as possible should be explicit goals of healthy and active ageing strategies. Moreover, as the WHO model of life course approach to health clearly shows the “dis-ability threshold” is not an unchangeable, natural or universal level for all seniors, but very much a socially determined threshold which can be lowered by appro-priate policy interventions (WHO, 2000). The WHO Age-friendly cities project is one example of a com-prehensive approach to creating such an enabling and supportive environment in urbanized space. By such a strategy, policy intervention and integrated effort at

local and community level can decrease dependence on the environment and the demand for informal and professional long-term care.

In recent years, much attention has been paid to the use of ICT in the provision of long-term care and in creating a supportive and safe environment for frail seniors. The issue of ICT in long-term care and ageing is often a part of the broader concept of e-health, e-inclusion, and digitalization of other important areas of society and life such as government, business or learn-ing. Nevertheless it needs to be emphasized that most such ICT-based initiatives are focused on research and development of innovative measures and that broader use of ICT in wider parts of frail populations lags considerably behind. Interest in the use of ICT is often accompanied and driven by “commodification” of social and public services and is part of a broader movement of silver economy, which is often presented as a consumption-based antidote to the economic consequences of ageing and decreased labour partici-pation of the ageing population. From the point of view of critical gerontology the prominence and rise in the use of ICT in policy and market-based solutions can be interpreted as a part of “aging enterprise” (Estes, 1976, 2001)2.

2 Estes, Carroll L. The Aging Enterprise Revisited. The Gerontolo-gist. Vol. 33, No. 3, 292-298 http://gerontologist.oxfordjournals.org/content/33/3/292.full.pdf


The ICTs have broad potential use in relation to long-term care and an age-friendly environment. It is not pos-sible to review all ICT-ageing projects here, nevertheless we would like to emphasize the role of ICT in creating a safe home environment and its potential to help bridge barriers between the social and health services. One important aspect of health and social integration is con-necting and sharing information between the two parts of the long-term care system and the contribution of ICT to seamless case/care management. ICT can significantly reduce the care burden in highly-intensive care in both a home- and institution-based setting and environment. One of the most challenging subgroups of frail seniors in this context is people with dementia. There are several projects addressing the needs of this group. Moreover, in some countries great attention is being paid to how dementia could be recognised in an early stage by tech-nology and thus its progression slowed (e.g. Netherlands). ICT not only can increase and enhance labour productiv-ity in formal LTC, but also ease the burden and mitigate risks for informal carers. CARICT is an example of a project seeking to explore and better understand how technology-enabled services and applications can allow informal caregivers and family-employed care assistants to better engage with the people they care for.3

Although from a public health and life course per-spective determinants of later disease and condition lie in early life and have life-long impacts, the possibilities

3 More information can be found at http://is.jrc.ec.europa.eu/pages/EAP/documents/ICTcarers4pageleaflet.pdf

of health promotion for and with older people are often underestimated due to scepticism and a culture of ageism (Killoran, 1997). Healthy ageing should start as soon as possible to have the greatest and long-term impact. Nevertheless it should end as late as possible as well. With an increasing longevity, we can argue that the scope for health promotion in later life is increasing as well.

The results of research on successful ageing are promising, providing knowledge for behavioural change, intervention and strategies to promote health in seniors. For example, Carmel et al. distinguish between proactive coping, which precedes the decline in health and functioning and constitutes preparation for potential scenarios of loss of health and functioning in later years, and reactive coping, which comes into play following such losses. Strategies of coping, its de-terminants and behavioural change need to be further researched, including the role of genetics, environ-ment, etc. Life course approach remains prerequisite for any long-term strategy for healthy ageing, allowing for a decrease in social inequalities in health and dis-ability and accumulation of disadvantage across the life course (WHO, 2000).

The conditions leading to disability change with time and ageing. While some conditions may diminish in prevalence, others may come in their place. Neu-rodegenerative conditions will represent a major chal-lenge for quality of life and years lost through disability

in the process of continuing epidemiological transition (Holmerová et. al, 2011). As an Australian neuropsy-chologist Henry Brodaty (2008) pointed out during the French EU presidency in 2008, which made research on Alzheimer across the EU one of its priorities, until the mid-20th century medicine was focused on infec-tious diseases, in the second half of the 20th century it was mainly cardiovascular and oncologic diseases and in the 21st century it will be a challenge of neurode-generative diseases (in Holmerova et al., 2011).

As the causes of death and disability change with rising life expectancy and longevity, the focus of medicine has to change and broaden as well. Its scope should move beyond disease-specific outcomes and be replaced with a primary interest in syndromes such as frailty as an era of diagnosis is over (Kalvach, 2008, 2011). Active effort for the creation of conditions for achieving dignity (“dignitogenesis”), self-respect and empowerment becomes a primary goal in health and long-term care (Kalvach et. al, 2011).

Although it is recognised that health problems are not manageable through clinical medicine and invest-ment in prevention is critically needed, it remains a largely unfulfilled promise as there is a huge gap between political practice on the one side and research evidence and expert recommendations on the other. In the Czech Republic, e.g., only 4% of total public spend-ing on health is used for prevention (Holcík, 2010).

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Demography, healthy life expectancy (HALE) and need for long-term care

The number of people “at risk” of need for long-term care depends on health, chronic disease and disability. The risk for society and the individual is rising with ageing. Nevertheless, comparing differences and development in life expectancies does not provide sufficient information about the state of health.

“Health-adjusted life expectancy” (HALE) or “healthy life years” (HLY) are becoming more widely used in relation to policy-making and health. For example, the EU uses HLY as a structural indicator to 1) monitor health as a productivity/economic factor, 2) introduce the concept of quality of life, 3) measure the employ-ability of older workers, 4) monitor progress made in access, quality and sustainability of healthcare4.

On a country level, for example, the United King-dom has used healthy life expectancy (HLE) to monitor progress towards achieving targets in a wide range of policies, for example: 1) The Department of Health’s (DH) National Service Framework for older people includes targets to increase HLE for older people; 2) The Treasury’s work on long-term fiscal sustainabil-ity sees future HLE as an important demand driver; 3) The Department for Work and Pensions’ strategy for tackling poverty and social exclusion uses HLE

4 European Commission DG Health & Consumers http://ec.europa.eu/health/indicators/healthy_life_years/index_en.htm

as an indicator5. Achievement of successful ageing re-quires that the onset of infirmity is delayed and healthy life expectancy increases more rapidly than average life expectancy, thus leading to compressing morbid-ity into a shorter period of life before death (Fries, 1980). In other words, it requires that we are able to prolong healthy life, not life itself, and that the focus should move to morbidity rather than mortality (Fries, 1980). Nearly all acute diseases have been replaced by chronic diseases, which can be approached most ef-fectively with a strategy of “postponement” rather than of cure (Fries, 1980). According to Fries (1980) the end of the period of adult vigour will come later than it used to. Postponement of chronic illness thus results in rectangularization not only of the mortality curve but also of the morbidity curve (Fries, 1980). If the rate of progression of disease is decreased, then the date of passage through the clinical threshold is postponed; if sufficiently postponed, the symptomatic threshold may not be crossed during a lifetime, and the disease is “prevented” (Fries, 1980). Again, it is only possible and sustainable through prevention. As Fries stated in 1990 “the ability of society to pay ever-increasing costs for ever-more vegetative existence has been called into question” (Fries, 1990; in Baltes, 1993).

The scenario opposite to the thesis of “compres-sion of morbidity” is provided by Gruenberg (1977),

5 Postnote February 2006 Number 257. Healthy life expectancy. The Parliamentary Office of Science and Technology. www.parlia-ment.uk/briefing-papers/POST-PN-257.pdf

Verbrugge (1984) and Olshansky (1991) who presumes that increase in life expectancy due to decreased fatal-ity of chronic diseases leads to expansion of morbidity and disability as a result of those diseases (in Holm-erová et al, 2011). Another theory (Manton, 1982; in Holmerová et al, 2011) presumes a dynamic balance between decreasing fatality and concomitant increase in disability on the one side and decreasing prevalence and incidence of chronic diseases on the other.

Robine et al (2011) focused on the relationship between longevity and health and the question of whether the increase in healthy life expectancy is slower or faster than the increase in total life expect-ancy. According to their analysis there is a north-south gradient in the functional health status of centenarians in Europe with better health in the north than in the south. An analysis of the correlation between life ex-pectancy at age 65 and the number of healthy life years (HLY) in 2006 for the 24 EU member states having comparable disability data (EHEMU, 2009) suggests that the strong increase in healthy life expectancy is more a feature of countries that are catching up with the best countries in terms of population health, rather than a characteristic of countries leading the longevity revolution (Robine et al 2011). However, there is a clear trend showing that the higher the life expectancy, the higher the healthy life expectancy. They conclude that there is no strong evidence today of compression of morbidity and disability in the countries that lead the longevity revolution (Robine et al 2011).


The pattern of relationship between life expect-ancy and healthy life expectancy remains unambigu-ous and needs to be further clarified. Nevertheless, it is clear that an activity and social participation are key determinants for delay of disease and dependence as

“inactivity and isolation accelerate physical and psy-chological declines, creating a negative spiral towards premature, preventable ill health and dependency.”6

As regards life expectancy, Europe remains di-vided into West and East, with Eastern Europe lagging behind the West, which shows that “the past has a long future” (Holcík, 2011). For example, when comparing the Czech Republic and Sweden, in 2010 the Czech Republic lagged behind Sweden by 4 years (76.9 as compared to 80.9). However, in terms of delay in years, i.e. the time when the Czech level had been reached in Sweden, the Czech Republic lags behind Sweden by more than 20 years (Holcík, 2011). Such a gap cannot be attributed to difference in quality of health care, medicine or pharmaceuticals (the Czech Rep. is not 20 years behind Sweden in those factors), but to broader determinants of health such as life style (especially smoking, consumption of alcohol, diet, etc.) and envi-ronment. The latest available data for HLY (Eurostat, EHEMU)7 show that people in the EU-27 could at

6 Report of the House of Lords Select Committee on Science and Technology on Ageing, 2005.

7 HEIDI data tool http://ec.europa.eu/health/indicators/echi/list/echi_40.html

birth expect to live another 60.9 years of healthy life (i.e. without disability or activity limitation) for men and 61.6 years for women. Men spend a longer part of their life in health and experience a shorter time of activity limitation as female life expectancy is higher than that of men. Women could live nearly three quar-ters of their total life expectancy (74.5%) without activ-ity limitations, while men approximately four fifths (79.4%) of their total life expectancy at birth.8 At the age of 65, men could expect to live another 8.2 years in health (without activity limitations) out of 17 years (to-tal life expectancy at 65), while women another similar 8.3 but out of the total of 20 years (EUROSTAT, 2009).

Across the EU, differences among member states were much greater for healthy life years (HLY) than for total life expectancy (LE). In 2009, the maximum difference in LE within the EU was 12.3 years for men (LE ranging from min. 67.5 to max. 79.8) and 7.6 for women (min. 77.4 to max. 85.0). In contrast, the maxi-mum difference in healthy life years (HLY) was 18.4 years (from 52.1 to max. 70.5) for men and 18.3 years (from 52.3 to 70.6) for women (EUROSTAT, 2009).

The lowest difference between healthy life expect-ancy (HLE) and LE in a given country, i.e. the highest percentage of life expectancy without disability, could be seen for Malta (88.9%), Sweden (88.8%), and Bul-

8 EUROSTAT, Healthy Life Years Statistics http://epp.eurostat.ec.europa.eu/statistics_explained/index.php/Healthy_life_years_statistics

garia (88.4%) for men and in Malta (85.3%), Bulgaria (84.8%), and Sweden (83.3%) for women, with Bulgaria having significantly lower values for both LE and HLE than Sweden (LE for men was 70.1 in Bulgaria com-pared to 79.4 in Sweden, and 77.4 compared to 83.5 for women). HLE for men in Sweden was even higher than total life expectancy in Bulgaria, which means that Swedes had a chance to stay healthy (without any limitation) until a higher age than Bulgarian men could survive. For the Czech Republic the values of HLE and LE are 60.9 and 74.2 years for men (82.1% of LE without activity limitations) and 62.5 and 80.5 for women (77.7% of LE without limitations). The Czech Republic thus lags behind Sweden in healthy life years for men even more than Bulgaria as Czechs could ex-pect to live 10 years shorter healthy lives than Swedes (60.9 and 70.5) (Eurostat, 2009).

Provision of long-term care forseniors in the Czech Republic

At present, there is no integrated system of long-term care in terms of a distinctive system of services for a specific segment of the population requiring social and health services based on their chronic condition. Re-sponsibility for long-term services is divided between the Ministry of Social Affairs and the Ministry of Health and is provided within both health and social care facilities.

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However, “long-term care” is provided under very different conditions within social and health care facili-ties. Social services and health facilities have different systems of registration of providers, quality standards, system of financing, division of competencies between state, regions and municipalities, sources and ways of financing. Social and health care facilities usually do not coordinate their services, and there is no care man-ager at local level. Nevertheless some providers are able to provide both social and health services in home or institutional settings, but this ability largely depends on local support from municipal authorities. The divi-sion of competencies between the social and health systems, and unclear responsibility are considered by many experts to be the key obstacles to provision of integrated seamless long-term care aimed at improving quality of life and the prevention of functional decline and permanent “institutionalization”.

Long-term care within the health care system

Health care in the Czech Republic is financed through general public health insurance. There are 12 health insurance companies (1 public and 11 private), which are operating under very similar conditions (according to the law on health insurance). There is no private health insurance in the Czech Republic. Out-patient health care in the Czech Republic is provided by general practitioners and other primary care physi-

cians such as dentists, gynaecologists, and ambulatory specialists. In-patient health care is provided in hospi-tals, “therapeutic facilities” (e.g. therapeutic facilities for long-term patients), psychiatric and rehabilitation hospitals. Under the law on health services (Law No. 372/2011), hospital beds are classified as acute hospital beds for intensive care, acute hospital beds for standard care, after-care hospital beds, and long-term hospital beds. Long-term hospital care is provided to “patients whose health cannot be substantially improved by therapeutic care and whose health would deteriorate without continuous provision of nursing care”. Beds for intensive hospital long-term care are for patients whose basic vital functions are compromised.

According to the law on health services health care provided in the “social environment of the patient” included visitation service of general practitioner and home health care. Home health care is defined within this law as “nursing care, curative and rehabilitation care, or palliative care provided in the home environ-ment of the patient”. Home health care is provided by nursing agencies. In 2010, home health care was provided to 143 ths. people, 79% of them aged 65 and over. Home health care received 7% of all persons aged 65 and over in 2010. Patients with chronic conditions made up 85 % of all patients. One worker (general nurse) made on average of 7 home visits per day; 92% of the care provided was covered by health insurance (ÚZIS ČR, 2011).

The General Practitioner as a primary care physi-cian is authorised to prescribe home care and drugs according to the patients’ needs. Medical aids, includ-ing incontinence pads and other so-called induced services, such as specialist consultations, other aux-iliary, laboratory, and imaging medical examinations, are also supposed to be prescribed and indicated by GPs and are included in GP’s hypothetical budget that is regulated by the insurance company. General Practitioner’s care is funded on a per capita basis which means that they receive regular payment according to the number of registered patients and their age. GPs are also supposed to visit their patients in their homes. In case of special care needs, patients are referred to specialists. If hospital care is needed, they are referred to acute care hospitals or long-term care hospitals.

Persons with long-term care needs are referred to long-term care hospitals. In such cases care provided is fully covered by the health insurance, even if patients stay there for several months or even years. Long-term care or “aftercare” units are parts of general hospitals or long-term care or psychiatric hospitals, etc. Despite the fact that they are part of a health care system, which has undergone important changes, received major investments and is relatively well developed, the positive changes do not apply to many of these units. Very often they are insufficiently equipped, located in decrepit hospital buildings, sometimes also with significant architectonic barriers. Very often the staff numbers and qualification are lower than necessary


and the quality of care is insufficient and these depart-ments are too “hospital-like” for long stays of persons with disabilities. Typically, people are required to stay in their beds even when it is not necessary and in consequence different restraints such as bed-rails, permanent catheters, etc. are overused there. Family members are not generally satisfied with the quality of care; nevertheless, it is easier for them to accept this as care is completely free, except for the “regulation fee” which nowadays amounts to 60 CZK (app. 2 Euros) per day. This might be one of the reasons why this inef-ficient and ineffective system has persisted for such a long time even after the change of political system and thorough changes in health and social care legislation.

Long-term care withinthe social services system

Persons with very similar health conditions and needs to those in health facilities can be found in homes for seniors (before 2006 called “pensioners’ homes”) or “homes with special regime” within the social care system. The law on social services stipulates different types of social services and conditions for entitlement to “care allowance” provided to persons with disability and decreased self-care capacity.

Persons with limited self-care capacity and in need of long-term care can apply for care allowance accord-ing to the law on social services. There are four degrees

of “dependence on care” based on assessment of activi-ties of daily life (IADL, ADL) by a physician (medical assessment service) and social worker (employed by the municipality) with four corresponding amounts of

“care allowance” (800, 4,000, 8,000 and 11,000 CZK, which amounts approximately to 32, 162, 323, and 444 EUR).

As a mandatory attachment to their application, a GP has to provide a report on the patient’s (claimant’s) health status (which usually summarises diagnoses) as well as a report by a social worker. The social worker has to visit the patient in his/her home, not in a health care institution. The report by a social worker includes a check-list monitoring which activities of daily living are impaired. However, social workers do not have suf-ficient skills in self-care capacity assessment. Therefore, they often only fill in the check-list as a questionnaire, asking patients questions about their self-care capabil-ity. Sometimes the responses are relevant, sometimes not. Especially persons with dementia overestimate their capacity (e.g. an 87-year-old woman with de-mentia who lives in a residential home answered that she is capable of managing all activities of daily living and she also takes care of her mother) – this opinion is documented in the check-list of ADLs and IADLs. Based on this, often biased information, the physician of the social department (who does not meet the pa-tient in person) decides which care allowance (degree of dependence) will be allocated.

The care allowance is financed by the state from the state budget (tax-funded) and is not means-tested. The care allowance is the main source of funding of care, both at home and in institutions. Persons who receive a care allowance may receive care either from their family caregivers or from registered social services. Social services are registered by the regional authorities according to the social services act. There are 14 regions in the Czech Republic, including Prague, the capital city which is one of the regions.

Persons with decreased self-care capacity and disability are supposed to purchase services from registered social care providers. Nevertheless, they may also be cared for by their family caregivers and other persons. In fact, the majority of receivers prefer to receive care given by a family member (app. 80 %). The share of care provided by family (informal) carers of course differs with dependence on care as people with the 4th degree of dependence have to rely more on professional services.

Homes for seniors are defined as social care institutions that provide care for seniors who need

“social care” (personal care or help with ADL), whereas “homes with specific regime” are defined as social care facilities that provide care to persons with “specific needs”, which include people with Alzheimer’s disease. Both seniors’ homes and homes with specific regime have an obligation to ensure provision also of health care either by their own staff or by professionals from

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health care services. This applies to availability of both physicians and nurses (medical and nursing care).

In comparison to long-term care health facilities, there are usually less staff available and also consider-ably less nursing staff in social care homes. It is difficult to find general practitioners and specialists for social care homes as their care is expensive and consumes much of their budgets. Due to the restrictions by insurance companies (and sometimes necessary out-of-pocket payments), difficulties may occur also in drug prescription which is sometimes very limited and does not respond to the needs of persons residing in social care facilities (e.g. very low prescription rate of cholinesterase inhibitors, antidepressants and also modern and effective analgesics, etc.). In general, we can draw the conclusion that people who live in social institutions have unequal access to health care and are disadvantaged in their opportunities to benefit from health insurance and health services.

People who stay at home are cared for by their family or other informal caregivers, alternatively they can purchase registered social services. Older people very often do not know and are not properly informed about what is the purpose of the money they receive as their care allowance and they tend to put it aside for themselves or their families without obtaining the necessary services.

Despite the fact that the social services act has brought about some important changes in the social care system in the Czech Republic, there are still many gaps and problems, especially in the care provision for persons with chronic conditions and need for long-term health and social care, most of them being older people.

Apart from that, another major problem is the avail-ability of services. It is generally known that especially small communities do not have access to sufficient (or any) social services. The authors of the legislation on social services expected that the law would bring about the spontaneous creation of a market in social services. However, these expectations were not met and a boom in the creation of new services for frail seniors did not happen. Social services remain underdeveloped as people do not spend their care allowance on purchas-ing social services they were offered and in some cases those services started to erode.

Obviously, there are also many other factors neces-sary for care provision in the home environment – dif-ferent types of support, education and respite care for family caregivers. These services are still unavailable to many seniors and informal carers. Despite the fact that most persons with long-term care needs (approx. 80%) stay in their home environment and are cared for by their family caregivers, the situation in formal care and comprehensive support of informal carers remains difficult.

Possibilities of integrated LTC provision in the Czech Republic

Despite the above-mentioned obstacles within the system of health and social care provision (especially in the field of long-term care where both components should be coordinated), some examples of integrated care provision already exist. Most of them have been made possible thanks to the active support from local authorities, and their interest in this kind of care.

The Gerontology Centre in Prague’s 8th District started its activity 20 years ago in 1992. The project of the Centre was designed in 1991 in close collaboration with the local authority of Praha 8 (a major district of Prague with 106 ths. inhabitants). At the beginning of the last decade of the 20th century, it became clear that there is an increasing demand for services for older people. In Prague 8 there was already a developed net-work of existing health and social services. However, it was clear that some services for older persons were still missing. After consultations with other care providers and local authority representatives, it was decided that the project should cover especially problematic and neglected areas – rehabilitation of older persons after their stay in hospital, and also situations when older per-sons are not able to stay in their homes because of their deteriorated health conditions and at the same time their condition is not indicated for acute care either. It was decided that “semi-mural” services (day-care unit) and domiciliary services would also be useful compo-


nents of the whole spectrum of care for older persons in the community. For the last two decades, the Ger-ontology Centre has been developing services in close collaboration with the municipal authority in Prague 8. Gradually, different types of services were established: a geriatric rehabilitation unit for 32 patients, palliative care unit for persons with dementia for 12 patients, day-care unit for persons with dementia (capacity 15 persons), home nursing care (60 clients), geriatric clinic, geriatric team visits and also auxiliary services such as meals on wheels, emergency button service for persons who stay at home, and home assistance. Col-laboration with three neighbouring residential homes was established, in the framework of which the Centre provides the service of a general practitioner. These professional health and social care services are comple-mented by the services of the Czech Alzheimer Society (founded in 1996 in the same premises and working in conjunction with the Centre). The services of the Czech Alzheimer Association include respite service at home, consultations, counselling, providing written information materials, etc. Another NGO under the roof of the Centre is GEMA which organises leisure activities for seniors: dance courses (well-established and popular for more than a decade), internet café for seniors, various meetings, trips, teaching activities, petanque, nordic walking, voluntary activities “for sen-iors and others”, etc. The strategy is based on proactive and preventive measures rather than just easing the symptoms. Older persons are encouraged to be part of activities which promote health and mental well-being.

We aim to maintain their participation by building a community of interested individuals. In case of illness, interventions are designed to help the clients regain their self-care capacity through a short-term stay in the department and the case management approach enables them to return to their home environment with the option of using a variety of our services.

Conclusion

At present, the situation in the health and social serv-ices in the Czech Republic does not allow for an inte-grated seamless care provision oriented on functional status, quality of life and social inclusion. However, this might change when communities and municipali-ties acknowledge the importance of quality services for frail seniors and take appropriate measures to assure integrated services for their citizens. The feasibility of this prospect was clearly demonstrated by the example of the Gerontology Centre and the local authority of Praha 8.

New legislation on long-term care which is now being prepared by the Ministry of Labour and Social Affairs and the Ministry of Health will hopefully bring about some substantial changes in the long-term care provision and in coordination of services on the community level such as establishment of multidis-ciplinary teams, community nurses, introduction of comprehensive evaluation, etc. which are the declared

main principles of this legislation. In our view, mu-nicipalities should play a crucial role in development of long-term care services. Their participation is not only indispensable for establishing a functioning system of integrated care services for older persons and other groups, but also for implementing an active ageing strategy and age-friendly policies at local level and thus increasing the quality of life of all generations.

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KEY WORDS: INTERVENTION PROGRAMME, QUALITY OF LIFE, AUTONOMY, PERCEPTION, SOCIABILITY


Background

The ageing of the population is creating substantial challenges for the societies of European countries, including Hungary. Examining the demographic indicators, it can be said that both the number and proportion of the elderly show a growing trend. One of the main causes of these changes is the big rise in life expectancy at birth. Although Hungary lags behind the countries of Western and Northern Europe in this respect, there has been a considerable increase in life expectancy of the elderly (Figure 11).

1 www.ksh.hu (forecast: HCSO Demographic Research Institute)

encouraging the correct health-conscious behaviour. The major factors behind the poor health status of the Hungarian society are unhealthy lifestyle, inadequate health culture (insufficient knowledge concerning physical culture and activities, unhealthy nutrition,

smoking, failure to undergo screening tests, self-destructive behaviour forms). Naturally, we are aware that other factors such as environmental hazards, inherited endowments, or various social processes with a negative effect also influence individual lifestyles, but in our opinion the greatest impact can be achieved by developing the correct, health-conscious lifestyle (Figure 2).

Although the table clearly shows that there is a dif-ference between the sexes, it is also evident that over time there will be a proportionate increase in the life expectancy of the population.

It is obvious that the challenge to society cannot be attributed solely to the demographic data; many factors contribute to creating a complex problem that calls for a response. They include the poor health status of the population, the change in the structure of households, the restructuring of the use of time, the housing situ-ation, income relations and many other factors beyond the scope of the present article.

The material we elaborated was intended to focus on preventing an unhealthy inactive lifestyle and

The Impacts of an Intervention Program on the Quality of Life of Elderly Recipients of Social ServicesTEODÓRA NÉMETH RÁCZ

2 Dr. Jellinek, Harry: Új egészségügyi ABC [New health ABC], Me-dicina Kiadó, Budapest, 1990

Health care system

Lifestyle

Biological factors

Environment43%

11%19%

27%

Figure 22 :: Factors effecting quality of life

90

85

80

75

70

65’00. ’05. ’10. ’15. ’20. ’25. ’30. ’35. ’40. ’45. ’50.

Average life expectancy

Women

Men

Figure 11 :: Average life expectancy

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This is an especially important factor for institu-tions operating the health services because it is on this area that professionals are able to exercise the most influence in their everyday activities.

Considerable changes could also be observed in recent years among those using the social services. The most drastic change can be seen in those living in homes for the aged: since 2008 this form of service has been available only to persons who need care for at least 4 hours a day. This clearly means in practice that the in-activity of the elderly persons living there is increasing, their health, physical and mental state is deteriorating. Multimorbidity is becoming a general characteristic: the residents have at least two or even more chronic illnesses. The phenomenon is also found in the case of the basic services available: elderly persons who are no longer eligible for residential care because of the relatively low hours of care need are using other types of service because their capacity to care for themselves is not sufficient for independent living.

In this approach too, lifestyle is an important fac-tor because many possibilities for preventing illness and achieving a long-term healthy, active life can be created by influencing it. In the WHO framework programme (2002) “active ageing” refers to a process that optimalises the health, social participation and security of the ageing and improves their quality of life. The goal for all is to be able to enjoy a state of physical, social and mental well-being for the entire

lifetime, and “active” means the continuous inclusion of the elderly in the life of society in accordance with their needs, wishes and capabilities, that is, not just the capacity for physical activity or participation in the labour market.

Hypothesis

We suppose that the physical activity intervention programme elaborated for elderly persons using the social services has an influence on physical perform-ance, concentration and quality of life.

Under the influence of the programme a longer and better quality life can be lived in old age too.

Target group of the investigation and methods

Target group

The research programme was conducted in two phases.

1. In the first phase of the sample the target group of the study was formed of volunteers living in the Homes for the Aged of the Gyôr Amalgamated Health and Social Institution, 38 elderly persons in all, 28.9% men and 71.1% women. 50% of the subjects were under 80 and 50% over 80. The average age was 77.23±9.94 years.

Regarding the length of time they had been in the institution, 60.5% had lived there for three years or less, 29.5% for more than three years.

68.4% receive a normal diet and 31.6% a special diet.

Regarding level of education, 47.1% had completed less than 8 years of primary school, 44.1% had more than 8 years and 8.8% had a school leaving certificate or a diploma of higher education.

2. In the second phase of the sample the target group of the study consisted of volunteers who were members of the Clubs for the Elderly of the Gyôr Amalgamated Health and Social Institution, 85 elderly persons in all, 15.6 % men and 84.4% women. The average age was 76.08±7.452 years.

76.5% participated in the programme actively and 23.5% passively. We do not have precise data on the nutrition of the target group because the club members provide for their own meals: some eat at home while others use the meal service of their institution.

Methods

The methods applied were divided into two groups. From one we could obtain data on the physical state and activity of the elderly and on any changes, while the other group focused on the mental state.


The following methods were used to measure the physical state:

a. Fullerton Functional Fitness Test that measures the state of physical fitness of the elderly with the following tests (Leg strength, Arm strength, Stamina, Flexibility of shoulder joints, Flexibility of lower limb joints, Dynamic balance and mobility)

The following method and tools were used to measure the mental state:

b. WHOQOL-OLD test comprising 24 items, meas-uring Sensory abilities, Autonomy, Past, present and future abilities, Social participation, Death and dying and Intimacy.

c. Assessment of the living conditions, social situation, disease groups, diet, and the state of health.

d. Rathus test measuring assertiveness and social skills

e. Mini mental test

Schedule of the research programme

1. Announcement of the project and information2. Applications for participation3. Preliminary medical test, individuals were included

in the programme only after coordination with the institution’s physician and with his or her approval

4. Status measurement using the methods listed above5. Analysis, evaluation of the data obtained6. 15 weeks of physical activity7. Control measurement8. Analysis, evaluation and comparison of the data9. Information for the participants

The programme was carried out with the participation of the Apáczai Csere János Faculty of the University of West Hungary (Dr. Ferenc Ihász associate professor, István Barthalos doctorate candidate SE-TSK) and the Faculty of Physical Education and Sport Sciences of the Semmelweis University (Dr. József Bognár associate professor SE-TSK).

Physical activity interventionprogram

The program was launched in January 2008 for a pe-riod of 15 weeks for the target group living in homes for the aged. It was continued from January 2009, when members of the clubs for the elderly operated by the institution could participate in a six-month physical activity program.

In both research programs we divided the partici-pants into 3 groups:Group 1: 2x45 minutes weekly physical activity (in

gymnasium or outdoors) conducted and led by a specialist

Group 2: 2x45 minutes weekly physical activity (in gymnasium or outdoors) conducted and led by a specialist and 1x weekly group lecture and discus-sion on lifestyle, health and physical activity

Group 3: control group (did not participate in the physical activity or in the lecture and discussion on lifestyle and health)

It can be clearly seen from the activities performed by the groups listed that the active target group took part in group exercises conducted by a group physiothera-pist twice weekly. This was supplemented in the case of one group with a session on lifestyle, health and physi-cal activity conducted by a mental hygiene specialist. It was an important consideration in our work that the form of physical activity chosen and the activity together should be cheerful occasions and a pleasant experience for the participants as a way of maintaining and strengthening their motivation. We were greatly helped in attaining our goal by the active college and university students who regularly visited the physical activity sessions.

From the viewpoint of research methodology both intervention programs were of short duration, but despite the fact that they lasted only 15 weeks, they produced substantial results.

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We found positive changes among members of the clubs for the elderly in the following areas:

– standing up from chair (leg strength)– arm curl with weight (upper arm strength)– 6 minutes walking (endurance)– bending forward from chair to outstretched leg

(lower limb flexibility)– standing up and walking (dynamic balance)

It is important here to note that although the tools used for the investigation did not include measure-ment of the subjective feelings of the elderly persons in this area, we received positive feedback from many

Results of the investigation

Physical measurement results

We measured physical fitness by Fullerton Functional Fitness Test. Considerable changes were found in this area (Figure 3, 4). In the case of the first group (resi-dents of homes for the aged) physical fitness improved in the following situations:

– standing up from chair (leg strength)– arm curl with weight (upper arm strength)– 6 minutes walking (endurance)– bending forward from chair to outstretched leg (flexibility of lower limb)

of them at the end of the intervention program: they considered that there had been a big improvement in their physical state.

A change was found in the FFFT indicators in both groups; in the case of those using day care services this affected more areas. At the same time it is important to note that the change was more signifi-cant among the residents of homes for the aged even despite the short duration of the program.

Mental state measurement results

We did not expect a measurable change in the mental state for the first group for the 15-week duration of the program. According to our hypothesis the effect of physical activity on the mental state, attitude to

life and quality of life become measurable and clearly perceptible over a longer period. However the meas-urement results exceeded our expectations because we observed a positive change even over such a short period. Among the numerous areas investigated we found improvement in the judgement of autonomy, social participation and intimacy (Figure 5, 6).

We did not observe any significant difference in the above areas in members of the second group, but there was an improvement in the mood of participants. This is confirmed by the fact that there was an increase in the demand to participate in the group and partici-pants expressed a definite desire for its continuation.

15,0

12,5

10,0

7,5

5,0

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Group: Exercise and mental

Standing up from chair before

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Standing up from chair a�ter

Figure 4

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Standing up from chair a�ter

Figure 3


Conclusions

In general it can be said that great emphasis should be placed on physical activity in the life of the elderly be-cause it influences the physical, mental and emotional states alike. The quality of life can be improved with a physical activity intervention program, making it possible to experience a full life in old age too. As our research also confirmed, it is necessary and possible to change the lifestyle and increase the role of physi-cal activity in old age too. In our opinion even more positive change can be brought about with a longer, regular program of physical activity.

Special mention must be made of the fact that the positive change in autonomy and social participation is especially important among residents of homes for the

aged. The feeling of independence in daily activities in-fluences the mood and life feeling and on the whole has a good effect on the quality of life. The strengthening of social participation has the same favourable effect. It is important here to refer to the consideration that coexistence in a community is an obligation for people living in the homes. The artificially created life situa-tion is the source of numerous conflicts and of isolation within the institution. The number of conflict situations can be reduced and the experience of belonging to the community enriched with active participation. Physical activity has a beneficial effect directly and indirectly on the everyday life of these communities. Indirectly, be-

cause it affects even members who do not participate in the physical activity program, through accounts of the experience, as a topic of conversation in the corridors and an event that brings colour to everyday life. Thus on the whole we can draw the conclusion that regular physical activity has a positive effect on the users of the social service, and that it is necessary and worth begin-ning and regularly continuing physical activity in old age. As a social service provider it is important for us that we carried out the research, because its results are used as a basis for health promotion programs that have a beneficial effect on the everyday lives of the elderly. They help to improve the quality of life of participants.

Sustainability

All this encourages us to continue organisation of the physical activity programs and have them held regularly. The demands expressed by the elderly themselves, the cheerful, relaxed time spent together for the activity improve their quality of life. We consider it important to introduce new forms of exercise for variety. For this rea-son in 2011 we introduced Nordic Walking for members of the clubs for the elderly. Besides the physical activity, this new form of exercise became an important social ex-perience combined with excursions and sightseeing tours.

We also considered it important that the physical activity programs we elaborated should contribute to the attainment of several goals. Besides the results and

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Group: Exercise

2

Intimacy after

Intimacy before

Death after

Death before

Social after

Social before

Past, present, future after

Past, present, future before

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y after

Autonom

y before

Sensory abilties after

Sensory abilties before

4

11

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Figure 5 :: WHOQOL-OLD

20

15

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Group: Exercise and mental

Intimacy after

Intimacy before

Death after

Death before

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Social before

Past, present, future after

Past, present, future before

Autonom

y after

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y before

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Sensory abilties before

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Figure 6 :: WHOQOL-OLD

110

effects presented here, the program offered an oppor-tunity for several generations to work together. Young people can support the elderly in physical exercises, and the cheerful time spent together is also an oppor-tunity to initiate informal conversations. With this we can take big steps towards our important goal of reduc-ing over the long term the distance between different generations. In our institution we have implemented a program running for several years and aimed at bridg-ing the gap between generations. The effectiveness of the work of college and university students taking part in our physical activity intervention program led to the idea that further results could be obtained by combining the two programs. The result has been our new project in 2012: All Ages Together in which one of the main methods of strengthening the connection between generations is performing physical activities together. The feedback so far is positive and shows that many forms of exercise can be performed by the elderly and sustainability can be guaranteed by placing emphasis on the pleasant experience.

Bibliography

Deurenberg, P.; Andreoli, A.; Borg, P.; Kukkonen-Harjula, K.; de Lorenzo, A.; van Marken Lichtenbelt, W.D.; Testolin, G.; Vigano, R.; Vollaard, N. (2001) The validity of predicted body fat percentage from body mass index and from impedance in sample of five European populations. European Journal Clinical

Nutrition 55: 973-979. DiBrezzo, R.; Shadden, B.B.; Raybon, B.H.; Powers, M. (2005) Exercise intervention designed to improve strength and dymanic balance among community-dwelling older adults. Journal of Aging and Physical Activity, 13: 198-209.

Marcus, B.H.; Williams, D.M.; Dubbert, P.M.; Sallis, J.F.; King, A.C.; Yancey, A.K. (2006) Physical activity intervention studies: What we know and what we need to know: A scientific statement from the American Heart Association Council on Nutrition, Physical Activity and Metabolism (subcommittee on physical activity): Council on Cardiovascular Disease in the Young: and the Interdisciplinary Working Group on Quality of Care and Outcomes Research. Circulation, 114: 2739-2752.

Rikli, R.E.; Jones, C. J. (1999) Functional fitness normative scores for community-residing older adults, ages 60-94. Journal of Aging and Physical Activity, 7: 129-161.

Shephard, R.J. (1996) Habitual physical activity and quality of life. Quest, 48: 354-365.

Susánszky É.; Kokoly-Thege B.; Stauder A.; Kopp M. (2006) A WHO jól-lét kérdôív rövidített (WBI-5) Magyar változatának validálása. A Hungarostudy 2002 országos lakossági felmérés alapján. [Validation of the Short Hungarian Version of the WHO Well-Being questionnaire (WBI-5). Based on the Hungarostudy 2002 national population survey]. Mentálhigiéné és

Pszichoszomatika, 3: 247-255.Tróznai T.; Kullman L. (2006) A WHOQOL-100 életminôség-vizsgáló kérdôív magyar verziójának validálása. [Validation of the Hungarian version of the WHOQOL-100 quality of life questionnaire]. Rehabilitáció, 2: 28-36.

Vécseyné Kovách, M.; Olvasztóné Balogh, Zs.; Gangl, J.; Bognár, J. (2007) The health-conscious behaviour of people over 55: A preliminary study focusing on gender, marital status, income and educational level. Kalokagathia, 45: 42-50.

Wyatt, H.R.; Peters, J.C.; Reed, G.W.; Barry, M.; Hill, J.O. (2005) A Colorado statewide survey of walking and its relation to excessive weight. Medicine and Science in Sport and Exercise, 37: 724-730.


KEY WORDS: OLDER PEOPLE; QUALITY OF LIFE; CITY CENTRES; NEIGHBORHOOD SATISFACTION; CZECH REPUBLIC

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Ageing in the city

Ageing populations and urbanization are two of the most important global trends shaping the 21st century (Global... 2007). In the context of East Central Europe especially, little attention has been paid to the mutual relationship between these two phenomena – the issues of older people in an urban setting, and the importance of the urban environ-ment for constructing the experience of ageing (cf. Kovács 2010; Steinführer, Haase 2007). In the Czech Republic (CR) 73% of the population live in urban areas; among seniors the rate is even a little higher – 75% of all persons over 60 live in urban areas (Source: Czech Sta-tistical Office: 401908ri02). We can assume that both these ratios will grow even higher in the future, as the Czech Republic approaches the socio-geographic and demographic profile of the EU-15. Here an important fact is that the Czech population in general is charac-terized by relatively low spatial mobility (Mikeszová [n.d.]). This mobility declines even further in old age,

fundamental needs and services are reached on foot (Marcellini et al. 2002; Mollenkopf et al. 2005). On the basis of these findings we can conclude that the majority of people will grow old in the place where they spent a great portion of their productive lives, and for Czech seniors this place is and will continue to be an urbanized area – the city.

In other words, the environment and changes in it have a great potential for influencing everyday lives; and on the other hand the “everyday routine” influences the living environment of the actor. This relationship is even more intense in old age, when the action radius of the actor has a practical and symbolic tendency to shrink and retreat towards the core formed by the intimate space of the ageing individual (Sýkorová 2008). If we speak here of a core, we are working from an illustration of the living environment as a model composed of con-centric circles around an individual, beginning at the micro level of room and apartment, moving outward to the neighbourhood, the town or city, region, up to the macro level of national states and super-national enti-ties. As shown by the European Value Study 1991–2008, there is a correlation between the age of a respondent and the size of the geographic area with which s/he identifies the most. Even though between the analyzed years there is a move away from the feeling of identifica-tion with larger areas in favour of the smaller geographic units in general, the older the respondent the stronger the feeling of identification with the village (the place where s/he lives) – see Table 1.

as the traditional reasons for a change in habitation usually disappear (Sochurková 2006; Sunega 2001). According to available studies, Czech seniors over 60 had lived in their apartments an average of 30 years (mode 40 years), and 79% of surveyed seniors are not considering moving in the near future (Kucharová 2002). This tends to be the typical inherited pattern of most post-socialist countries. (In the MOBILATE research e.g. in the Hungarian sample, 2 settlements, older people have lived in their home 36.5 years on the average)2. Moreover, foreign studies (Baltes, Baltes 1990) estimate that 70 to 90% of seniors’ time is spent in the immediate vicinity of their home and many

2 MOBILATE project, 2000-2003, participating countries: Italy, Germany, Finland, the Netherlands, Hungary. The settlements in Hungary were: Pécs a county seat, Jászladány, a rural settlement.

Future Cities for thePeople of the Past, or Vice Versa? The Dynamic Challenges of Ageing and Urbanization1

LUCIE VIDOVICOVA

1 This article was supported by the project “Ageing in the Environ-ment: Regeneration, Gentrification, and Social Exclusion as New Is-sues in Environmental Gerontology”. (Czech Science Agency grant No. P404/10/1555) – http://starnuti.fss.muni.cz. The author also thanks the Office for Population Studies, Faculty of Social Studies, Masaryk University. The theoretical introduction is based partly on a text by Vidovicová, Gregorová (2010).


We believe that possible changes at this mezzo level are at least equally important for shaping the experience of ageing, as the now well-documented relationship between quality of life in old age and the micro environment.3 In Czech geronto-sociology, how-

3 Often cited is the study “Living and Dying at Murray Manor” (Gubrium 1997), which shows that the environment (that is the rooms, the floors, the offices) determines in a fundamental way the worlds of interaction between clients and personnel, and thus forms worlds of life meaning for individuals. For other examples see Levy (2003), Bell et al. (2001), Oswald et al. (2007), and others. In the Czech environment and context of autonomy this topic was addressed by Sýkorová (2007, 2008).

ever, this higher level, the living environment defined as the neighbourhood and/or town/village where the senior lives has previously been given a minimum of attention. Meanwhile it is precisely this geographic or territorial level that is one of the most important and most illustrative platforms for the dynamic changes in (post)modern society (Giddens 1999). Smith (2009) in her publication “Ageing in Urban Neighbourhoods” attempted to summarize the basic characteristics of towns, es-pecially their centres that

may form the specific life conditions for their ageing inhabitants4 and thus, either directly or indirectly, affect the quality of their lives. Although, or rather because, the urban environment is seen in its essence ambivalently (for a basic review of the discussions see for example the above-cited Giddens 1999), its char-acteristics too can be divided into “pro-senior”, that

4 Likewise in the Czech Republic the centre of town is where the population is oldest. The example of Prague was detailed for exam-ple by Dvořáková (2008), the case of Brno and Ostrava by Vaishar et al. (2009).

is beneficial for “ageing well”5, and the characteristics that detract or threaten to detract from the quality of life in advanced age. Among the indicators of ageing well Smith (2009) mentions higher population density and better access to services and shops, which help to satisfy the basic needs of everyday life. As a result, says the author, the feeling of identification with the place increases, or there is greater civic involvement in the local community.

The challenges

Services in the city centres are usually accessible in greater variety and can thus support the diversity of heterogeneous lifestyles among seniors. Frequently, however, the assortment of services is filtered by the economic conditions of seniors, and their acces-sibility may (paradoxically) become limited for seniors threatened with social exclusion (Scharf, Phillipson, Smith 2005). Similarly, globalization has an ambivalent

5 The World Health Organization has its own definition of age-friendly places. It considers eight categories on the basis of which a city might be [evaluated]. Categories defined under this concept are relatively broad, and their detailed operationalization presents a nearly impossible task. On the other hand they are a good indicator of the complexity characteristic of the urban environment, which has a direct influence on ageing well. These include housing, social participation, respect and social inclusion, civic involvement and employment, communication and information, community support and health services, rural environment and buildings, and finally transportation (Global ... 2007).

Source: European Value Study 2008, own calculation.

Figure 1 :: Identification of respondent with geographic area according to age group (%)

Country Geographic Entity 17-29 30-44 45-59 60-74 75+Czech Republic

locality or town 56 57 57 64 72

region country 10 14 10 12 7

country as a whole 27 26 27 21 19

Hungary locality or town 52 52 53 58 71



Poland locality or town 67 68 69 69 70



Slovak Republic

locality or town 52 51 58 61 63



114

impact on the urban environment and the seniors in it. Phillipson (2007) mentions the diversity of social, cul-tural, and economic urban spheres which are shaped by globalization, and which serve as a foundation for the shaping of new types of “movement” in old age. We find positive impacts of these changes more among those who, as the author says, are, thanks to their health and financial resources, able to adapt and adequately react to the changes brought by globalization. For others who are unable to “take advantage” of globalization changes, globalization represents increased risks and destabili-zation rather than maximizing welfare. Globalization thus produces new social inequality “between those able to choose residential locations consistent with their biographies and life histories, and those who experience rejection or marginalization from their lo-cality” (Phillipson 2007: 321). For this reason, too, the Madrid action plan for ageing rates urbanization as one of the risks of development. Priority Directive I states that (among other things) “... migration, urbanization

... [and] other socio-economic changes can marginalize older persons from the mainstream of development, taking away their purposeful economic and social roles and weakening their traditional sources of support”. In some sense, these changes are even more pronounced in the context of East Central Europe with the current demographic and economic development (Steinführer et al. 2010; Haase, Steinführer 2009; Steinführer, Haase 2007). As Burcin and Kučera explain: “inner parts of large [Central European] cities are usu-ally more demographically aged due to the outflow

of their more mobile (i.e. younger) inhabitants during the past decades. This process was amplified during the period of economic transition and restoration of market mechanisms. Rapidly growing dwelling prices especially in the inner parts of the cities launched long time curbed suburbanization which further drained their younger population, ... The recently appeared process of gentrification was only a small step against ageing, namely under the conditions of social protec-tion of the long-term living autochthonous population through housing rent regulation as it has been the case in the Czech Republic.” (Burcin, Kučera 2010: 132-133). As these social protection mechanisms are being gradually ruled out, the new challenges for older people ageing in urban places appear.

Older people in the city centres and their environment-based quality of life: the Czech case

So what is the quality of life of older people in cities of East Central Europe? How satisfied are they with their environment and what challenges do they perceive in their living urban environment? To at least partially answer these questions we will draw on the representa-tive survey “The Quality of Life of Older People Living in Cities”, which was taken on 5 to 9 May 2011 among the urban population of the Czech Republic over 60 years old. The data collection was done in thirteen larger cities in every region of the CR and the capital

city, Prague.6 The method of data collection was quota selection in the form of 1001 face-to-face questionnaire interviews. The selection quotas were set for town, gen-der, education, and share of younger and older seniors. Only populations in the central parts of the cities were included; suburban and peripheral areas were excluded from the sample. As the study mainly concentrated on quality of life for seniors in regard to the external char-acteristics of their environment, interviews were held only with respondents who had left their apartment at least once within the last six months. If the respondent

6 The following cities were included in the survey: Praha (N = 120), Kladno (N = 49), Ceské Budejovice (N = 61), Plzen (N = 74), Karlovy Vary (N = 45), Ústí nad Labem (N = 81), Liberec (N = 70), Hradec Králové (N= 66), Pardubice (N = 73), Jihlava (N = 54), Brno (N = 94), Olomouc (N = 64), Zlín (N = 68) and Ostrava (N = 82).

Table 2 :: Basic socio-demographic characteristics of sample

% N

Gender men 42 419

women 58 582

Age 60 – 69 55 550

70-79 34 342

80+ 11 105

Education basic education 10 99

trade school, secondary without graduation

47 472

complete secondary with graduation

31 307

university 12 121

Total 100 1001


did not fulfil this condition, the interviewer was to end the interview. As the project is designed as a complex three-year enterprise using the mixed methods ap-proach, the results presented here represent a selection of basic analysis of currently available data; further analysis will follow. (For the list of publications see http://starnuti.fss.muni.cz).

Selected survey results

The average age in our sample of urban seniors is 69.6 years (+/- 6.96) and is the same for both genders. The share of women and university graduates is slightly overrepresented compared to the regular population as a result of the feminization of the senior popula-tion and higher levels of education among the urban population. The basic characteristics of the sample are summed up in Table 2.

As we have said, our research included only persons who had left their residence at least once during the six months prior to the survey. Of this sample, 79% are ac-tive, everyday users of the external environment, some even in advanced age. Among persons eighty years or older, 60% of those surveyed leave their residence every day. Meanwhile just 15% of seniors in the entire sample and a quarter of those in the oldest group were accompanied by another person. In the vast majority of cases (80%) this is provided by someone from the family, which points to a so far little noticed form of

intergenerational solidarity in old age. Another 13% of urban seniors leave the residence with an animal friend. Twenty-four percent of those surveyed use some sort of aid when they walk outside, for example a crutch. It is worth noting that 85% must negotiate stairs on the way out from their flat or house. More than a half of the respondents (56%) have or have had a driving license, but only 63% drive at least occasionally (29% regularly), more often men. Nearly seventy per cent (66%) have an available parking place close to their home at least most of the time, while 7% never have this opportunity.

As to the assessment of how much older people are attached to their place of residence, we found that 65% were born in the same city where they now live. Confirming the low mobility theory, only 28% moved 3 or more times in their life, 55% once or twice, and 17% never moved in their life. Out of those who do have experience with moving, only 15% did so after the age of 59. The majority (85%) never thought of moving (again), 9% did give it a thought, but had done nothing about it; only 4% had started to look around, and 2% already had a new place to move to. Therefore we are not surprised that 92% of interviewees say they would like to stay in their flat/house for the rest of their lives.

Generally it can be said that the clear majority of seniors in cities are satisfied with the environment of their residence and surroundings, 79% said they were very or rather satisfied. While this indicator did not vary with the gender of the respondent, satisfaction

falls with increasing age: among sixty-year-olds 82% are satisfied, of the oldest age group of eighty and above it is 11% less. In view of what we already know about the relationship between age and disability, an-other unsurprising result is that persons with greater disability are usually among the people less satisfied with their surroundings.

Most of the respondents also perceive a strong social-physical dynamic in their neighbourhood. If we leave out the 3% of respondents who were unable to give an opinion having just moved to that place, only 13% of seniors describe their surroundings as unchanging. On the other hand, 35% say their neighbourhood has changed a lot, and another 50% describe the change as somewhat less significant. These changes are for the best, say 35% of interviewees; for the better another 50%. The remaining (15%) see the changes as making the neighbourhood worse or much worse. A big part of this evaluation is determined by the pace of turnover among the neighbours. As long as the majority is old neighbours, seniors rate the changes positively. But if there is a fundamental change in the composition of the neighbourhood and most old neighbours are gone the negative evaluation of the whole neighbourhood is considerably higher.

However, the changes in social composition of the neighbourhood are only part of the story. Older people living in central areas of big cities identified a list of challenges inherent in and specific to the urban

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environment: heavy traffic (48%); a lot of night bars and gambling rooms (42%); poor winter maintenance (“icy streets lock me in at home”; 37%); houses are vandalized (33%); not enough parks and green spaces (31%); more and more unknown and homeless people (31%); not enough traffic lights for safe crossing (30%); garbage and dirt in the streets (21%); more and more tourists in the streets (26%); streets and sidewalks not maintained (26%).

Important threats to the quality of life are (sub-jective) fears of danger lurking in the outside world. The statement “in the area of my residence it is quite dangerous to go out even during the day” is agreed with by 15% of seniors and almost a fourth of these strongly. The feeling of security declines with rising age; it is lower among women than among men, and is lower among persons with health problems or limited mobility. Especially among women there are increased risks limiting mobility in public areas – they live longer, perceive their health as worse, and experience a reduced feeling of safety in public areas. The feeling of danger and insecurity when moving in the external environment understandably lowers the feeling of satisfaction in one’s environment in general. Up to 39% of seniors surveyed regard their surroundings as dan-gerous at night. There is a wide gap between cities in the share of respondents expressing their fears in this way: more than half are afraid at night in Kladno (57%) and Pardubice (54%), but only 25% in Liberec. In the case of being afraid during daylight, the gaps are even

wider: while Kladno and Pardubice (28% and 23%) are regarded as dangerous even in the day, only 2% in Zlín say so, and in Hradec Králové 5%.7 From the current analysis we cannot determine the cause of this signifi-cant variation among cities, but it is clear that not all towns are equally age-friendly, and that even relatively small changes in the physical environment can lead to better conditions for staying active in old age.

Discussion

Our data send us the following key messages: today’s cities do not endanger the quality of life in old age in general; however, cumulative disadvantages, mainly based on gender, disability or deteriorating health, do play an important role in increasing the pressure and the risks of an urban environment. Despite the gen-eral satisfaction expressed by older city core dwellers, there are considerable challenges in both the physical and social environments. Therefore we believe that different levels of environmental impact on ageing of individuals and the population must be recognized, studied, and addressed, since modern urban dynamics (sprawl, shrinkage, regeneration, gentrification, sub-urbanization, etc.) have differing impacts on different socio-economic and demographic groups. Policies implemented in the urban environment should be

7 The level of insecurity varies also on country level as shown by Marcellini et al. (2002). In Hungary for example 31% of people aged 75 and older felt insecure, while in Finland it was only 9%.

age-mainstreamed, i.e. tested and evaluated as to pos-sible impact on different age groups. As Kresl and Ietri (2010) argue, older people are an important resource for the urban economy: they (re)populate the city cen-tres, participate in the cultural and art life of the city, and take part in intellectual and educational activities which are considered vital for many CEE cities.


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Sýkorová, Dana. (2007) Autonomie ve stáří. Kapitoly z gerontosociologie. Praha: Sociologické nakladatelství.

Sýkorová, Dana. (2008) Prostor a věci v kontextu stáří. Sociologický časopis/Czech Sociological Review. 44 (2): 401- 421.

Vaishar, Antonín, et al. (2009) Současný vývoj vnitřních částí Brna a Ostravy. Ústav Geoniky, AV ČR.

Vidovićová, Lucie; Eva Gregorová. (2010) Nová města a staří lidé. Sociální studia 7 (3): 81–94.

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http://seb.soc.cas.cz/postoje2001/prezentace/seb_sunega_idealnibydleni.pdf


KEY WORDS: REAL ESTATE, SENIOR HOUSING, DEMOGRAPHIC CHANGES, CULTURAL CHANGES, POLAND

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Introduction

As with most industrialized countries, the issue of ageing is becoming more and more important in Poland. While many areas of ageing are being dis-cussed, an area that receives relatively little attention is housing. How do sen-iors want to live? Where do they want to live? What do they want where they live? Social and cultural mores are changing in Polish society and these changes are helping to drive demand for a new type of housing within the senior demographic. While government and developers are focusing on building more nursing homes and social housing units, there is a large group of seniors who do not fit into these two existing categories of housing. These seniors are still active and healthy but may live in large apartments or houses that they cannot afford to maintain or no longer want. Maybe they do not want to live with their children. Maybe they are over the income level of eligibility for social housing. They do not need or want nursing home care. They want to live on their own as long as possible.

The senior demographic will be the largest grow-ing demographic in Poland over the next 25 years. As a consequence, the median age of the population is projected to rise to 47.5 years in 2030 and 52.9 in

the demand for a new type of housing focused on independent seniors – the group not in need of nurs-ing home care and over the income level of eligibility for social housing. The information presented is sup-plemented with original qualitative and quantitative research performed by the author.

Who is an Independent Senior?

Within the senior demographic there is a group that is considered by medical and sociological professionals to be independent. This means that the person is able to live on his or her own with minimal daily assist-ance.2 To measure levels of independence the Activi-ties Daily Living (ADL) index is used. Referred to as the Barthel Activities Daily Index, this index contains a list of basic tasks of everyday life. The ADLs are the basic tasks of everyday life, such as eating, bathing, dressing, toileting and transferring (i.e., getting in and out of a bed or chair). Those persons with an ADL score of 40 and under are considered independent by Polish social and medical standards. This growing demographic has housing issues not currently being met in the Polish residential market. And with seniors living longer and becoming a greater portion of the

2 Wiener, Joshua M. and Hanley, Raymond J. “Measuring the Activities of Daily Living Among the Elderly: A Guide to National Surveys”. U.S. Department of Health and Human Services, As-sistant Secretary for Planning and Evaluation, Office of Disability, Aging and Long-Term Care Policy. (October 1989); p. 6-7.

2050. In the case of the elderly (65+), there will be a constant increase in number. A significant feature of these changes will be a substantial rise in the number of the oldest old (80+) persons up to the end of 2043.1

The issue of active ageing is already being discussed by the Polish government in the areas of work, health and pension reform, but little attention has been paid to where and how these 21st century seniors will be living. The following is a brief discussion of the demo-graphic, social and real estate factors that are driving

1 Matysiak, Anna and Nowok, Beata. “ Population Trends – Cur-rent Trends.” Stochastic forecast of the population of Poland, 2005

– 2050. Demographic Research, 17 no. 11: 301-338. 20 November 2007. (accessed April 27, 2010). http://www.demographic-research.org/Volumes/Vol17/11/17-11.pdf, p. 4.

A Brief Discussion of the Factors Driving the Demand for Independent Senior Housing: PolandGRETA GARNISS


overall population, the time has come to focus on their housing needs.

Life Expectancies in Visegrad Countries

As Poland is a member of the Visegrad Group, compar-ing life expectancies among member states is presented in Table One. As seen in Table One, each country has seen substantial increases in overall life expectancy over the last 20 years. Additionally, with the exception of Hungary, women substantially outlive men (Table 1).

Healthy Life Years

According to Eurostat, the definition of healthy life years (HLY) is the number of years that a person lives without disability. The respective (HLY) figures for the Visegrad countries are a) for men: Slovakia 52.3, Hungary 56.4, Poland 58.5 and Czech Republic 62.2 years; b) for women: Slovakia 52.1, Hungary 58.6, Poland 62.2 and the Czech Republic 64.8 years.

Among the Visegrad countries the Czech Republic has the best position while the figures for HLY in Poland are poor but somewhat better than in Hungary. It can be concluded that in three of the Visegrad countries health problems or a decrease in the functions needed to carry out everyday life activities start already in an early period of the life cycle, especially for men.3

3 http://epp.eurostat.ec.europa.eu/statistics_explained/index.php/Healthy_life _ years_statistics

Improvement in Overall Health and Mortality Rates

Despite the above seemingly poor data, living longer has led to reduced mortality rates in each Visegrad country. In Poland, the factors for increased life span include but are not limited to: more advanced diagnos-tics and therapies in a number of diseases, especially diseases of circulatory system; changes in diet; and extensive promotion of a healthy lifestyle. Following in the footsteps of highly developed European countries, a number of institutions and nongovernmental associa-tions have been emerging in Poland, which attach great importance to the information policy associated with the issues of health-threatening factors.

The media contributes immensely to promoting healthy lifestyle, with their campaigns expanding with each subsequent year. The activities of all institutions and associations which promote our own health care, thus encouraging an increased physical activity, bal-anced diet, and limited consumption of alcohol and nicotine, seem to have been generating positive results.

Surveys on the health status of the population, conducted by the Central Statistical Office (CSO in Warsaw) in 1996 and then repeated in 2004, confirm the research that health behaviors in Poland underwent favorable changes. While in 1996 over 45% of residents of Poland evaluated their health as less than good, by the end of 2004, such opinions were expressed by

Source: http://apps.who.int/ghodat, accessed July 27, 2012

Table 1 :: Life Expectancy At Birth

Male Female

1990

Slovakia 66.7 75.5

Czech Republic 67.6 75.4

Hungary 69.4 65.1

Poland 66.5 75.5

2000

Slovakia 69.1 77.4


Hungary 71.9 67.5

Poland 69.7 78.0

2009

Slovakia 71.3 78.9


Hungary 74.2 70.1

Poland 71.5 79.9

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less than 39% of Poles. The health status evaluation improved with respect to both men and women, and it was observed that the higher the education level, the higher the share of people evaluating their health as good or very good.4 As of the date of this paper, these results (2004) are the latest statistics available.

The results of surveys conducted by the CSO are subjective in nature, since they are based on respond-ents’ own knowledge or evaluation of their own health. Nonetheless, they indicate that adult Poles are satisfied with their own life as over 75% of adults evaluated their life (health) as very good or good.

The benefits associated with the development of new medical technologies and innovative diagnostic methods, as well as with considerable improvement of the health condition of Poles, resulting from a more health-oriented lifestyle, are reflected in a constant drop in mortality.5

Housing and Its Impact

Housing construction has a great significance in both its production process and its final product. Housing influences a country as well as the living standard of its citizens. Its construction has four aspects:

4 Population Projection for Poland, 2008-2035. Głowny Urząd Statystyczny, Department Badań Demograficznych, Warsawa 2009. p. 107

5 Ibid, p. 108-109.

• individual – it satisfies one of the basic human needs – the need for shelter and also enables people to start and raise a family;

• social – it forms the base for essential community ties;• material – its products form an important element of

family, community and state wealth;• economic – it is one of the most important ways of

economic development because it creates jobs, work places, technical infrastructure and a base for social infrastructure.6

Within the Polish market, the housing needs and wants of the independent senior are not being met. The current Polish housing market is instead focusing on developing nursing homes and public/social housing units for its seniors. These units are needed as a mix of tenancies is necessary for an integrated, heterogene-ous real estate market. While some seniors do prefer to remain in their current residences as long as possible, there is a growing sector in the senior demographic that does not need or want the level of care in a nursing home and is over the income level of eligibility for pub-lic/social housing. They are willing to move from their current residence if the right opportunity is presented.

However, in order to understand what is driving the demand for independent senior housing development,

6 Werner, Witold A. Urban Development Issues Research Quar-terly, Institute of Urban Development, 1/2010, Yearbook VII, p. 8.

it is necessary to briefly discuss general trends in the senior community, the role of the family, and historical housing activity since these sectors are interlinked.

Seniors and Family

This relationship has endured for centuries. There is the historical concept that children have a duty to support elderly parents. It has been articulated in both religious and nonreligious traditions and in a variety of geographical places and literary works. Additionally, each tradition imposes legal and financial obligations as well as moral duties on the children and family.7

According to Polish law adult children have finan-cial obligations toward their elderly or disabled parents similar to their obligations toward their children. The government also has an obligation to provide care on the basis of international and national regulations. This obligation is set out in the Constitution of the Republic of Poland, (Dz.U. 97.78.483), Article 71 of Act 1.8 Families are considered the primary care tak-

7 Moskowitz, Seymour. “Adult Children and Indigent Parents: Intergenerational Responsibilities in International Perspective” Marquette Law Review, Vol. 86, Num. 3, Winter 2002 p. 406. http://epublications.marquette.edu/cgi /viewcontent.cgi?article (accessed June 6, 2011).

8 Błe˛dowski, Piotr and Pe˛dich, Wojciech. “Services Supporting Family Carers of Elderly People in Europe: Characteristics, Cover-ages & Usage”, EuroFam Care, National Background Report for Poland. July 2004, pp. 19-20.


ers – physically and financially – of their older family members when the need arises.

While adult children caring for older family mem-bers has been the norm for decades, this care model is changing. Changes are occurring due to a variety of factors including but not limited to: space issues in the adult child’s home (there may not be space for additional members); affordability (the family may not be able to afford to care for a family member at home); work issues with the adult children (globalization, working in other cities or in other countries) and time with immediate family members working long hours outside the household.

Where Do Seniors Want to Live When They Are Older?

In Polish society, it was assumed for generations that an older parent would move into the adult child’s home when they were in need of living assistance. However, this assumption is changing.

Recent research has shown that seniors do not plan on living with their adult children, nor do they want to be a burden to them when they are older. The author has been conducting quantitative research that shows that seniors have definite opinions about what they want when they grow older; where they expect to

live when they grow older; and how the family/their children play a role in their later years.

In the winter and spring of 2011 and 2012 surveys were conducted in two cities in Poland (Kraków and Gdansk) to ask seniors what they wanted in terms of housing and their overall expectations concerning where and how they wanted to live their lives. Us-ing the Lickert Method of quantitative analysis for qualitative data, the customized survey consisted of 20 questions, with an answer range of 1-5. A “one” answer was strongly disagree and five was strongly agree. An answer of three was considered neutral or no opinion.

One of the questions was “I plan on living with my children when I am older”. On a scale of one to five, the average score was 2.05 (disagree), indicating that many seniors do not plan on living with their children when they are older. Also seniors do not want to be a burden on their children when they are older (4.23 – strongly agree). Seniors were also asked how important it was to live their lives as they wished when they were older. The answer was a resounding yes with 4.74 out of 5.0 (strongly agree). Having choice as they grow older is important to many seniors. It provides a sense of autonomy, empowerment and control which is vitally important to them. Seniors who retain control over their lives do not see themselves as old. They con-sider themselves old when they experience significantly deteriorating health and physical fitness, and become

more dependent on others.9 They want to remain in-dependent as long as possible. Many Poles do not plan on living with their children when they are older. So what are their options in the current housing market? Now it is nursing homes or social/public housing units.

Nursing Home Units

Nursing homes are not viewed favorably as they are seen as a place to die. While strides have been made over the years to make nursing homes less institutional and more home-like and desirable, the negative image

9 Halicka, Małgorzata and Halicki, Jerzy.“Polish Senior Citizens’ Opinions Concering Old Age and Preparing For It”, Polytika Społecznia. “Medical, Psychological, Sociological and Economic Aspects of Aging in Poland”. PolSenior Project. Social Policy 2011. Nr indeksu 369209, PL ISSN 0137-4729. p.18

Source: G. Garniss (November 2011)

Photo 1 :: Photo 2

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persists. In most cases there are also affordability is-sues involved in paying for a nursing home. Also many seniors do not need this level of care yet. There is no independent option as nursing home units have no individual bathrooms, kitchens or private living area. Rooms are usually shared and in many cases resemble university dormitory rooms with little space for per-sonal things. Additionally, nursing home waiting lists range from six months to two years.

Photo One through Six show nursing home units in Gdansk and Kraków. The nursing home in Gdansk was originally constructed in the 1970s but most of the property was renovated over the last two years. Shown is a single-room unit. Double rooms in this property (as well as in Kraków) resembled dormitory rooms with two to four beds, two to four wardrobes for clothes and

minimal personal items, and no personal or private space for residents. There is also very little space for any personal belongings. These dormitory units are not shown in the photographs.

As seen in Photo 1 this is a small single-person unit in Gdansk. This gentleman has so little space his bed is a pull-out sofa. He has a small, flat screen TV and a small wardrobe. He has made it his own with the ad-

dition of plants and a handful of personal items. Photo 2 is of the common hallway in the property. The rug provides a more domestic touch compared to bare tile flooring which tends to be the norm in nursing home units. Residents in Gdansk are very creative and their art and craft work is displayed throughout the common areas in the property.

Photos 3 and 4 show the bathroom and shower facilities which are shared among residents. While rela-tively new and in good condition, these nursing home bathrooms have no bathtub and offer little privacy for residents while in use.

Photos 5 and 6 are photographs of a newer single- room nursing home unit in suburban Kraków. Once again, the room itself is in very good condition with new wood floors, new kitchen sink with motion de-tector tap and new wardrobe. However, this room is extremely small with a sofa bed for sleeping and only a few meters of living space in the unit. This gentleman has only a flat screen TV, small table and one chair as these are the only items that fit into this room. It has no private bathroom or kitchen area and very little storage space. There is no opportunity for independent living as these units have no kitchen or bathroom in the unit. Facilities are all shared.

These nursing home units represent the newest units and the upper end (in quality in this market sec-tor). But this is the exception not the norm. Nursing home units have a generally low standard especially in the case of publicly managed nursing homes. Private nursing homes are being built and contain more mod-ern, bright, and spacious rooms, and tend to have more group-oriented activities, promoting social interaction. However, even these new nursing home units have shared living spaces. Shared living spaces have the po-tential to lead to conflicts with complete strangers living

Source: G. Garniss (November 2011)

Photo 3 :: Photo 4

Source: G. Garniss (May 2010)

Photo 5 :: Photo 6


with each other in close quarters. This can lead to stress and additional health problems among occupants. Also the newer nursing home properties are constructed at a considerable distance from goods, services and public transportation – potentially isolating residents from key social and medical activities which they need and want.

Nursing homes provide 24/7 care for their residents. These housing units are necessary for many seniors, however, there are a number of nursing home residents who could live independently but are living in the nursing homes because they have nowhere else to go. The two gentlemen in these photographs have been living in their respective nursing homes for over 10 years. By all medical and social standards, these gentlemen could easily live in independent housing units. If independent seniors were able to live in hous-ing more tailored to their needs, nursing home units could be available for those truly in need of 24/7 care. As mentioned earlier, nursing home waiting lists range from months to years depending on location.

Social Housing Units

It is difficult to define what constitutes ‘social housing’ in Poland. It is commonly understood that it includes rental dwellings and social rental dwellings owned by municipalities; dwellings with regulated rents pro-vided by non-profit housing associations (called TBS); and dwellings provided by state-owned companies or

the state treasury for their employees. Usually cooper-ative dwellings with tenement title to use cooperative apartment (as opposed to owner-occupied title) are also considered as social housing. All ‘protected dwell-ings’, i.e. dwellings for disabled persons and other groups with special needs or shelters for the homeless constitute social housing as well. Owner-occupied housing constructed or purchased with state aid (in particular, the program ‘home for every family’) is also considered as social housing.

Criteria for units vary according to the different programs. In general, the access to social housing is based mainly on people’s income. Tenants residing in social dwellings are families with moderate income, who have no legal title to any other dwelling, who are not able to buy a place in the open market or rent a flat on the market. The maximum income per person per household is defined by the law and refers to the average salaries in regions (TBS stock) or is defined by the local authority (communal stock). There are also specific limitations on the floor area of the apartment to be assigned to families according to the number of persons and the special needs in communal stock.10

Many of the social housing units are located in older high rise, concrete block buildings that have seen little or no renovation since their original construction

10 CECODHAS Housing Europe, Social Housing Country Profile, Poland. http://www.housingeurope.eu/publication/social-housing-country-profiles/social-housing-in/Poland. Accesses July 30, 2012.

– 30 to 50 years ago. Because these buildings and units were owned by the state and then by municipalities after 1989, there was little extra money to perform replacements and upgrades of systems (plumbing, heating, electric). Many of these units were given to residents who also had little money to perform neces-sary repairs and upgrades. Therefore, social housing units are also considered undesirable due to size (small) and/or condition (old and rarely updated). Additionally, many independent seniors are over the income level of eligibility for these units. These units are also open to other categories such as single parents, recovering addicts and the handicapped. Seniors are competing among a greater pool of residents for these units.

While nursing home and social housing units are necessary, there are many seniors who do not fit these traditional housing models, and their needs should also be considered in the housing market. These sen-iors tend to be equity rich – owning their own homes. These homes may be too big for them and/or may be too expensive to maintain. These older homes/apart-ments have older systems and low energy efficiency leading to high utility bills. The largest costs to seniors in their housing budget are the utility bills. Seniors may also have mobility issues due the challenge of climbing stairs, or their units may have slippery or uneven floors. These homes tend not to have mobility aids such as grab bars, or railings. While some mobility aids can be installed to keep seniors in their homes longer, there is still the expense of maintaining an older home and a

126

potential size issue. Some seniors do not have the extra funds to perform necessary updates of their properties. These building/architectural barriers can lead seniors to change their residence because they do not feel safe in their own homes.

The Root of Housing Problems and Their Current Effects

Building and architectural barriers are at the root of the problems of current real estate. Poland, and Cen-tral and Eastern Europe, have housing issues that are not present in Western Europe and the west due to their real estate development history. Post World War II through 1989, the primary developer of housing was the state. The state gave almost no consideration to quality, design and utility. In order to build as much housing as fast as possible to replace homes destroyed in World War II, housing consisted of grey, concrete-slab, mid-rise and high-rise buildings. These concrete buildings housed thousands of residents in urban and exurban areas around city centers.

State-developed housing consisted of small, utilitar-ian units with minimal functionality. It was constructed as shelter. Lifts were only installed in buildings more than four stories high. Kitchens were so small and narrow that oven doors could not fully open. Frequently kitchens had no windows and bathrooms tended to have no bathtubs. Owned and operated by the state, rents were low and

subsidized. Because of the quick and cheap construction, energy efficiency was nearly non-existent. Single-family home development was not non-existent but was not the focus of the state. Homes of that type were built mainly in the rural areas of the country.

Post 1989

After 1989 when units were no longer part of the state system, local communities were given primary respon-sibility for repair, maintenance and management. But with little experience in real estate management and maintenance and almost no capital for repairs, many of these properties fell into disrepair. Many units were given to residents at little or no cost. (The system was similar in Hungary where it also caused and continues to cause problems for the elderly). The concept of legal title and legal, contractual protections for buyers and sellers was non-existent. The western concept of a real estate market (title, insurance, mortgages) did not exist.

The majority of new unit owners did not have enough money to update/upgrade their units so hun-dreds of thousands of these units are in substandard condition to this day. Almost one third of Poles live in these units and nearly one third of these units should be demolished according to World Bank data. How-ever, Poland has a current housing shortage of nearly 1.5 million units. Therefore, these older units cannot be removed from the market because there is no place for displaced residents to go.

Because of the original construction, many of these buildings and units have architectural barriers that either cannot be overcome (adding lifts to buildings) or are too expensive for many senior owners to undertake. Updating unit kitchens and bathrooms is extremely costly and common area maintenance and updating of systems is beyond the budget of many properties.

Pre-war homes and apartments are also popular in cities. While some pre-war urban homes and apart-ments have been updated to some extent, many still have outdated and old heating, plumbing and electrical systems and are not the most energy efficient places to live with old windows, little insulation or energy efficient fixtures. The primary cost of housing is the utility bill, as many seniors own these pre-war homes/apartments. In very convenient locations for seniors

– close to goods, services and social networks – these homes and apartments can have excess space for many seniors since their children have left to start their own households.

Single-family home development has not been non-existent but has been located in more rural com-munities with intergenerational families. Rural housing also has issues of accessibility and mobility as well as location issues since they are away from city centers, goods and services. However, the rural communities though important, are not the focus of this discussion.


Modern Development

New construction over the past decade has created slightly larger units with energy efficient systems and modern conveniences such as lifts, open space and onsite or underground parking, but this construction is target-ing upper-income households and families. Seniors need slight adjustments to the current new models of construc-tion. For example, slightly wider doors to accommodate the use of mobility aids. Electric stoves or hobs instead of gas; grab bars in the bathroom; slightly lower counters and cabinets in the kitchens and more unit storage. Seniors also want open gardening space and an exercise room. All of these amenities are possible in the current development market, but have yet to be utilized for this specific demographic. It is a niche waiting to be filled.

Conclusions

Healthy ageing is dependent to a large degree on autonomy, which essentially reflects the fact that older people have the right to self-determination. Autonomy allows individuals the opportunity for self-realization and development.11 One of the ways seniors can retain their autonomy is by having choices in life, including the choice of where and how to live.

So where do seniors go if they do not live with their families, are not in need of the 24/7 care of nursing homes and are over the income level of eli-gibility for social/public housing? Independent senior housing is the answer. It provides this demographic with housing that is appropriate to their basic needs. Developing this housing creates jobs in both the con-struction and subsequent management and operation of the property. Needed tax revenue is generated for cash-strapped cities and towns to help provide serv-ices. Families are happy because they know that their parents have a safe place to live with a modern unit and common amenities tailored for them. Seniors will be able to maintain their desired independence and not be a burden to their children. They are also with

11 Beggiato, Matthias and Risser, Ralf. “CHANGE – Care of health Advertising New Goals for Elderly People.” State of the Art – Pub-lic Report of Work package No 2. Project Number: 142101-LLP-1-2008-1-IT-Grundtvig-GMP Grant Agreement: 2008 – 3486 / 001 – 001. Sub-programme: GRUNDTVIG – Multilateral Projects. October 2009. p. 80.

their peers, maintaining and potentially expanding their social circles. They will live healthier and longer, staying out of the nursing home community longer, leaving those units available to people who truly need that level of care.

Independent seniors may also use less government social and welfare services because they are healthier longer. The social and welfare systems are already see-ing a strain on use. Developers and investors will be satisfied because they will have full buildings, generat-ing cash flow and returns over the long term.

It is this combination of demographic, social and real estate factors that is driving the demand for independent senior housing. “If you build it, they will come” – Field of Dreams.

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Bibliography

Beggiato, Matthias and Risser, Ralf. CHANGE – Care of Health Advertising New Goals for Elderly People. State of the Art – Public Report of Work package No 2. Project Number: 142101-LLP-1-2008-1-IT-Grundtvig-GMP Grant Agreement: 2008 – 3486 / 001 – 001. Sub-programme: GRUNDTVIG – Multilateral Projects. October 2009.

Błędowski, Piotr and Pędich, Wojciech. (2004) Services Supporting Family Carers of Elderly People in Europe: Characteristics, Coverages & Usage, EuroFam Care, National Background Report for Poland. July 2004, pp. 19-20.

Halicka, Małgorzata and Halicki, Jerzy. (2011) Polish Senior Citizens’ Opinions Concering Old Age and Preparing For It, Polytika Społecznia. Medical, Psychological, Sociological and Economic Aspects of Aging in Poland. PolSenior Project. Social Policy 2011. Nr indeksu 369209, PL ISSN 0137-4729

Matysiak, Anna and Nowok, Beata. (2007) Population Trends – Current Trends. Stochastic forecast of the population of Poland, 2005 – 2050. Demographic Research, 17.11: 301-338. 20 November 2007. (accessed April 27, 2010). http://www.demographic-research.org/Volumes/Vol17/11/17-11.pdf.

Moskowitz, Seymour. (2002) Adult Children and Indigent Parents: Intergenerational Responsibilities in International Perspective Marquette Law Review, Vol. 86, Num. 3, Winter 2002 p. 406. http://epublications.marquette.edu/cgi /viewcontent.cgi?article (accessed June 6, 2011).

Population Projection for Poland, 2008-2035. (2009) Głowny Urząd Statystyczny, Department Badań Demograficznych, Warsawa.

Werner, Witold A. (2010) Urban Development Issues Research Quarterly, Institute of Urban Development, 1, Yearbook VII


KEY WORDS: FRAIL ELDERLY, OBSTACLE-FREE HOMES, MOBILITY, QUALITY OF LIFE, INNOVATION

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International outlook

Europe already has the oldest population in the world and over the next 50 years will experience a continuing rise in life expectancy. However, longer life is not the same as years spent in good health. Even in countries with the longest healthy life expectancy (HALE) such as Sweden, individuals are likely to spend the last years of their life with loss of function and illness when previously unnoticed archi-tectural obstacles appear in their homes. The sharp increase in the proportion of the population over 80 is therefore raising the question of obstacle-free housing in old age also in the EU mem-ber countries. From the early 1990s the HOPE1 (2008) programme, with the participation of Danish, German, Dutch, Swedish and British housing construction entre-preneurs and building communities, has been seeking solutions that enable the elderly to continue independent living in their own homes despite loss of function and poorer health, as well as solutions that ease the task of care for carers in the accustomed environment of the elderly. The ENABLE Age project (2002-2004)2 showed

1 Trends in Housing for older people.

2 Enabling Autonomy, Participation, and Well-Being in Old Age: The Home Environment as a Determinant for Healthy Ageing. Participants: Sweden, UK, Germany, Hungary, Latvia. See also Iwarsson et al 2004; Löfquist et al. 2005.

problems that needs to be dealt with is the question of “Happy ageing in the home and living environment”.

Action research: making homes of the elderly obstacle-free

The solution to dealing with loss of function in old age by making the home obstacle-free was entirely unknown in Hungary. Eldercare belonged largely within the competence of the social institutions, as the Social Welfare Act No. III of 1993 made it a mandatory basic social task for local governments and defined the forms of care to be provided as follows: home help, social meals on wheels, village caretaker service and caretaker service in isolated farm areas. The nursing fee paid to a relative who provided 24-hour care for a disabled or elderly family member was also part of social care. However, because of the low sum of the social benefit very few people undertook continuous care of a family member. Because of the state of their health the elderly also received acute health care provided by the local doctor, hospital or specialist clinic. Home nursing was available for the elderly only in acute cases, as a form of rehabilitation financed by social insurance for 14 days. It was only later, with the amendment of the Social Welfare Act in 2004, as a result of an earlier successful innovative model

that in all countries removal of obstacles in the home and environment of the elderly resulted in greater daily activity, increased independence and reduced depres-sion. Although research has unequivocally confirmed the importance of obstacle-free housing, a study in 2007 carried out with the participation of 13 European countries found that only 1% of the elderly in the EU live in obstacle-free homes. In Germany alone 2.5–3 million people need obstacle-free homes (Stula, 2012). The FUTURAGE project (2009–2011)3 that examined various aspects of old age and made recommendations for the medium term to the EU found that one of the

3 A Road Map for Ageing Research http://futurage.group.shef.ac.uk/. 14 EU member countries, including Hungary, participated in the project.

Elderly-Friendly Housing Model: Results of anAction ResearchZSUZSA SZÉMAN


programme4 that a technical solution, the emergency alarm system was included in the social services as a supplement to home care in the form of home care with emergency alarm system. Society and decision-makers applied the concept of obstacle-free, indirectly via EU regulations and guidelines, to the following: obstacle-free access to public buildings, making the area leading to them obstacle-free, obstacle-free public transport vehicles, and more recently the creation of obstacle-free services and the creation of obstacle-free homes for the disabled, mainly the physically handicapped, and the provision of financial support for this purpose. As a result, making homes for the aged obstacle-free became generally accepted, but making the homes of the elderly obstacle-free was an unknown area. Home improvements for the elderly were understood to mean painting, renovations and improving conven-iences. Even those who really tried to make their home obstacle-free were unable to alter their environment. The necessary approach was lacking, although by then it had appeared in German society, and in Sweden5

there was widespread awareness of the importance

4 The alarm bell model programme (1993-1994) was a joint pro-gramme of the Institute of Sociology and the Hungarian Maltese Charity Service (MMSZ). The MMSZ subsequently undertook the further development and dissemination of the system and also achieved its incorporation into the Social Welfare Act.

5 In Sweden it is the task of occupational therapists to assess the necessary alterations on the basis of a 128-item measuring instru-ment taking into account the physical state and functions of the elderly and the state of the home, and to submit the findings to the local government that finances the alterations.

of the environment and a regulation introduced in 1992 made it compulsory for new housing to have obstacle-free access. One of the important tasks of the 30,000 occupational therapists was to assess the loss of function of the elderly and the obstacle that had arisen for them and to report to the local government on the home alterations that appeared necessary.

However, it was extremely difficult to obtain fund-ing for the Hungarian model programme because of its different approach to the problem. In the end the Ministry of Youth, Family and Social Affairs and Equal Opportunities contributed to the launching of the pro-gramme in 2003–2004. The main goal of the 3-year model programme was to show that frail older people could continue living at home safely and independently despite their changed functions and the deterioration in their health if the obstacles in their homes are re-moved and their immediate environment is adapted to their loss of functions, and that it would have a remark-able cost effective impact on the macro level as well (e.g. in reduced hospital expenditure). The project was funded with a total of 20 million HUF (approx. 78,000 EUR) that was divided into smaller sums (300,000 Ft/1200 EURO) for the alteration of individual homes.

Target group

The action research was aimed at persons aged 75+ who received at least one of the following types of aid: a) home help, b) home care with emergency alarm system, c) elderly persons cared for by a family carer receiving a nursing allowance, mainly persons living alone, or in the case of needy persons, living with one other person. The average age of the persons in the sample was 80 years, the majority were widowed women with a low level of schooling, three-quarters lived alone.

The project used a method based on several pil-lars: mapping the elderly people’s subjective opinion of their own health; a semi-structured questionnaire on safety and accident risks in the home; a home measure-ment questionnaire elaborated by an interdisciplinary team; selection of a sub-sample; technical assessment and on-site inspection of the homes by an engineer; ongoing analysis of the experiences of the alterations; discussion of the problems as they arose; follow-up of the results of the alterations at the end of the first year using a questionnaire developed for the purpose.

In the first year of the model program 20 elderly people were selected in (Budapest), and 20 in a country town (Debrecen). In the second year, 2004 a further 10 persons were included in the sample in each of the two original places and in a new settlement type, a micro-region (Tiszavasvári). In all, the homes of 50 elderly persons were altered during the two years.

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It appeared necessary to include the micro-region because it could be assumed that the problems of removing obstacles in homes in a micro-region would be different from those in an urban environment. The experiences of alterations in the housing types included in the sample in the first year – pre-fabricated housing estate flats, flats in multi-storey city buildings, individual family homes – showed that elderly people face entirely different obstacles in the different hous-ing types and the alterations consequently require different solutions.

Health state of the elderly – obstacles in their homes

Because of the poor state of their health the majority of the elderly were cared for by two persons (in addi-tion to the home help, 40% received care from family members and one tenth from neighbours). Their state of health can be described as follows. One quarter were unable to leave home because they could not step down from the footpath or stairs. Their outdoor mobil-ity was greatly diminished, more than a tenth were bedridden, almost all saw their doctor several times a month, they took an average of 7.5 medicines daily and in the year prior to the interview they spent an average of 16 days in hospital, 15% on two occasions and close to one fifth on three or more. Close to two-thirds men-tioned problems or operations related to eyesight and one quarter to hearing. On average they used four aids:

most frequently aids for bathing (25%), grips (23%) devices assisting use of the toilet (13%), sticks used to leave the home (38%).6

Their health problems were aggravated by the fact that they had lived in the same home for a long while, an average of 29 years, and three-quarters of the homes had been built in the years after the Second World War. The total area of the homes in Budapest was small with few rooms; the homes in the micro-region were larger and had more rooms but generally had much worse infrastructure. There was no mains water in 17% of the homes, one eighth (all in the micro-region) had no indoor toilet and 13% (likewise in the micro-region) no bathroom. Most of the homes in the micro-region were heated individually, with wood, coal or gas, or a combination of those fuels, while the homes in the cities (pre-fabricated housing estate buildings in Budapest) for the most part had district heating. The problem of removing obstacles was complicated by the fact that, although alterations had been made in the room, bathroom or washroom of a few of the elderly in the previous year (2002), these had been restricted to painting, renovations and plumbing but there had been no removal of obstacles, such as eliminating slip-pery floor surfaces or removing high thresholds and consequently these continued to represent a source of

6 Far more elderly people needed therapeutic aids. 40% would have liked an aid to help bathing (because they didn’t have one); 42% wanted something to help mobility within the home; 27% wanted something to help them get in or out of bed and 10% an aid for toilet use.

danger. The majority of the respondents had had a fall in the home, one tenth had frequent falls, 38% more rarely, but it was found that more than a quarter of the falls were due to obstacles in the home rather than to the state of their health. There was a specially high risk of accident when moving around the home or bathing. The elderly persons mentioned many problems in this connection when giving the reasons for falls before removal of the obstacles, e.g. “I slipped after stepping out of the damp bath”; “I slipped on the PVC floor in the kitchen”; “my slipper got caught in the threshold”;

“I slipped on the carpet”. In the micro-region many of the respondents had had falls because of obstacles around the home outside: an uneven garden path, the poor state of the steps leading up to the door, lack of a handrail, in autumn and winter a slippery, icy path to the outdoor toilet.

The number of obstacles and in part also their nature differed according to the rooms. The most problematic room was the bathroom with an average of 4 obstacles identified (in the first phase) and 7 in the second phase when elderly persons in the micro-region were included, although there were cases of 9 and 13 obstacles. The most frequently mentioned were: stepping into and out of the bath, slippery floor; grips, washbasin, taps, light switches in the wrong place. Only 8% of the elderly subjects felt safe in the bathroom. An average of 2 obstacles were identified in the kitchen and a higher proportion of respondents, 17%, regarded that room as safe. In general the hazards mentioned


were the too low or too high work surface (40%!), and the small size of the kitchen (more than 50%), as well as use of the gas stove. One of the major problems in the homes was the difference in levels, most frequently the threshold, the step out to the terrace, and almost everywhere the 60 cm wide doors of the bathroom, toi-let and pantry, the smallest size allowed under earlier standards, impeding use of a wheelchair or walking frame. They were not able to use some of the technical installations in the flat when the “obstacle” was not that the socket was placed too low or too high but that it was not properly installed (e.g. not earthed, bad phase wiring, contact fault caused by rigid aluminium wire). A similar problem existed in the case of the doors and windows: the most typical problem was not the height but rather that they were difficult to open or close be-cause of warping or a broken lock. Other “obstacles” in the same category were switching the lighting (in two out of four cases the lighting did not function). In the village and in village-type houses there were problems in the outside environment belonging to the home: the outdated steps leading to the garden or the street. The obsolete technical state of the homes reflects the general situation in Hungary: the elderly typically lived in obsolete flats in a poor technical state. An obstacle of a different nature arose with the loss of function in the case of the use of heating installations when they were not suitably placed or accessible and considerable strength was needed to turn them on.

The programme examined the activities that caused difficulties for the elderly. On the basis of a three-step scale – causes great difficulty, a little dif-ficulty, no difficulty – the following picture emerged. Shopping, handling official affairs, heavy housework and cleaning represented the biggest difficulty with values approaching 3. The next group, with still high values (2.15–2.4) comprised moving around the home, light housework, cooking, lifting (1-3 kg) and bathing. Getting out of bed, going outdoors, dressing and meals were in the third group of activities causing the least difficulty (1.5-1.75) (Figure 1).

Activities classified in the first group require human resources – carer, family member, neighbour, friend – and in the sample they were performed mainly by the home car-ers and (also) relatives (e.g. cleaning).

At the same time activities ap-peared in the second and in part in the third group that are closely related to obstacles in the homes, because of which they find it dif-ficult to move around the home, do light housework, bathe or cook. Be-cause of the nature of the obstacles already described, bathing involved the greatest difficulty: the grip was hard to reach (50%), its shape was not suitable (20%), it was located

in the wrong place, the taps were difficult to operate, the bath or the edge of the shower was too high, the floor was slippery (half of the elderly), the bathroom cupboards, clothes drying rack, mirror, shelves, toilet paper holder were placed too high/low, the sockets were difficult to use, were too small/big (close to one third). The tradesmen removing the obstacles faced a special problem in the micro-region. The houses had been altered to improve the level of comfort long after the original construction by adding a bathroom and toilet at the end of the building, sometimes as far as 12 metres from the living room/bedroom, and with reduced mobility this distance represented an insuper-able obstacle.

DressingMeals

Going outdoors

Getting out of bed

Lifting (1-3kg)

Bathing Cooking

Indoor mobilityLight housework

Cleaning

Shopping

Heavy housework 2,7

2,62,6

2,552,42,3

2,25

2,15

2,25

1,75

1,65

1,51,6

O�cial a�airs

Figure 1 :: How much difficulty do the following activities represent?

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For this reason some of the most frequently ap-plied solutions for removing obstacles were limited to one room (bathroom, kitchen), while in other cases the same solution could be applied in several rooms, and there were also special cases of removing an obstacle, such as creating an opening in a 12-metre wall. Some of the most typical removal solutions were: replacement of the bath with a shower cabin; moving the clothes dry-ing rack to a more suitable place; installation of simpler taps; changing the placing and form of grips; placing mirrors more conveniently or changing their size; mov-ing shelves that were too high or too low in the kitchen, bathroom; replacing floor coverings; raising low work surfaces or the reverse; replacing door handles, locks; removing thresholds, differences in level; altering kitchen furniture; moving or altering lighting, furniture.

The follow-up investigation made a year after the alterations clearly found a reduction in the number of falls. Despite the fact that the health of many of the elderly had deteriorated, compared to the year before the alterations there was a substantial improvement in the number who did not suffer falls and often were not in need of hospital treatment or care in a home for the aged. In almost all cases there was an improvement or a very big improvement in the conditions for personal hygiene, cooking and meals.

This clearly shows that seemingly minor problems, such as moving a mirror, rearranging furniture, things that require little expertise and are relatively easily

remedied can make life easier and safer for the elderly. More skills are required to remove other obstacles, such as cutting an opening in a wall (structural en-gineering), eliminating larger differences in level, or major interventions in the bathroom (plumbing).

Although the model programme applied exclu-sively to alterations within the home, as a “by-product” in the micro-region obstacles also had to be removed in the external environment because space expands in the case of village-type family houses: the environ-ment outside the home, the steps leading down to the garden are also part of the home and because of the ownership relations it was possible to make alterations there. (In the case of pre-fabricated and multi-storey housing where the flats are condominiums or owned by the local government and permits are required for such intervention, such alterations were not included in the original aim of the model programme.) In the course of the research one element that had not been taken into account in the planning often impeded the removal of obstacles: the state of the housing was an unforeseen problem and planned or already begun work for the removal of obstacles could only have been completed after time-consuming permits were obtained. In these cases a different solution had to be applied. The model programme clearly demonstrated that a positive change could be achieved in the quality of life of the elderly by altering their environment and making it obstacle-free; this was also reinforced by their opinions.

Changes in the lives of the elderly: subjective judgement

Personal hygiene

• “Using the toilet is easier and safer now.”• “It’s best for me this way that I can now use the

bathroom safely, alone, it’s only because I am afraid of a collapse that I don’t dare take a bath.”

• “Using the bath is much safer this way.”• “Washing is easier, I have something to hold on to.”• “It’s much better for me this way to sit while I’m

washing.”• “It’s easier to take a bath, the toilet flushes very

economically.”• “I can step into the bath easily.”• “It’s easier to get in and out in the bath.”

Housework

• “My everyday life is simpler now that the switches and sockets have been changed.”

Cooking, meals

• “Use of the kitchen has become simpler.”• “It’s much lighter, it makes cooking easier and so I

don’t have to rely on others.”• “The kitchen became safer after they changed the

gas stove.”


• “With the new tap I can easily turn on the water with my arthritic hand.”

• “I really needed to have this non-slip floor installed.”• “The kitchen is much safer now.”

Mobility

• “I no longer need to hold onto things now that I have the non-slip floor covering.”

• “The non-slip paving on the terrace and the steps have helped a lot.”

• “The outdoor grip is a really big help.” (family house)• “I have to negotiate three steps and it’s a lot easier now

that the old wooden rail has been replaced with a steel one.” (village-style house)

• “There’s no more risk of accident with the new PVC floor covering.”

• “It’s easier to move around without the thresholds.” (she does not fall)

Feeling of security

• “I can now take a bath alone thanks to the steps and the grip.”

• “It’s easy for me to use my home despite my advanced age.”

• “My life is safer.”• “I wouldn’t have thought that my flat could be made

so safe.”• “I move around much more safely since the grips have

been installed in the bathroom.”

The obstacle-free project would not have been success-ful without taking the opinion of the elderly persons themselves continuously into consideration before and during the implementation because they did not always request the technically most modern solutions that were the best in the circumstances. As a result there were three types of solutions: a. technically modern solutions (if they were accepted by the elderly person); b. solutions adapted to the knowledge and earlier demands of the elderly person but that were not up to date; c. mental help, explaining the technical solution (often a time-consuming procedure). In the course of the alterations it was often necessary to apply solutions in the b. category. (For example, in a number of cases the elderly persons did not want a shower cabin in place of the bath that represented an obstacle, either because they were not accustomed to one or because in the housing estate flats people dried clothing on a frame above the bath and there would have been no place for this after installation of a shower cabin.) In all cases a solution adapted to the given situation had to be found; this is why all the opinions expressed either explicitly (feeling of security) or implicitly reflected an increase in independence and the feeling of security.

Expansion of the action research

The lessons of the 50 homes altered in the pilot phase in 2003-2004 were presented in a book published in 2006 (Széman and Pottyondy). The description of the problems it contains, their schematic presentation and photographs of the actual procedures for the removal of obstacles serve as a guide that can be readily un-derstood and followed. Its estimates of the cost-savings also persuaded the ministry of how effective the obstacle-free house/flat is in eldercare: the incidence of fractures increases with old age creating the need for hospitalisation or placement in a residential home. It was calculated that the relatively small cost of the one-off alteration is only half of the cost of a one-week hospital treatment for a hip fracture and less than half of the cost of a one-year stay in a residential home operated with state normative funding.

As a result of this successful project and the ef-fective former innovative model elaborated by the Hungarian Maltese Charity Service (such as the alarm system), the Service has accumulated trust capital at the macro level, enabling it to obtain substantial fund-ing for a new idea which was not part of eldercare and unknown in Hungarian practice. As a consequence, in 2009 the Ministry of Social Affairs and Labour as the successor to the Ministry of Youth, Family and Social Affairs and Equal Opportunities requested the Hungarian Maltese Charity Service to invite ap-plications for implementation of the project to remove

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obstacles in the homes of elderly persons to enable them to continue living independently longer. Ap-plications were invited from elderly persons over the age of 65 receiving a basic social service. The former 75 + age limit for the pilot programme was lowered to 65 + but there was no change in the other condi-tions, that is, applicants had to be recipients of care and in a functionally poor state. The lowering of the age limit was justified by the poor health status of the Hungarian population as more than half of those over 60 already have one or more chronic diseases. This time funding of 250,000,000 HUF (approx. 1,000,000 EUR) was made available, an average of 400,000 HUF/home (1600 EUR). Within a month 2744 applications were submitted (2421 were valid , that is 5.8% of the care recepients over 65 years). The number of success-ful applicants chosen on the basis of the two sets of data elaborated by the Methodological Centre of the Hungarian Maltese Charity Service (a questionnaire and the evaluation of the texts by an evaluation com-mittee) was over 700. It was found that the applicants came from among the socially most needy and many from the most disadvantaged regions, their fates and life situations were often very disturbing. Often the creation of an obstacle-free home helped not one but two disadvantaged persons living together.

Lessons of the action research

The action research ended with many positive results: the elderly persons in need of care were able to con-tinue living safely in their own homes for a longer time or until the end of their lives and need less help from others. After the alterations of the flats there were no more falls or their number was substantially reduced. There were no fractures so the elderly persons were not in need of hospitalisation or placement in a resi-dential home. It became clear that the removal of a few obstacles at relatively low cost (eliminating differences in levels, providing non-slip floor coverings, changing the level of objects, etc.), met basic needs and resulted in a positive change in the quality of life. The costs of alteration undoubtedly represent a potential saving for the public sphere. The practice is welcomed also under no-public spending. Families of older people, or older people themselves, are glad to have this solution enabling them to continue independent life in their own home. During the implementation there were many calls from families asking for concrete guidance on how they could or should alter homes to make them obstacle-free; some of them were even willing to pay the costs. This shows that families may also have an important role by contributing to costs or convincing older people when necessary of the importance of the alteration in order to continue an independent life.

However, the most socially needy older people who do not have their own funds for the removal of

obstacles will not preserve their independence or can-not live a more independent life. Those at financial risk will be excluded even if they know that the cost of care paid by them in case of a residential home would be much higher (monthly fee and often high entrance fee) than the small cost of the one-off alteration. The public sphere therefore has great responsibility to include frail older people by ensuring funds for creating an obstacle-free environment.

It is very important to learn how an innovative mod-el drawing on research results and ideas, elaborated and implemented by an NGO and with public funding could socially include older people. Furthermore it is also essential to build up trust capital with the general public, including the elderly. During the period of ap-plications (2009), several applicants expressed their gratitude that someone is trying at the level of personal care to find a real solution to the problems that affect them on a daily basis. Trust capital based on earlier collaboration between the NGO and decision-makers also insures that even local decision-makers take a positive attitude towards the model. The NGO is able to convince local policy-makers to expand the practice. The latest example of this is the invitation for applica-tions announced already in 2011 and again in 2012 by a county seat (Municipality of Gyôr) on the basis of a contract signed with the Western Transdanubian Region of the Hungarian Maltese Charity Service for improvement of the living conditions of elderly persons by making 16 homes obstacle-free, with a budget of


5,000,000 HUF (approx. 18,000 EUR). The practice pointed beyond the mandatory services set out in various acts and regulations, and expanded the possi-bilities of the institutional system serving the elderly by elaborating a suitable method and guidelines described above and has means of dissemination for expansion of the practice. Creating obstacle-free homes/flats may have an impact on the labour market too. The build-ing industry is one of those hardest hit by the global financial crisis, many people have lost their jobs in the past few years and creating obstacle-free homes/flats could translate into jobs in the building industry and reduce unemployment. The innovation in its present form is suitable for incorporation into long-term care. Refinement of the practice (with the inclusion of new housing types) could be based on the outcome of the latest follow-up.

Literature

ENABLE-AGE (2002-2004). Enabling Autonomy, Participation, and Well-Being in Old Age: The Home Environment as a Determinant for Healthy Ageing. http://www.enableage.arb.lu.se/pub.html

FUTURAGE (2009-2011). Road Map for Ageing Research http://futurage.group.shef.ac.uk/

HOPE (2008). HOPE (Trends in Housing for older people). Conference Report. Copenhagen. (1-82)

Iwarsson, S., Oswald, F., Wahl, H.-W., Sixsmith, J., Sixsmith, J., Széman, Z., & Tomsone, S. (2004, July). Home and health in very old age: New perspectives on an old topic? Abstract, IASP Conference, Vienna.

Ch. Löfquist, C. Nygren, Zs. Széman, S. Iwarsson (2005), Assistive devices among very old people in five European countries, Scandinavian Journal of Occupational Therapy, pp. 1-13.

Stula, Sabrina (2012). Wohnen im Alter in Europa- aktuelle Entwicklungen und Herausforderungen. Arbeitspapier Nr. 7 der Beobachtungsstelle für gesellschaftspolitische Entwicklungen in Europa. Bundesministerium für Familie, Senioren, Frauen und Jugend. Deutscher Verein für öffentliche und private Fürsorge e.V. :Berlin.

Széman, Zsuzsa; Pottondy, Péter (2006). Idôsek otthon. Megszokott környezetben, nagyobb biztonságban. [The elderly at home. In their accustomed environment, in greater security] Magyar Máltai Szeretetszolgálat Egyesület-Magyar Tudományos Akadémia Szociológiai Kutatóintézet: Budapest.

http://www.maltai.hu/data/nodes/5/file/Idosek_otthon.pdf

http://www.enableage.arb.lu.se/pub.html

http://futurage.group.shef.ac.uk/



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KEY WORDS: INFORMATION AND COMMUNICATION TECHNOLOGIES (ICT), ELDERCARE, RESEARCH AND DEVELOPMENT, QUALITY OF LIFE, AAL JOINT PROGRAMME


Introduction

A few characteristics of the ageing soci-ety relevant to the theme are: a rise in life expectancy at birth, the appearance of ever larger cohorts of the elderly and an increase in the number of elderly persons living alone.

Nowadays more and more elderly persons are obliged to live alone, in part because of the changing family struc-ture (increase in the number of one-person households). A substantial proportion of those who find themselves alone in old age cling to this way of life (preferring to live alone) as they wish to preserve their independence

– even in spite of the difficulties that arise. We generally understand independent living to mean performing simple everyday activities independently. However, independence is often curtailed, most frequently due to the decline in general cognitive and physical capac-ity that often accompanies ageing making it difficult or in cases impossible to perform everyday activities independently, although there are great individual differences. This can lead to growing dependency of the elderly person who becomes reliant on external support of a care and nursing nature. If the elderly are unable to maintain independently the way of life they have created for themselves and conduct as they wish, in addition to the obvious and direct negative impact

elderly are able to maintain relatively autonomous liv-ing and a satisfactory quality of life. The rapid spread of advanced multifunctional devices able to communicate with each other on the internet or mobile networks (mobile phone, computer) and the way in which they are used (e.g. “web 2.0”) is opening new perspectives in society and it is expected that, among others, they will be the source of innovative solutions in improving the quality of life of the elderly. In this context numerous R&D projects examining these possibilities and seek-ing an answer to these challenges are under way, for example, in the EU countries.

The aim of the project called “A Home based APProach to the Years of AGEING”, known by the ac-ronym “HAPPY AGEING” (referred to here as “HA”), supported by the EU and the NIH2 within the frame of the AAL JP programme3 and with the participation of several countries was to develop an ICT device system able to support the elderly in independent everyday living. The HA integrated system contains three main elements: 1) lifestyle monitor: monitors the daily activi-ties in the home and compares them to the user’s habits, intervening in case of need (e.g. by alerting carers in

(2004) that its use became widespread. Since then the state fund-ing for the emergency alarm system has been changed, the sums allocated for the purpose have been reduced, the institution of normative support has been ended and transformed.

2 National Innovation Office

3 Ambient Assisted Living Joint Programme

this has on their quality of life it can also undermine their self-esteem, bring uncertainty into their lives and create numerous other problems on their subjec-tive well-being and quality of life. One of the most negative scenarios for the elderly occurs if they are no longer able to live in their homes – an environment to which they are generally strongly attached – even with external support, but are forced to move, to live with relatives or into an institution (Kucsera, 2008).

One line of solutions compensating for the decline in cognitive and physical capacity and improving the quality of life is the use of infocommunication technol-ogy (ICT) devices to support a way of life1 in which the

1 The use of ICT devices for this purpose is not without precedent in Hungary either; an emergency alarm system, for example, has been in use for over a decade although it was not until the early 2000s and the introduction of a system of normative state funding

Improving the Quality of Life of the Elderly with ICT – Resultsof an R&D ProjectCSABA KUCSERA

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case of serious anomalies); 2) device to aid navigation: helps the user to move around the immediate environ-ment; 3) personal assistance: a) with reminder solutions (e.g. when to take medicines), b) solutions helping to find objects.

Overview of the project, the problem raised, technological answers

Seven institutions from 5 countries participated in the HAPPY AGEING R&D project4. The project ran from April 2009 to August 2011 and its aim was to create the prototype of an ICT device system that could provide effective support primarily for elderly users living alone with a quality of life curtailed as a consequence of a chronic reduction of cognitive or physical capacity. A key element in this R&D project was the continuous involvement of the elderly – as potential users – in the development of the device, mainly in the research phases of the project.5

4 The institutional leader of the R&D consortium was the Italian INRCA (National Institute of Health and Science on Aging) and the individual leader was Fiorella Marcellini. The HAS Institute of Sociology took part in the project as the Hungarian consortium partner led by Zsuzsa Széman.

5 In this paper I give an overview of the main results and lessons of this series of research activities. I shall not go into details of the complex technical parameters or the development technology solu-tions of the HA device.

The HA device system consisted of the three main modules already mentioned; their main functions and contribution to improving the quality of life of the elderly can be summed up as follows.

“Lifestyle monitor”: the aim of the module is to monitor the user’s everyday activities in a non-invasive way, and to detect and assess if it observes any unusual or probably abnormal deviations. For this the device has to be able to record for days and weeks in a self-learning way the different elements of the user’s lifestyle (e.g. the average time spent in the bathroom at a given time of day), then, in active mode, to compare the stored typical lifestyle pattern with the actual behaviour. If, for example, the user spends substantially more time than usual in the bathroom it is possible that she has collapsed or had an accident (e.g. she has slipped and cannot stand up alone or call help). If the device identi-fies the given situation as a danger situation and the user does not deactivate the delayed automatic alarm when requested to do so6, the device can then call for help, for example by sending a text message. The person entered into the device to receive the text mes-sage (e.g. neighbour, relative, carer) is specified by the user. The device monitors the following activities: 1. meals / cooking (whether they occur at the accustomed time); 2. fluid intake (drinking: quantity and timing, if necessary the user is warned of the insufficient fluid

6 It uses a light and sound signal to ask the user whether everything is OK; if there is no response it can send an alarm, but the user can also halt the countdown.

intake); 3. movement (whether there is any movement in the home); 4. medication (whether the prescribed medicine is taken at the specified time); 5. perception of falls (with a detector that can be worn on the wrist).

“Navigation assistant”: the primary aim of the module is to help the user navigate around the home and the immediate environment by showing the current position on the map fed into the system and the route leading to the destination. The hardware is a PDA (personal digital assistant) together with an RFID reader, using software developed by the team. The user obtains the route by reading the orientation points placed at salient spots in the home (information stored in RFID tags) and entering the destination.

“Personal assistant”: the aim of the module is to provide support for the user in the following daily activities: 1. finding important objects in the home environment (it shows on the map of the home – fed into the device – the location of objects provided with small RFID tags); 2. remote switching of electrical household appliances; 3. phone calls to carers and other important persons initiated by the user (simpli-fied call by touching the image of the contact person on the touch screen); 4. monitoring whether the user is preparing to take important objects with her when she leaves home (e.g. medicine provided with RFID tag, keys, etc.).


The main elements of the prototype of the device entering into mutual interaction with the user are a PC, a touch screen connected to it, and a PDA. Peripherals supplementing the system include an RFID reader, motion detector, CO sensor, temperature sensor, remote-controlled electric switch, and similar devices. The elements of the system communicate with each other via a network of ZIGBEE wireless sensors, and in addition the system is connected to the internet.

Data recording steps, the user’s feedback in the development

The potential users are persons at least 65 years old, with reduced cognitive and physical capacity, living alone or spending most of their time in the home envi-ronment alone, who actively participated in the whole process of development. The research was conducted in three countries, the Netherlands, Hungary and Italy7. It began with a survey by questionnaire of 180 persons (the combined total for the three countries, the average age of respondents was approx. 76 years), followed by in situ trials of the actual prototype with the participation of 15 persons (combined total for three countries). Interviews by questionnaire were conducted before and after the trial and in one week of the test period fieldwork using largely ethnographic methodology was conducted.

7 The research findings presented here are based mainly on the data survey conducted in the Hungarian sample and its analysis.

The following is an overview of the more interest-ing results and experiences and / or those most likely to be of use for other researchers.

Some interesting problems of the early research phase

The early surveys threw light on a few findings that may perhaps be specifically characteristic of the target group, and also provide more general lessons, pointing beyond the concrete HA device.

The first such finding was the mistrust shown by the elderly towards the researchers. This is partly due to the fact that the elderly consider themselves as potential victims at greater risk of certain crimes (theft, robbery, fraud, etc.), and are therefore very cautious regarding any contact. This is especially true for a project such as HA where the data survey was carried out in the home environment and it was indispensable for the operation of the device, for placing and tuning the sensors, to measure and draw a plan of the apart-ment precise to a few centimetres. Besides feeling that their physical safety and assets were at risk, an-other source of their mistrust was sensitive questions concerning their personal data. The data recorded electronically by the sensors and used by us in the development, questions regarding the habits of the eld-erly (concerning, for example, sleep, meals or the times they left the apartment), as well as information on sick-

ness and medication are all sensitive data of a highly personal nature. To win trust it was therefore essential to involve a mediating organisation, the Hungarian Maltese Charity Service (MMSZ) that the elderly fully trusted. We asked clients of the organisation’s home care service to take part in the research. Armed with a letter of recommendation from the MMSZ we had no difficulty in achieving a relationship of trust. Naturally the principles of data protection, the measurement and data storage were made transparent, and the elderly were informed of this, but it seemed to be the mediat-ing organisation they knew and respected that really convinced them.

Another interesting problem concerns the aver-sion of the elderly towards ICT devices. Our survey by questionnaire conducted in a small sample in the specific target group showed that there is a striking group within this age group – comprising the oldest persons with the lowest level of education and the most socially isolated – who have a fundamental aversion to modern ICT devices and are reluctant to have high-tech systems operating in their home. But at the same time, in more general research on larger representative samples on the spread of internet use in the society it was found – and this applies not only to Hungary but also to other EU member countries – that the elderly are lagging behind the younger age groups (Dombi,

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Molnár, & Kollányi, 2009)8. A similar generational “lag” could be observed earlier in the case of mobile phones9. The digital gap is a real phenomenon and age is one of its best indicators. However, it is worth taking into consideration two things here that do not rule out from the outset any justification for ICT developments aimed at elderly users.

Firstly, older people are still becoming users of the internet and ICT devices and even catching up in this respect. This is due to two factors. The general expansion and deepening of the spread and borders of the information society has an influence on them too; a growing number of services are targeting the elderly in particular and there is a steady growth of contents intended for this age group; more of them have themselves become content producers; internet use has become relatively cheap; with the spread of new gadgets, the family’s old computers are often passed on to elderly members; the use of certain communication software for contacts among family members is spread-

8 It is typical of the situation that such research often regards the 50+ age group as old (compared to other surveys and categorisa-tions the biological age limit is set very low; for more details see: (Széman, 2008)), and they generally do not take into account further age-based / generational differences within the 50+ age group. An encouraging exception in the recent past was the ITTK research on “Challenges of the ageing society”, the results of which were published in Információs Társadalom, 2009, vol. 4.

9 This generational imbalance has probably been reproduced and the generation gap widened with the appearance of smart phones and the services they offer.

ing, etc. It can perhaps be said that we have already passed the innovation tipping point (Gladwell, 2007) among the elderly too.

Secondly it seems likely that the device we developed and other similar developments will gain widespread acceptance when one generation younger than today’s “target group” reaches the age of target group status. This still younger generation has a much stronger and more striking use of ICT devices and will naturally carry this experience with them into old age. They will very probably show less aversion to devices of the HA type, because they have been accustomed to using ICT devices and ICT-based services.

Some people are worried about having sensors in their home that can provide real-time data about them. Aversion to a device that relays images and sound somewhere, to someone from the user’s home is entirely understandable. However, a few people show aversion not only to solutions that clearly and unacceptably violate privacy but also to solutions like the HA device that does not record and does not relay either images or sound. The HA device “only” monitors the user’s behaviour indirectly (e.g. opening doors, the user’s movement, whether medication has been taken and when, etc.), compares this to the user’s “normal” (usual) behaviour pattern and evaluates the results. It transmits data (e.g. in the form of a text message alarm) if the need for external intervention arises. But it is definitely important to explain clearly to the user how

and in what cases information is forwarded and made accessible to others, as well as the threshold limit for such alarms.10

However, there are potential users who are reluc-tant to accept any kind of observation or monitoring; for one person it brought to mind the phone tapping and secret surveillance carried out in the period of state socialism and for this reason she would definitely refuse to use a device of this kind. The use of such a device would certainly not represent an alternative for them, or at least they would not be among the early adopters.

Their aversion could be overcome if, for example, they saw the device in operation in the home of an ac-quaintance, and especially if they saw its positive ben-efit in the life of another user. Those who show aversion to the device for some reason – for example, because of the “surveillance”, or because they are averse to ICT devices in general, or because they thought that they have been managing without it and will not need one in the future either – could be convinced if an event were to occur within their network of social connections demonstrating the positive benefit of the device. In the course of the interviews several participants were able to mention examples of acquaintances who could have benefitted from such a device, for example in the case

10 At the same time the elderly do show an affinity for the idea of remote diagnosis that is to a certain extent related to the problem discussed here. According to the analysis by Andrea Gyarmati more than a fifth of the elderly (50-75 years) would be interested in remote diagnosis (Gyarmati, 2009).


of an accident in the home that made them immobile and unable to call help. Those who knew of such a situ-ation first hand therefore found it much easier to place a device of this kind into their own circumstances and to imagine its direct and immediate benefit in improv-ing their quality of life. Putting this phenomenon in more general terms, the integration of the device into a social context could help its dissemination. In our case the physical scene and background for such integration was the club operated by the MMSZ, providing day care for elderly persons. This constituted an informa-tion hub where elderly people visiting the club could exchange information with other club members (in a similar life situation), such as their experiences of emergency situations. The experts operating the emer-gency alarm system (an early ICT device) reported a similar phenomenon. A typical entry scenario was when elderly persons had such a system installed after they had heard from “an acquaintance in the street” or the friend of a friend how beneficial the alarm system had been. It is important to see that it was not the “ob-jective state” of the elderly person ordering the service that had changed in such cases, but their sense of being at risk may have increased, or parallel with that they came to see after such an event that the alarm system could have a place and be useful in their own lives too.

Besides acting as a catalyst in this way, the social inclusion could help the spread of the device in other ways as well. Relatives and carers can provide the elderly with practical support and information. In case

of need the elderly can count on advice (and support in operating the device), especially from younger family members who generally have better knowledge of ICT. They can also receive big help in defining the device from family members and carers who are generally the most familiar with the user, with his or her individual situation and special needs. They are able to explain the often abstract instructions of the service requiring familiarity with ICT, translating them into language the user can understand, and place the device in the user’s life. Relatives and carers can also help in obtaining the device with support or a contribution of a financial nature.

A few of the users saw the danger of creating a kind of social trap through the use of the device. This conclusion was reached by a few of those who find it difficult or impossible to leave their homes and for whom regular visits by the carer are an important opportunity for personal meetings with people. The fear is that if the device is able to substitute or take over, at least in part, the activity of the carer there would no longer be a need for the carer to make such frequent personal visits and this would deprive them of the human relations side of the care visits (e.g. direct emotional feedback, bringing “news from the outside world”, etc.).

Building up the system andthe user interface

We collected direct feedback from potential ageing users on the most important development steps. In practice this concerned principally elements of content (e.g. logic and clarity of the menu system) and form (e.g. the form and colour of the individual elements) of the graphical user interface (GUI), and was quite HA-specific. But here too we were able to record a few more generally applicable experiences that I will share after I have described the essential elements of the system, in part together with the experiences of the in situ trial.

The HA device runs on two pieces of equipment: a fixed central display unit (DU), which in practice is a PC running on Windows with a touch screen (where the menu points could be selected with a touch of the finger, moreover in one case the PC was not a separate unit but was built into the screen case). The other piece of equipment is a portable device (personal unit), that gives the user greater freedom to operate the majority of the functions from any place. This portable unit was a PDA that communicated with the central PC over a local radio frequency (Zigbee) network. A graphically very similar menu system ran on the two devices. The system has various sensors as peripherals, that typi-cally communicate with the central unit via the Zigbee network:

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– a scale to measure personal water consumption that operated by monitoring changes in the weight of the water bottle (quantity and time);

– electric socket that measured electricity consumption at local level and could be used for remote switching of the electricity service;

– a big RFID reader monitoring medicine consumption, the RFID-tags were placed on medicines stored in their original packages (it is not unusual for elderly persons to take 4-5 different medicines regularly) in such a way that the individually programmed tags were placed on one side. The device monitored from the reader which medicine package was moved for at least 30 seconds (indirectly indicating that the medicine had been taken);

– temperature sensor, monitoring temperature changes in the kitchen (indicating that food was being pre-pared or heated);

– sensors of the mobile transmitter and its signals, placed in 4-5 different places in the home, to deter-mine by triangulation the precise location of objects provided with a transmitter, and display this location on the layout plan uploaded individually;

– door-opening sensor fitted on the refrigerator to detect behaviour indirectly indicating meals;

– motion detectors to detect typical and atypical (and possibly abnormal) patterns of movement within the home;

– RFID tags as points of orientation and to operate the “voice instructions” function.

The majority of users preferred contrasting colours in the menu system (the icons were dark blue picto-grams on orange buttons), although it appears to be a good idea to supply the final device with skins offering 1-2 extra colour combinations (e.g. black pictogram on a light grey background) so that users can customise the device to suit their taste or perhaps their percep-tion (sight) capacity. The elderly were also divided over the relatively large monitor of the central unit: some preferred the orange version while on such a large scale others preferred the less showy grey-blue version. The orange version was the clear favourite for the smaller screen of the portable PDA unit.

The icons designed by graphic artists proved to be easy to use and readily understandable for the elderly. There was a problem only with one and that case is a good illustration of the cultural difference that characterises the perception and cognition patterns of the elderly, in this particular case based on personal life history experiences. For a few elderly people the icon for the navigation assistant resembled the “Ar-row Cross”, the symbol of the late Hungarian fascist party, evoking bad memories of the war years. The icon consisted of arrows pointing in four directions, the dif-ference compared to the Arrow Cross was that they did not meet in the middle. There was a generational and cultural difference between the functional approach of the relatively young graphic artists and the associa-tions of the elderly who lived through the Arrow Cross

terror.11 In the end this icon was replaced, the new version resembles a compass and the four points of the compass are suggested in a different way.

Lessons of the in situ trial

We approached four women and one man to participate in testing the device in their own home environment. They all had at least one chronic illness (lung disease, cardiac problem, Parkinson’s, balance problem), but their cognitive status was suitable (tested with the

“CODEX” test), and their sensory functions were good, apart from a moderate degree of hearing impairment in two participants. They all lived alone in their own homes, and because of various functional problems they all used the home help service of the MMSZ. Two of the participants used aids for mobility outside the home (a stick, rollator), and two could only go out if they were accompanied by someone to support them (a family member, professional carer, etc.), but going any distance away from home was a big challenge for the others too. Nevertheless, even with these limitations they managed relatively well alone at home, and they wanted to continue this form of living alone even if they used external help (formal and informal carers) to maintain their quality of life. Some had an extensive network of informal supporters (relatives, acquaint-ances and neighbours), but there were others for whom

11 Naturally, this association arose only in Hungary, not in the other two test sites (in the Netherlands and Italy).


the professional carer was practically the only support available.

Two of the participants were qualified skilled work-ers and three had tertiary qualifications, but they were all retired. They all had a PC with a mobile internet connection that the MMSZ had lent them just under a year previously. They were not very experienced users, but they were able to use e-mail and SKYPE, two were even able to do simple word processing tasks, but none of them were able to install and configure software (e.g. adjusting the settings to meet their personal require-ments).

Before setting up the device we collected data on the 5 users participating in the trial. We obtained information, among others, on their health status, their medication patterns (what medicines they take regularly and when), their use of therapeutic aids, the phone numbers of the acquaintances they called most frequently, photographs of those people, and a layout plan of the home with measurements. These data served to customise the device to the person and place and were fed into the device before it began operation.

Unfortunately, one of our potential participants lost patience during the process of installation, becoming nervous and slightly confused. We agreed to leave and complete the installation the following day, but when we returned he withdrew his declaration of approval, consequently in the end we tested the device with only

4 persons in Hungary as there was not sufficient time to select a new participant. The users’ frustration must have been serious or at least is was something that nei-ther they nor we foresaw, because they looked forward to installation of the device with a basically positive attitude, and they did not expect that it would take so long (and to a certain extent we did not either, the delay was caused by difficulties with the communication flow among the development teams).

The users looked forward with great interest to installation of the HA device and compared to this they were disappointed by its relatively limited usefulness, the imperfect and unreliable working of the functions. The users were fully aware that we had asked them to participate in the development of a prototype, they were not receiving a mature device for use, but its tech-nical content (the current state of its development and relatively rudimentary state) only became clear to them in the course of the trial. We undertook to provide con-tinuous support for the device, but compared to other devices already available on the market the prototype did not have user-friendly comfort and control functions and as a result the users felt considerable frustration.

Because the funding we received was not sufficient to develop entirely new hardware elements, most of the hardware elements of the prototypes were not developed specifically for the requirements of the HA device, but were based on more general-purpose ele-ments available on the market.

It was not easy everywhere to find space for the central unit (in practice a PC in a separate case with a separate touch-screen), and although a final version to be launched on the market could have a PC with a touch-screen in the same case requiring much less space (we had one such unit), the space required was more of a counter-argument for potential users when judging use of the device. It is not easy to introduce a new element into the appearance of a home; a screen can represent a different or even conflicting style to the interior design, something that could disturb women in particular.

After installing the device, we taught the users how to operate it. Some relied only on their memory but others made notes during the instruction. Operation of the system did not cause any great problems for the users during the test week; in general it took a day – not spent with continuous use or tries – for them to become familiar with its use.

There were users who at first enjoyed the test, but as fewer elements functioned (problems arose with the stability of the system, with the life of the batteries used in the peripherals, etc.), their frustration grew. The attitude of others towards the device took the opposite course: at first they had reservations about it but as they gradually learnt how to operate it their user experience became increasingly positive. But on the whole their constructive attitude is best summed up by the slightly ironic remark made by one of the users:

“at least the device has stimulated my sense of humour”.

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Interestingly, they did not find the presence of the device intrusive, it did not “disrupt” the harmony of the home environment, or at least not in a disturbing way. Over the longer term – not for a week-long test, but designed for prolonged use – the expectations for the device could be different because it is possible that they could tolerate something for a week but find it disturbing over the long term, although this could be counterbalanced by finding a more suitable place for it rather than just a temporary one.

I shall mention problems concerning only two of the device’s services that concern problems of the basic concept rather than shortcomings or imperfec-tions in the concrete development. One was that the problem of measuring other fluid intake was a chal-lenge for the water consumption measurer (e.g. water drunk directly from the tap, or soup during the meal); or the widespread use of plastic pill boxes in contrast to the present solution of the medication monitoring function.

The impact of the system as a whole on the qual-ity of life could only be measured in general terms; it would be more correct to say that “it could be felt”. There were many reasons for this. The device was not at a sufficiently advanced stage of development for this to be measured realistically, and the test situation basi-cally focusing on feedback needed for the development was also a factor. It is important also to be aware that the HA device being tested was not configured to meet

the individual and direct support needs of the elderly persons testing it; in this sense it was not customised.

One of the main (and most obvious) expectations of the HA device is that it should increase the user’s feeling of security and reduce the stress that can be caused by uncertainty and a feeling of being at risk in elderly persons living alone with at least one chronic illness. During the test week use of the device did not increase – and as I have already noted, could not have increased – “unequivocally” and “to a great extent” the users’ feeling of security, although two of the users did feel that, despite the imperfect functioning, it did increase their feeling of security to some extent and gave them a kind of back-up support.

But seen from another angle – as an incidental effect – two participants expressed their pleasure at having been able to take part in the test, at being able to help in creating something new. Their self-esteem was increased by what one of them expressed as feeling that he was “not yet so senile” (referring with self-irony to his forgetfulness) that he could not learn to use such a device.

It could be an important consideration in the future, if the device is to be launched on the market or used as a basis for a more complex service, that family members should also become familiar with its use. Family members will only be truly reassured and trust the device if they are familiar with its operating

principles and know what it can be used for and what it cannot. In addition, their supportive attitude can be an important factor in buying the device and in shaping the user’s experience. It is also an important consideration that it is principally family members or other persons familiar with other areas of ICT who could help the elderly with technical assistance should a question arise during use of the device or in case of a more complex task, such as entering into the system the name of a new medicine and the times at which it is to be taken.

An important observation made spontaneously by the participants at the end of the test was that the de-vice would not be able to replace live human contacts. This remark is interesting because we, who came into contact with them as researchers or developers, did not promise and it was not implicitly in the functions of the device that it could in some way substitute for human relations (only that it facilitates maintaining contacts by making it easier to make a phone call). It can take over certain elements of care, but it cannot replace the “most human factor” of care, psychological and emotional support. The remark can probably be regarded as a manifestation of the fear that the device could isolate its user from other people, and shows the exceptional importance of such emotional support.


Conclusion, the wider context of the experiences and its relevance

The first element of the conclusion places the results in a wider, international context. However small the sample of our investigation, there was no substantial difference between the different test sites in the subjective evaluation of the device. We were not able to identify distinctively Italian, Dutch or Hungarian users’ opinions or record characteristic interpretations of the service. This is an important message regarding the universality of the device, namely that we were unable to identify “east-west” differences at user level, at least not with the tools we used.

Another important finding of the research was that the device is not so complicated that elderly people who lack real user experience with ICT devices could not learn to use it after a day of use on the average. This finding is especially important because there were fears that the generally low level of skills of the older age groups would be a serious obstacle to the usefulness and spread of the device.

The fact that it is easy to learn how to use the device is welcome news. Especially if we consider that the final product would necessarily have product sup-port (instructions for use, helpdesk), that would make the operation and use problem-free and even easier. It has also been suggested that a control centre could be set up for its operation to give technical support in

addition to the necessary intervention protocol (in case of emergency).

However, the test of the prototype was not without problems. There were problems in all the test places that could be attributed to the imperfection of the prototype, and that caused frustration in the users. Most of the problems could be remedied relatively easily, and this would considerably improve the user experience.

The test confirmed our awareness that the device could be really successful if it can be customised to meet a very wide range of individual requirements even in varied environmental conditions. It is possible over the long term that there will be a need to create service packages containing only certain modules of the HA device because the user does not need them all.

Literature

Dombi, Gábor; Molnár, Szilárd; Kollányi, Bence (2009). E-Befogadás Magyarországon. Éves jelentés, 2008 [E-reception in Hungary. Annual report, 2008]: Inforum.

Gladwell, Malcolm (2007) Fordulópont: ahol a kis különbségekbôl nagy változás lesz [The Tipping Point: How Little Things Can Make a Big Difference], Budapest: HVG

Gyarmati, Andrea (2009). Az aktivitás szerepe az IKT idôskori felhasználásában. [The role of activity in the use of ICT in old age] Információs Társadalom, IX(4): 32-48.

Kucsera, Csaba (2008). Egyedülálló, idôs budapestiek szubjektív életminôsége [Subjective quality of life of elderly Budapest residents living alone]. Unpublished Dissertation, ELTE, Budapest.

Széman, Zsuzsa (2008). Ki az idôs? - Az öregedés különbözô szempontjai. [Who is old? Various criteria of ageing] Esély, 19(3): 3-15.

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KEY WORDS: FRAIL OLDER PEOPLE, LONELINESS, INNOVATION - ICT, YOUNG VOLUNTEERS, INTERGENERATIONAL RELATIONS


The role played by technology in elder-care was already the subject of research projects in the early 1990s (COST A5), and these made it possible to elaborate model programmes in Eastern Europe and integrate them (e.g. Zivot 90 in the Czech Republic, the alarm system in Hungary). As a consequence of the strong ageing trend, infocommunica-tions technology helping the life of the elderly has appeared in EU policy on the elderly (ICT & Ageing, www.ict-ageing.eu). The EU places special emphasis on devel-opment projects based on modern technology (AAL-JP programmes), on research related to eldercare and ICT (Mollenkopf et al. 2010), and on research regard-ing the carers (CARICT 2011). In Canada and the United States too, the connection between eldercare and technology is a key research area (Marziali 2004; Marziali 2005; Chiu et al. 2009). One of the most important questions in such investigations concerns effectiveness. The innovation studies supported by the EU seek effectiveness indicators, figures that can be translated into fiscal terms, wishing to demonstrate the cost-savings effect. At the same time, it is difficult to express in figures “young” or innovative solutions still at model level, to produce tangible proof. The goal to be attained, preventing the social exclusion of the elderly through the use of technical innovation, cannot always be shown by quantitative means because of the novelty

poor: despite the improving trend the level of infocom-munications skills of the elderly is still very low. In 2007 10% of those aged 65-74 years used a computer, in 2008 this figure was 20% but barely more than 5% used the internet (KSH 2009a, 55, 58). Numerous programmes designed to help healthy elderly persons learn to use the internet, such as Kattints rá nagyi (Click on it Granny!) and Folytassa nagyi (Carry on Granny) are bringing improvement. As a result, elder persons already using the internet had the same level of internet skills as young people, they are catching up to them (KSH 2009a, 60).

However, the majority of those receiving care of some kind, especially long-term home care, have no experience with computers or the internet. Conse-quently, they are not familiar with Skype either, as a form of communication serving as a substitute for personal meeting. The basic hypothesis of the research was that if use of an infocommunications means that is already widespread among young people were to be incorporated into the life of older persons requiring long-term care, who feel lonely, or are depressed their activity and customs would change and their daily time schedule would be different. At the same time family carers would be supported as the increasing activity of older people would ease their care burden too. By keeping in touch via Skype the earlier network of contacts of older people could be maintained or even expanded. The difference between the generations in infocommunications skills could be reduced, and as a

of the solution. The Skype Care intervention research presented here ended in 2011 and its effectiveness is difficult to measure statistically or financially, but even without figures its results are already instructive and striking, the experiences can be easily adapted and applied in practice. The findings of the action research are especially important in the light of the infocom-munications skills of the Hungarian elderly.

There is already an extremely wide gap between the infocommunications skills of the 55-74 years age group in the countries of Northern Europe and those of Southern and Eastern Europe (Tošnerová and Zvonícková 2006).1 The figures for Hungary are very

1 Percentage of population age 55-74 with no basic computers skills in 2005 e.g.: Greece 93%; Lithuania 90%; Cyprus 88%; Italy 87%; Latvia 83%; Poland 81%; Slovakia 73%; Austria 67%. While the fig-ure for Luxembourg is 45%; Iceland +36%; Norway 27%; Denmark and Sweden 27%.

Skype as a Means of Integrating Older People in Long-term Care: an Action Research ZSUZSA SZÉMAN

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result the elderly would feel less isolated despite their poor health. Their passivity caused by the need to rely on others, lack of mobility, lack of purpose and isola-tion could be transformed into activity. In this way, by rectifying their lack of infocommunications skills they will be capable of preventing their own social exclusion.

Initial difficulties of the research

The seemingly simple task of obtaining computers for those in the intended sample came up against major difficulties. No research funds were available and the prejudice in society made it almost impossible to find other sources: people are convinced that a digit-ally illiterate, elderly and sick person receiving care is incapable of learning to use a computer, as many elderly people even have problems with mobile phones. Because of this prejudice, companies with a stock of computers and a sponsoring budget thought the idea was ridiculous and would not support an experiment with a doubtful outcome, especially one that they considered held no prospect of being able to win a new consumer segment. Without funding, state institutions had to be ruled out. Finally a small firm sensitive to the problems of the elderly, and the Hungarian Maltese Charity Service (that had previously directed numerous model programmes) undertook to procure the computers. Then another difficulty arose: the costs of internet connections. The big internet service provider and potential sponsors rejected a request for a

one-year internet subscription (for the duration of the programme), although the sample comprised only 15 persons and the monthly subscription fee would have been very small. In the end the problem was solved: the Hungarian Maltese Charity Service made its mobile internet connection available. After these difficulties that lasted for a year and a half, the action research planned to run for one year began in December 2010 (in Budapest) and January 2011 (in the county seat).

Sample, place

The criteria of the sample were: elderly recipients of home help/care

• receiving mental care (conversation) and/or physi-cal care (personal hygiene, basic nursing, shopping, medication, delivering or giving food, handling administrative affairs, etc.);

• having limited outdoor mobility; • having family members, family carers; • suffering loneliness and/or depression. Out of the

sample of 15 persons two older persons had made earlier suicide attempts (once or more times), and one was an alcoholic.

• no computer skills. This was considered as an impor-tant condition.

The sample included one person who became a care-recipient as a result of caring for his wife. The research was carried out in the Hungarian capital (Budapest,

ten persons, home care/help recipients with emergency alarm service provided by in the Hungarian Maltese Charity Service) and in a county seat (Székesfehérvár, five persons of the home help/care centre provided by the local government). The average age was 82 years, the majority of participants were women. The sample included two former blue-collar male workers (miner/boilerman, TV repairer), the others were white-collar workers (with secondary or tertiary schooling). The elderly persons used the mobile phone for brief contact but this did not satisfy their “conversation” need.

Method

The heads of the care centre open-minded to innovation played an active part in the preparation and throughout the entire research. They helped to select the sample as they knew the personalities of the care recipients, their physical and mental problems, behaviour, social and family circumstances, their interpersonal network of contacts and their attitudes towards technology.

The observation made during the installation on the spot and the conversation at the time with the elderly person was of fundamental importance for later comparison. The systems manager or his deputy, the head of the care centre, as well as a carer and the researcher who elaborated the programme were present when the computers were set up. The sum-maries drawn up on the basis of the experiences of the


technicians, the carers, the head of the care centre and the researcher made it possible to judge the initial attitude of the elderly person towards technology, what the person expects from the programme, how he or she receives it, who they would like to be in contact with on Skype and why.

Intensive observation followed in the first week, the carers made note of the problems, and the systems managers found solutions to the difficulties signalled by the carers. Parallel with this the carers observed the elderly persons’ behaviour, recorded when they used Skype, for how long, with whom, what contacts they had, and the extent of change in their mood, daily schedule and activity. These notes were passed on to the heads of the care centre and they made a weekly report to the heads on their experiences. The researcher managing the programme conducted depth interviews with them, at first weekly, then every two or three weeks and finally monthly. In addition, the heads of the care centres signalled every event, or departure from customary behaviour they thought to be important. In the fourth month of the research a number of social work students at a university college joined in the work. Their task was to analyse the impact of Skype on the basis of a conversation touching on set points with the elderly person and the carer and their own observation, but they were intentionally not given any preliminary information on the earlier care prob-

lems (e.g. that a person had earlier received care for depression). In Székesfehérvár the PCs were installed before Christmas, from December 16th because it was anticipated that the family would have time during the holidays to help the elderly persons.

From the fourth month of the research also second-ary school students were involved. They were given the task – with the intention of intervention – of helping the elderly persons and reporting on their difficulties and progress.

County Seat

Before the computers were installed the elderly per-sons went through successive waves of emotions:

1. amazement (that they were getting a computer) 2. interest3. disclaiming “I’m too old for that, that’s for the young” 4. a great degree of fear, alarm.

The head of the care centre and the carers dispelled this last, negative emotion, fear, with reassuring talks, bringing up examples and explaining the benefits of the computer, setting off a wave of positive emotions.

1. impatience “When will I be getting it?”2. excitement “What will it look like, how will I use it?” 3. joy at reduction of the knowledge gap between gen-

erations. “I’ll have one, just like my grandchild.”…. “It will be good if I can use it.”

The presence of the younger generation and help from them (at Christmas) made learning easier, they were able to practise together, several of them made a note of the instructions for use given by a child or grandchild.

“When he got the computer (before Christmas) one of his sons who is good at computers went over and did all the settings for him. He wrote down everything on a piece of paper for Uncle A.: how to turn it on, all the basic steps.” (social work student)

But the learning was more difficult if family members were unable to provide adequate help. One of these was an 88-year-old woman whose child and grandchildren lived in the United States; she became very uncertain but she did not give up her will to learn in the hope of being able to have contact with her grandchildren (carer’s observation).

She was not the only one with the desire and the will to learn, this was true for everyone in the sample.

“Uncle A. told us that he would never have learnt how to operate the PC without a strong will.” (social work student)

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The loss of function and motor problems of the eld-erly also made use of the computer difficult. Most had difficulty using the mouse because of problems with their joints and because the icons were too small for their poor eyesight. One person even had difficulty switching on the computer. Technical solutions were found for some of the problems: the sensitivity of the mouse was reduced, the icons were made larger (30% bigger 1024x768 instead of the default 800x600), and solutions already in use in other countries were also suggested. The carers’ creative thinking also helped to adapt the PC to their physical functions, making use easier, e.g. several minutes of warm-up hand exercises before using the mouse.

With the appearance of Skype a two-way, interac-tive connection began. At first, because of reluctance on the part of the elderly, it was used solely for commu-nication with family members, for about an hour a day.

“I don’t want to talk to anyone else, just my son and my grandchildren” (78-year-old man)

This raised the possibility that as Skype became important to the elderly person, it could with time become a burden for the family. However, the reality turned out to be precisely the opposite, for several rea-sons. The daily contact replaced the activity performed by the family member that had been at times tiring and in cases involved considerable costs, for example

for travel; it gave the possibility for monitoring and communication without interrupting activities at home.

“Besides, I have to see whether everything is in order with my mother.”

The younger generation also joined in the communica-tion; for those who spent a lot of time on the internet, writing email, chatting, using Skype, such contact was natural, not an onerous task.

“I am on Skype every day with my grandchildren too, sometimes I practically fall asleep at the PC be-cause they could go on talking forever while I am tired, but I don’t mind.”

The “too” throws light on an important factor. A “divi-sion of conversation” developed within the family; several family members took part in the conversation in turn, freeing time for the family carer.

The video camera is important because it encour-aged various forms of activity in the elderly. The 88-year-old woman who previously had hardly been able to get out of bed, did her hair and put on make-up before speaking with her grandchild in the US. The motivation was the same as in the case study that gave the idea for the research: feedback from family mem-bers was important for the elderly person.

“I can see my grandchildren all the time and they can see me.”

The elderly were once again able to become active participants in family life.

“My great-grandchild will be born soon and I can use the web camera too to show a lot of things, like things (hobby carpentry) I have made at home” (78-year-old man).

This bilateral contact was soon replaced by an expand-ing network of interpersonal contacts.

“I look up old acquaintances to find out if they have a computer too.” (The 78-year-old man who at first rejected contact with others.)

“I looked up an old fishing friend, and I found him” (84-year-old man).

They began catching up to the younger generations, the information gap between the generations was reduced and with it the emotional ties were also strengthened.

“Our contact is much better since I have my com-puter and use the internet. We finally have something to talk about that interests us both!” (78-year-old man).

The contact was characterised not only by feelings and Skype not only made it easier for the family to monitor


and care for the elderly person. The reverse could also be true.

“I don’t worry so much (about them), because I can see them every day.”

The research also had many unexpected results, Skype acted as a catalyst. The sense of achievement gained with Skype encouraged the elderly people to learn to send email, chat, browse the web for topics of interest to them (e.g. fishing), and they continuously learnt something new. Learning to operate Skype gave them the skill base they needed to exploit other opportuni-ties provided by the internet, encouraging them to acquire new knowledge. As a result they began a learn-ing process and each obstacle overcome enabled them to advance to a higher level. In the fourth month of the action research the quicker learners had the same infocommunications skills as younger people.

“When we asked him about the computer, he imme-diately switched it on, went on Skype and checked to see who was online. I saw six people connected. Uncle A. tried to talk to one of his old friends while we were there, but for some reason the other person did not re-ply, so he said: “No one’s answering, let’s talk instead”. He told us that so far there are 300 family photos on the internet, and he stressed that they are there on his computer, and what a lot that is. He also said that he listens to a lot of music every day on the computer (his favourite is Zámbó Jimmy). He told us that he reads

the news every day online. He has ordered a set of cards on use of the computer so that he can handle it even better.” (social work student)

The many multifunctional opportunities offered by the internet have also had a beneficial effect on their mental state. Dependency (alcoholism) caused by loneliness has ended. The mild depression caused by caring for a wife with dementia (she could not be left alone so the husband was unable to go out) had not only disappeared by the fourth month of the action research, there had been a great improvement in his mood.

“Uncle A. has opened up like a rose.” (head of the care centre)

“Uncle A. seemed to be a well-balanced, confident, communicative, optimistic person with good empathy.” (social work student)

The conclusion drawn by two social work students on the basis of their conversation and observation is interesting because they did not know about the man’s earlier mental problems. They found an open, enquir-ing and optimistic personality indicating a process that had occurred within a very short space of time, only four months, during which the mental state of the mildly depressed elder person turned into the opposite. This positive change can be clearly linked to infocom-munication and the internet.

“Uncle A. said that the computer is very good for him because he goes out very little and it gives him a little extra challenge, something to keep him busy, and he can talk with his family members and friends every day on Skype.” (social work student)

In the assessment of older people too, there was a positive change in the general mood and sense of well-being as well.

“She herself said that she feels much better since she has the computer. Because she could finally get in touch with her old friends and with her grandchild in Italy. It seemed to me that she was making an effort to learn to operate the computer as soon as possible!” (social work student)

The change is even more striking in the light of their initial state.

“The carer told us that the first time she mentioned to Uncle A. that there was a possibility for him to get a computer (and use it to talk to people), he at first re-fused.” (case study by social work student with carer)

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Intergenerational contacts: the other pole

The social work students drawing up the case study were not given the task of recording their own feelings, but they described their own enthusiasm. The elderly persons’ desire, will and efforts to learn was something the students had not expected and evoked an emotional response that they considered worth reporting.

“That day when my student partner and I visited Uncle A. in the morning, the meeting had a positive influence on our whole day because it was a very good feeling to talk with him; that conversation gave us a lot of energy.” (social work student)

The reference to “a lot of energy” was surprising even for the social work students although they are learning in theory and in practice how to deal with and help to relieve human and social problems. Social prejudice lies behind this surprise. Even among the young social work students there were some who doubted that the programme would be successful, they judged the action research as superfluous in view of the reduced functions and poor health of older people and in this respect their attitude was the same as that of the companies.

The Capital

Experiences here were the same as those in the county seat, but the positive effect of Skype was even more striking in the case of the elderly persons who had ear-lier made suicide attempts. In the unanimous opinion of the carers it was depression caused by loneliness that led to the suicide attempts.

The combination of loneliness and suicide is regarded as a problem of special importance in the EU. In its Sum-mary Reflections 2010, the European Commission cites loneliness, dependency and isolation among the causes of depression and in serious cases suicide among the elderly. In the UK the rate of successful suicide attempts is the highest among the over 75 age group. In Hungary the rate per 100,000 persons in the age group concerned is 51.7 for men aged 60-64 years and 14.9 for women; 127.6 and 27.5 for those aged 80-84 years and 160.6 and 28.5 for persons over 85 (KSH 2009b, 24, 26). The rate of suicide among the elderly rises with age and is much higher among men than among women. Although suicide has many causes, it seems likely that the shrink-ing network of personal contacts ranks high among them. There are no reliable figures on suicide attempts; the two attempts in the sample do not appear in the statistics and presumably carers following the lives of elderly persons and familiar with their mental state and personal sphere are aware of such attempts and also know their causes.

In the sample of 10 persons in Budapest the two su-icide attempts in old age had been caused by passing or lasting depression resulting from loneliness and a lack of purpose in life. The recipients of care had greatly restricted activities and because of objective obstacles (children working, grandchildren studying, friends in distant places, etc.) they were unable to relieve their lasting or temporary loneliness with their otherwise extensive interpersonal connections. An 89-year-old man attempted suicide while the family was away for a short holiday.

“He wanted to commit suicide because he was overwhelmed by loneliness and depression, we found him by chance.” (head of the care centre)

In his case (too), the possibility of using Skype set off a process of infocommunications learning, it gave a feel-ing of success and encouraged further learning. This process activated him and transformed his daily activ-ity. Skype and the internet together kept him occupied for 3-5 hours a day.

“Since then his mood is well balanced and good.” (head of the care centre)

The seriously ill woman (asthmatic) carefully planned her 15 suicide attempts (conducting electricity into the bath) and in addition constantly made alarm calls to the carers seeking urgent intervention. Because of her chronic mental problem and psychosomatic ill-


nesses the general practitioner requested her forced admission to a closed institute, but the carers thought that such a permanent solution was not fortunate and instead accepted the additional burden of care.

Learning to use Skype strengthened her fam-ily ties (regular conversations with her two sons) and expanded her other interpersonal connections (regular chats with others). Using the skills she had acquired she began to explore the virtual world offered by the internet. The Google browser and visits to various websites gave her access again to leisure programmes that had been part of her life before she became ill: attendance at concerts, visits to museums and theatres. She made a conscious effort to end her loneliness by visiting dating sites. Apart from her main illness, her symptoms soon disappeared and she made no more suicide attempts, she became well balanced and addicted to the internet, often continuing to browse while the carers were present.

In the above cases the positive effect of Skype and the internet appeared within the very short space of 1-2 months, although at the beginning of the research there was doubt about the elderly persons who were basically afraid of technology. One old lady was afraid that the mouse would eat her food. Another was afraid that the computer virus would infect her and asked for immunisation (an injection). However their technologi-cal catching up was very rapid. One elderly person, for example, who did not dare even switch on the compu-

ter, by the fourth month was capable of doing what the bolder and more skilful do, only perhaps a little more slowly.

“ … she was the timid one, now she keeps in touch with five people on Skype, reads email messages and uses the Google browser like an expert”. (head of the care centre)

An elderly woman with Parkinson’s disease also became extremely active and even got as far as editing a newsletter. Six months after the start the eld-erly participants in the programme regularly read the newspaper, watched television, films and photos, some of them went to church, one of them began research on her family roots. Their vocabulary has expanded with infocommunications terms: a) with entirely new expressions: drive, surfing, wireless internet, keyboard, systems manager, email, chat, Facebook, website, Google, browser, download, YouTube, virtual; b) or with existing words with a new infocommunications content: mouse, window, library, virus. They have soon acquired the same knowledge and habits as the young (e.g. online shopping).

“You ask what information technology has given me. It has opened up the way to acquiring knowledge! The computer has brought great help and constant curiosity into my home. …I am doing research on my family roots on the internet, tracing all the com-plicated paths from 1311 right up to the present. So

far I have been able to put together a few detailed biographies. I will have something to pass on to my grandchildren. I conduct a lively correspondence with my family members and friends. We exchange photos and videos.” (76-year-old woman)

All this refutes the widely held prejudice about the abil-ity of sick elderly persons to learn, especially anything related to infocommunications. Prejudice appeared at different levels.

1. family level

“Oh, I hadn’t thought of that, but if it could be done it would be good.” (daughter)

“The family didn’t believe that it would be worth giving an old person a computer.” (head of the care centre)

The quotations show the implicit or explicit preju-dice of the family but these examples have not revealed how deeply this acceptance influences the behaviour of older people towards technology. While writing this paper a new action research has been launched (Oc-tober 2012) and during the sample selection a crucial problem arose: many of the elderly selected and willing to take part in the research cancelled their participa-tion because they were convinced by their families that it was superfluous.

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2. the older young, intergenerational level

The “30-year-old boys” who set up the computers, based on the gap between their higher level of techni-cal knowledge and the lack of technical skills of the elderly declared:

“I’d like to see what these old people are going to do with these computers: probably put a lace doyley on them, and a vase on that and then look at them.”

The same prejudice was reflected in the disbelief of social work students mentioned already.

3. societal level

In the light of these opinions, the earlier refusal of market firms and institutions to support the model programme cannot be regarded as deviant behaviour either. Computer skills of persons aged 75+ do not appear in statistics either as it is believed such skills simply do not exist. The prejudice found in the family, even among the social work college students and the young men installing the computers reflects the exist-ing prejudice in society.

0 level. older people themselves

The different levels of prejudice interact with each other and create a vicious circle. All these percep-tions have a negative impact on frail older people and

strengthen their belief in their own “inability to learn” anything and even more that the idea of acquiring a computer and learning to use the internet is ridiculous. Therefore this level should be considered as a basic one, 0. level.

If the lack of infocommunications skills in the eld-erly recipients of care had been accepted as unchange-able as suggested above, the action research would have been unsuccessful without the intervention and help of regular volunteers.

The role of the volunteers

Increasing emphasis is being placed on volunteering in both national and EU policy. The most recent empiri-cal studies have analysed the social role of volunteering along the factors of gender, age, level of schooling and satisfaction with the life career (McCloughan et al. 2011), and aimed to explore how elderly people prevent their own social exclusion through voluntary activity helping other old people (Ehlers, Naegele, Reichert 2011). The first-mentioned research examined volunteering among persons over 18, while the second focused on those over 65 and 60. Youth in Action, a sub-programme of the European Voluntary Service, is directed at developing the competences and skills of 18-30-year-olds related to voluntary activity through informal training, and in exceptional cases also involves 16-17-year-olds (be-tween 1996-2006 30,000 young people participated in

the programmes, and the organisation aims to increase this by 10,000 a year from 2007-2013) (Kucharczyk, Lada, Pazderski 2011, 6).

In contrast with this, young people aged 16 in formal education took part in the Skype Care model programme. For the practical voluntary activity that was part of the curriculum in a secondary school, the 16-year-old students could choose among various types of voluntary work and eight of them (grouped in two pairs) decided to give infocommunications help to elderly people. Besides giving this help they had to examine the problems of the elderly, assess their level of competence, their attitude towards technology and their mood. The volunteers vis-ited the elderly persons in pairs and drew on each other’s impressions in making their notes. Here too, as in the case of the social work students, they did more than was expected of them in recording their own feelings.

Volunteer 1

“Aunt G.’s technical skills and problems: watches soap operas online, has difficulty using the keyboard, searches for her friends on international sites, searches for information, her use of the net is made difficult because of the keyboard. We will continue to visit her. Because we like to see the progress she is making.”

Volunteer 2

“We spent time on the internet with Aunt K. We browsed for things that she wanted to buy. We showed her how to look at the TV magazine on the net, but she wasn’t


very good at it. She wanted to buy woollen yarn on the net but she has not succeeded yet. We will continue to visit her.”

Volunteer 3

“We taught Aunt K. to use the internet. She learnt to switch the PC on and off and to use the mouse, to visit port.hu, create an email account. I have a lot of other plans for her, which is why I would like to continue intensive voluntary work with Aunt K.”

Volunteer 4

“Aunt J. can switch on the PC, she can use Skype and search in the Google browser, her control of the mouse is uncertain but she is enthusiastic and uses it.”

Volunteer 5

“O. has made a lot of progress, it was worth helping her. She is very enthusiastic and attentive. She accepted everything we told her. She also took the advice we gave. It was a pleasure to work with her. We were able to help her a lot in using and handling the internet, the screen and the web camera.”

Volunteer 6

“She learnt to switch the PC on and off. She also learnt how to use Skype, to read and hear the news on the internet. We would like to stay in touch with her.”

Volunteers 7-8

“Uncle … learnt to switch the computer on and off, he can listen to music, use Skype, call his daughter and others and read the news on the net. He worked out how to do a lot of things by himself. He learns easily. (He is 90!)

Behind the positive feelings of the young volunteers we can see, expressed directly or indirectly, the pleasure they felt at the progress made by the elderly learners. As the student became teacher and the elderly person a

“good student”, the difference in infocommunications skills between the two generations was reduced.

The problems of the elderly, their progress, the results achieved

Overall, the findings with the 15-person sample can be summed up as follows.

• In a number of cases the teaching process began from the most basic level (switching the computer on and off).

• They learnt to use Skype very quickly.• Learning the new functions related to the internet

was the main problem.• Through the internet they have found a way to satisfy

a wide variety of desires and interests (from buying yarn to listening to music).

• There were typical difficulties (use of the keyboard). • They all showed a strong desire to learn.

• The pace of learning differed, but they were all able to reach a similar level.

• Two factors in particular encouraged them: a) they could again carry out activities with the help of the virtual world; b) they had a much more colourful, wider range of leisure activity.

• New customs appeared in their lives (such as shop-ping on the net, watching soap operas online).

• They needed helpers, both to learn and to catch up.• After a while the elements they learnt became per-

manent knowledge and the help was needed not to maintain that level and overcome the initial difficul-ties, but to reach the next level of knowledge.

• Volunteers helped them to move on to new levels; after mastering Skype they could also learn to use the internet.

Change in the behaviour of the young volunteers

• Emotional plus based on positive feedback, • with the result that they undertook to continue the

voluntary activity.

In the fourth and fifth months of the intervention research there was a marked positive change in the quality of life of the elderly persons. It began with closer relations between generations that could be called a quasi “grandparent-grandchild” relationship.

“It was a pleasure to work with her.” The young people

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with empathy played a key role in the social integration of the elderly persons through infocommunications. At the same time provisions must be made, both in the sample and in general, for the problem caused by volunteers dropping out temporarily (students’ sum-mer vacation) or permanently. Various solutions can be found for providing the continuous help so important for the elderly: regular reserve volunteers for the

“drop-out” periods (e.g. a university student); a roster of volunteers; a “volunteer on call” (for occasional problems); Hungarian-speaking volunteers from the neighbouring countries; volunteers based on other interpersonal relations (neighbour, friend, colleague), more intensive involvement of grandchildren (when they have more free time during the summer break) (personally if they live in the same settlement, by Skype for those living elsewhere). The role of grandchildren is especially important: the elderly persons have strong emotional ties to them and readily accept their role as teachers.

This new type of relationship is capable of setting off a positive trend and changing negative stereotypes regarding the elderly.

Change of interpersonal network

Three phases can be distinguished in the wish and efforts of the older people to maintain connections, resulting in the change of their interpersonal network.

Phase 1. Intention to talk only to family resulting in • Maintaining or strengthening their relationship.

Phase 2. Attempt to find a friend, acquaintance resulting in • Keeping old relationship alive.

Phase 3. Efforts to find other older people resulting in • Wider social network.

1. At first most of the elderly persons accepted Skype solely for contact with relatives and despite encouragement they did not want to contact others through this medium, not even other participants in the Skype programme. 2. This behaviour shifted to a qualitatively different dimension when they started to find acquaintances, friends, schoolmates. 3. As their infocommunications skills grew, their interpersonal network became even wider and entered into an intra-generational phase (in the fourth month) when besides entertainment and learning they began to make efforts to contact and help each other. E.g. one of them found information about the harmful effects of internet use (damage to the spine, etc.) as well as various health tips to counter this (rising early, eye exercises, etc.) and sent this to other recipients of care and acquaintances. An unexpected result of the third phase is that elderly per-sons performed voluntary activity via infocommunica-tions. This can be regarded as an element increasing the well-being of the peer group. The most important

lesson of the change is: not a shrinking but an expand-ing personal network!

The relationship between the formal carer and the recipient of care also changed. It became possible for the care centre (Budapest) too, to maintain contact through Skype in addition to the earlier personal or phone communication. This reduced the time input needed for certain types of care, often replacing use of the telephone and so saving costs for the care centre.

Conclusion

The model action programme has proved that even very elderly, sick persons in need of nursing are capable of learning to use Skype, something entirely foreign to them, if they have the motivation and are given suffi-cient help. In addition, Skype acts as a catalyst, leading to a higher level in the learning process; successful learning arouses the curiosity of the elderly about new forms of infocommunications and the internet. By learning to use the internet they can acquire new knowledge and keep themselves busy. This fills their days with 3-4 hours of activity, and the new interest gives them a purpose in life. While use of the internet often causes dependency in the younger generations, for the elderly it represents a positive dependency and stimulus. However, the learning process requires a helping mediator; in addition to support from carers, relatives, neighbours and technicians, the regular


activity of volunteers is indispensable. A lack of success can slow down or block continuous learning but with time the “learner” can become “self-propelled” and will be capable of discovering new things alone. Their loneliness and depression end and their interpersonal contacts expand. With the end of depression many health problems also disappear. At macro level this reduces costs for the health service (the research made no measurements in this respect) (medication needed for psychosomatic symptoms, emergency service calls, visits to the general practitioner) and the burden on so-cial carers is also eased. By making use of the possibili-ties offered by infocommunications the elderly persons are capable of reintegrating themselves into society. In this way the infocommunications skills acquired by sick, elderly recipients of care have a positive effect at both macro and micro levels. All the participants in the sample were capable of acquiring close to the same level of skills; any difference found was only in the speed of the learning process, so it was only a matter of a phase lag. The most important positive feedback is that all participants were ready to pay for an internet connection after finishing the program and the reason they gave was that their life had basically changed.

The research disproved the social prejudice that elderly persons in need of care, with deteriorating functions and a poor state of health are incapable of acquiring the skills needed for modern technology.

Developments after the research was concluded reflected general surprise in society, then joyful recog-nition that simple, widely available cost-effective ICT is capable of easing care problems. All the participants in the program became internet subscribers and with the PC modern technology became part of their lives. After dissemination of the results, local authorities indicated that they intend to launch similar initiatives in their own area. We have received feedback from families, saying that they would willingly buy comput-ers for their elderly family members. The university college participating in the experiment included the results in its curriculum and as a result the social work students have learnt about the ICT “eldercare format” previously unknown to them. Care centres have signalled their intention to introduce Skype care as a way of facilitating their work and reducing costs. The hypothesis that it would be difficult to recruit volun-teers has also been disproved. By the time the project came to an end, twice as many 16-year-old volunteers wanted to help elderly people (not as part of the volunteering included in the school curriculum). The reason for the increase in the number of volunteers is simple: the young people gladly transfer to the elderly the internet skills that are an integral part of their lives and in doing so they learn to love the elderly people, understand their problems and gain empathy. In this way the young people play an important role in social inclusion of the elderly.

Market actors too need to rethink their business policy and take into account two large target groups with a demand for computers and internet subscrip-tions: elderly sick persons in need of care who can afford to buy PCs for themselves, and families wishing to buy PCs for elderly family members.

At the same time, the highly effective program also raises new questions. How can this positive process be launched for people with disadvantages, even multiple disadvantages? What phase lag must be anticipated for elderly persons of different age, social background, level of schooling, gender, type of settlement and region? Could the attempt be unsuccessful and if so, to what extent and in what cases? What other type of problems could arise and what intervention would be needed to solve them? The research presented here serves as a guideline, but the questions together with many others building on the results obtained so far can only be answered with a new action research already in progress.

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http://www.isisemd.eu

http://is.jrc.ec.europa.eu/pages/EAP/enclusion.html

The present book covers a comprehensive picture of the challenges of ageing in the Central European Visegrad

Four – Poland, Slovakia, the Czech Republic and Hungary – and at the same time also formulates answers and

presents the results of several new researches, action researches including good examples that can be applied

in practice. Each of the articles is a separate unit but together they trace an interlocking picture. The first

part of the book focuses on the analysis of challenges of demographic trends, population ageing, macro socio-

economic, labour market trends, societal, environmental, ICT and care challenges with special emphasis on

long-term care. The book highlights the diversity, the similarities and differences of the research findings until

now hardly or not at all accessible for the “English-using” scientific world.

WARSAW

PRAGUE

BRATISLAVA

BUDAPEST

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