Self-help hypertensive groups and the elderly in Yugoslavia

JAY SOKOLOVSKY, ZVONKO SOSICAND GORDANA PAVLEKOVIC SELF-HELP HYPERTENSIVE GROUPS AND THE ELDERLY IN YUGOSLAVIA ABSTRACT. This study examines aging in Yugoslavia in the context of rapid demographic and social changes over the last several decades. Since this time, urbanization and the population aging of the society have begun to place a stress on the ability of the family and the formal health care system to deal with the needs of the elderly. Responses to this stress have included new types of residences for the elderly and various types of self-help groups dealing with a variety of health care needs. This paper focuses on the development and functioning of self-help groups to deal with the problem of hypertension among the elderly in the Republic of Croatia. Preliminary results indicate that such groups have been relatively successful in regulating blood pressure and slightly reducing mortality. However, the success of groups requires a long term commitment from public health institutions and a recognition of how such groups must be adapted to different social environments. Key Words: health, hypertension, self-help, Yugoslavia W h e n first beginning to study the elderly in Yugoslavia in the early 1980s, anthropologist Jay Sokolovsky was told this story: After they married, Slobodan and his wife moved into the small house of the man's parents near the center of Belgrade. When the younger couple started having children they began taking over more of the limited space in the dwelling. By the time Slobodan's wife had their third child, his mother was dead and his 74-year-old father was becoming frail. Slobodan requested that his father give up his larger bedroom to him and his wife. As his children grew, Slobodan haphazardly built a tiny room onto the house and coerced the father to move into this new space. Eventually, although Slobodan's father was still able to take care of himself, he was asked by the son to move into a large new residential complex for pensioners on the outskirts of Belgrade. Two years later the father died. Shortly after that, Slobodan received a call from the director of the residence for the elderly, asking when Slobodan was moving out of the house. Puzzled, Slobodan asked why the director should ask such a question. He was informed that Slobodan's father had been so appreciative of how he was treated at the residence that he had deeded his house to the residence for its use. While this tale was never taken at face value, this type o f story carries within it the contemporary dilemma of aging in societies such as Yugoslavia. H o w can nations now undergoing rapid urbanization and industrialization cope with the stress that the growing numbers o f citizens living past their sixth decade place on health care systems seeking to maintain them as healthy adults? In particular, those nations that are demographically aging from "youthful" (4 to 7.9 percent over age 65) to "mature" populations (8 to 9.9 percent over age 65) are beginning to feel a real impact on their ability to deliver health services to their citizens. Increasingly, such societies are also witnessing a shift in the major health concerns o f their longer surviving elderly, from acute illnesses to chronic diseases. Cultural traditions to the contrary, two consequences of these changes Journal of Cross-Cultural Gerontology 6:31%330, 1991. © 1991 Kluwer Academic Publishers. Printed in the Netherlands. 320 JAY SOKOLOVSKYET AL. are: (a) the difficulty of providing care for the aged solely within the bosom of the family and; (b) the challenge of managing health problems of the elderly within a model of acute care provision involving primarily physician/patient dyads. Yugoslavia, although still a relatively youthful population compared to other European nations, finds itself grappling with these two problems. Over the last twenty years, the combined effects of improved health care and reduced family size have transformed this country into a demographically "mature" society with 9.4 percent of its citizens over 65 (Lukovid and Ivankovid n.d.). This aging trend is most prominent in the Republic of Croatia (11.4 percent over age 65), with the Republics of Slovenia and Vojvodina close behind (Defilipis and Havelka 1984). In the center-city area of Zagreb, Croatia's main city, almost one out of five inhabitants is over 65 years of age, a figure matched in rural areas that are marked by heavy out-migration of the young. It is little wonder, then, that in Croatia one finds both the nation's highest number of special residences for the elderly (Dom Umirovljenika - "home for retired persons") and the most selfhelp/mutual aid groups (susastita) oriented toward their health problems. For example, of the 120 such mutual aid groups in Yugoslavia in 1987, 70 were in Zagreb alone, with only two in Belgrade and one in Slovenia. The rapid development of these homes for retired persons and communitybased mutual aid groups is an intriguing issue in a nation so traditionally focused on the mechanisms of kinship, family organization and personalism for dealing with most of life's problems (Hammel 1968; Halpern and KerewskyHalpern 1986; Simid 1990). In this paper we will focus on the development of susastita, self-help and mutual aid organizations, as they developed in Croatia as a mechanism for dealing with the specific health care needs of the elderly during a period of rapid demographic transition. 1 Special attention will be paid to the susastita groups that deal with hypertension because this is one of the most common health risks that Yugoslav older adults face, and because these groups are perhaps the most successful of the various self-help groups that have emerged to deal with health problems of the elderly. To explore this issue, after a brief discussion of aging in Yugoslavia we will examine two specific locales where self-help groups were developed, one urban and the other rural. AGING IN YUGOSLAVIA Yugoslavia is a small Eastern European nation of only about 25 million inhabitants but with dramatic elements of cultural pluralism. The nation is composed of six republics and two semi-autonomous provinces. It has two different alphabets, Cyrillic and Latin, and three official languages, SerboCroatian, Macedonian and Slovenian. Numerous ethnic groups, including Albanians, Turks, Serbians, Croats, Hungarians, Macedonians, Slovaks live within its borders. In 1990 and 1991 ethnic tensions have nearly reached civil war proportions, especially in the south of the country where Albanian and Serbian ethnic groups are battling over control of the Kosovo region. Despite SELF-HELPHYPERTENSIVEGROUPSIN YUGOSLAVIA 321 these intra-societal cultural differences, Yugoslavia is a country firmly rooted in the belief of family support for the elderly. Andrei Simi6 notes: Until the 1960s the majority of Yugoslavia's population was rural with the peasant family constituting the basic unit of production and social identity. In much of southern and central Yugoslavia the prevailing model of the village family was the zadruga, a patrilocally extended household controlling land, livestock, equipment, and other material and ritual property communally. In some cases these households were quite large with as many as eighty or more coresident members (1990:96). Simi6 further points out that, despite Yugoslavia's rapid urbanization during the last three decades and the fading away of the zadruga, ties within the extended family, although smaller and less structurally encompassing than before, remain the most intense and morally encompassing of any social relations. These feelings are based on a world view that stresses the corporate nature of kinship units and the symbiotic rather than independent relationship among generations (Simi6 1990; see also Halpem and Kerewsky-Halpem 1986). This cultural emphasis is also supported by constitutional law. For example, Article 190, section 10 of the national constitution, states in part: "Members of the family shall have the duty and fight to maintain parents ... and to be maintained by them, as an expression of their family solidarity." Although a facility opened in 1341 (and still operating) in Dubrovnik, Yugoslavia is one of the oldest homes for the aged in all of Europe, the general opinion in the country is that no one in his or her right mind would want to live in such a place or send his or her parents into such oblivion. In 1982, when Sokolovsky first developed an interest in the issue of non-familial environments for the elderly in Zagreb, scholars in the United States advised him not to bother. He was told that there was so little interest in homes for the aged that most of the rooms had to be rented out to students or tourists. This was no longer the case in 1983, however, when Sokolovsky found that each of the nine Dom Umirovljeni in the city was now filled to capacity and some had waiting lists of over one year. Moreover, each local district was embarked on planning for its own homes for retired persons. Nationally, there was an element of intra-societal variation continuing to differentiate more family oriented Serbia from Croatia, which bears the influence of its many years as part of the Austro-Hungarian Empire. In Croatia the family orientation was more similar to that in West European countries, and there was a quicker acceptance of non-kin based housing and care organizations to deal with the needs of the aged. In Serbia, even by the late 1980s, non-familial care and residences for elders remained quite rare. By 1988 there were 13 Dom Umirovljeni in Zagreb, all small and linked to the local community. Yet, in the Serbian capital city of Belgrade, with 25,000 more elderly, there were just two such residences. In comparing Yugoslavia to other newly urbanized societies which also continue to maintain kinship structures as a basis for supporting health care of the elderly, one must take note of the distinct decentralized socialist system that has developed there since the 1950s (Kavar-Vidmar, Meser, Milosevi6 and 322 JAY SOKOLOVSKYET AL. Tanaskovid 1980; Lang, Woolhandler and Himmelstein 1982; Parmelee 1985). The organization of health care in Yugoslavia is firmly embedded in this political structure which shapes all public institutions from hospitals to sports facilities. 2 The provision of medical care is keyed to general practitioners and nurses who are assigned to health centers associated with local self-managing communities of interest (samoupravne interesne zajednice - SIZ's) within district comunes (opcina) and smaller neighborhood units (mjesna zajednica). Each center is intended to provide comprehensive primary care services. In Zagreb these opcina range in size from 8,000 in the city center to 160,000 in the newer, outlying areas. Funds for health care are raised by taxing the work organizations and adults in a given SIZ. It is common that in the largest opcina each general practitioner will have a quite heavy client load, typically 2,000 patients. The development of community health centers in Yugoslavia predates the socialist revolution, originating in the "homes of people's health" (domovi narodnog zdravljia) established by the pioneering work of Andrija ~tampar in the 1920s. The contemporary system went through several phases of development (Kunitz 1979; Lang, Woolhandler and Himmelstein 1982; Yugoslavia 1983; Jakgid 1984) and was legislatively implemented in 1974. In Yugoslavia there has always been a strong attempt to avoid creating special medical environments or institutions focused exclusively on the elderly. The only exception has been the development of psycho-geriatric wards in mental hospitals. HYPERTENSION AND THE NEED FOR SELF-HELP GROUPS Hypertension has become a significant health problem in Yugoslavia as in many other nations. By the 1970s, hypertension among Yugoslavian adults of all ages had become a major concern of health planners (Kozarevid, Jogipovid, Thurm, Vojvodid and Ra6id 1979). In the Republic of Croatia an estimated 20% of the population (600,000 persons) suffers from essential arterial hypertension, although only about seven percent have clinically diagnosed cases of hypertension (Kul6ar, Bijelid, Grahovac, Matega, Dro~djck, Barath, Hartman, and Hecimovid 1984). While hypertension is not restricted to the older adult population it is more prevalent in the elderly population and more likely to be found among females than males. A 1976 survey indicated that among those age 65 in the city of Zagreb, 39% of females and 18% of males suffered from hypertension (Defilipis and Havelka 1984). Nutrition is certainly a factor contributing to high levels of hypertension, as the traditional Yugoslav diet, except in coastal areas where fish is more common, contains a good deal of salted fatty meats. Growing prosperity after World War II not only increased consumption of meats but also led to increased cigarette smoking and the consumption of alcohol. Throughout the early 1970s, as an increasing flood of hypertensive patients came to the attention of health care workers, it was found that "the taking of SELF-HELPHYPERTENSIVEGROUPSIN YUGOSLAVIA 323 periodical blood pressure measurements was seriously interfering with practically all other activities and even with the work of detecting new cases" (Kulrar et al. 1984:1). Zagreb physicians we interviewed during the 1980s emphasized that it had become increasing evident in the previous decade that not only was hypertension the main cause of morbidity in relation to other chronic diseases but that most of their hypertensive patients adhered to therapy only sporadically or not at all. A different approach to the traditional doctor-patient treatment of this medical problem was clearly called for. HOW THE SELF-HELP GROUPS STARTED IN YUGOSLAVIA Since the founding in the United States of Alcoholics Anonymous in 1935, a wide variety of self-help/mutual aid groups have been created where individuals who are similarly afflicted affiliate with each other. A growing body of data indicates that such groups can emerge as a critical resource within a "health promoting" approach to illness or psychosocial crisis, as distinct from a traditional "sickness" approach (Borman 1983). Over the last two decades an explosive growth of such groups has taken place in Western industrial societies (Caplan and Killilea 1976; Gussow and Tracy 1976; Robinson and Henry 1979; Frate, Logan and Wade 1983; Diessenbacher 1988). Such social entities that touch on the lives of the elderly tend to be of three types: life-cycle transition groups, e.g., widow to widow; support for care-giver groups, e.g., care-givers for Alzheimer's; and affliction groups, e.g., alcoholism, hypertension. The last type of group, which is the focus of this paper, is often a reaction to gasp in the classical medical care system which fail to provide individuals with appropriate levels of support needed to connect between medical treatment, adaptation and rehabilitation (Gussow and Tracy 1976). The essence of any such association is a collection of people who share a common problem and band together for mutual support and constructive action toward shared goals. How did such groups emerge in Yugoslavia? In response to the growing number of hypertensive patients, key medical faculty at the Andrija Stampar School of Public Health in Zagreb, drew upon the already existing experience of self-help groups in Europe and the United States. They thought that if a practical way could be found to facilitate patients taking their own pressure measurements and keeping records then this would remove the great burden of well-care these chronic patients were imposing on medical personnel. It is important to note exactly how the first clubs were established, as this experience has contributed to their continued effective functioning. THE CASE OF THE JARUN HEALTH DISTRICT In 1976 a physician from the Public Health School proposed the idea to a general practitioner in the urban neighborhood of Jarun (south Zagreb); it was to be a club for self-care and mutual help for hypertensive patients. At about the same time, clubs for alcoholics and dibaetics were also set up in this health 324 JAY SOKOLOVSKYET AL. district. While the alcoholics' club still functions, the club for diabetics became absorbed into the hypertensive group because most of the diabetics also had high blood pressure. Over a period of a year, through the efforts of nurses assigned to the Jarun health district and using two sphygmomanometers purchased by the local community, patients were trained to take accurate blood pressure measurements and record them in workbooks - later to be called health passports. After this time the general practitioner in charge of the group told the members, "You now know how to take your pressure and record measurements. We have taught you about diet, and drug regimens. Go home and take care of yourselves." However, as this doctor recalls, the people were highly insulted and angry to be dismissed in this fashion and forced him to continue helping support the group. The people simply preferred the group environment for supporting the difficult task of maintaining a controlled blood pressure. This is important, as hypertensives cannot be cured but must maintain their drug, diet and weight control regimen or suffer the consequences of severe disease states brought on by high blood pressure. Despite the importance of medical professionals in promoting the self-help groups, health planners at the Stampar School have made a strong effort to remove the hypertensives from the local clinical setting. Instead they have promoted an identity of these persons with healthy self-care and mutual support, discouraging any connection with a "sick role". The model that has been used by planners calls for the heavy initial input of health professionals in the establishment of a club and the training of its members. Ideally, over a period of three years a gradual transition would take place so that at the end of this period most of the activity of the club would be carried out by its own members. While planning goals of the Public Health School call for 90 percent of the hypertensive club activities to eventually be run without the need for health professionals, this range of professional input seldom is attained even in the best clubs. To distance hypertensives from a perception of being in an active illness state, meetings are not held in medical centers but in nearby general use community buildings. These groups are not intended to be perceived as medical units, but as a mechanism for promoting self-care in the community. This is also a strategy to get the local authority to take financial responsibility for supporting the groups. An interesting aspect of the non-medical nature of these collectives is the diverse social activities carried out by members. These can include excursions, organizing concerts, cleaning parks and producing badges or brochures promoting the club. As each group is quite small, with 15-30 active members, there is an opportunity in these settings to intensify intimate social bonds which can play an important role in group mediated health seeking behavior. It was observed in some rural areas that group meetings can take on a very social function and will sometimes include elderly participants who are not even hypertensive but are there to help keep their weight down or just to be with friends. It should be noted that membership in these hypertensive self-help groups is by no means restricted to the elderly. However, because of the greater prevalence of this SELF-HELPHYPERTENSIVEGROUPSIN YUGOSLAVIA 325 disease and the higher chance among this part of the population for having free time, in a majority of hypertensive groups those over 50 years of age constitute the bulk of the membership and are most likely to be active in leadership positions. THE CASE OF BELEC VILLAGE - ISSUES IN RURAL SELF-HELP GROUPS In rural Yugoslavia the attempt to apply non-traditional approaches to controlling high blood pressure did not begin until the 1980s. This was not due to lack of need. A health screening in 1983 of the rural Croatian community of Belec showed that almost 36% of those over age 18 had severely elevated blood pressures: over 160 mmHg. systolic and/or 95 mmHg. diastolic (Pavlekovi6 1985). We will focus on this village to provide a contrast to the urban situation described above and to highlight issues in self-help group development particular to rural regions of Yugoslavia. Fieldwork we conducted in Belec during the mid-1980s indicated that while typically 70% of those over sixty lived in some type of extended family, these households seldom numbered over five or six persons (e.g., an older woman, her married son and daughter-in-law and one or two children), and that the day to day social support systems of elderly peasants consisted of a circumscribed group of resident kin and a few neighbors. Quite often, the sons in these "potentially" extended households were only sporadically resident in the village, either because they were "guest" workers in Germany or because they worked and lived most of the time in Zagreb. Our research findings agree with the pathbreaking work of Nada Smoli6-Krkovi6 (1976), who in the 1970s demonstrated that despite the ideals of kin support, social and economic supports provided by the family were simply inadequate to provide for many of the basic needs of Yugoslavia's elderly peasant population. Certainly this was the case in the area of health needs. It is in rural areas of Yugoslavia where modem medical institutions and personnel are the least likely to directly connect with the health care needs of the populace. One of the problems with rural health care delivery is that doctors usually do not reside in villages. In terms of general health organization there is a lack of integration of physicians and nurses with the traditional community/local health providers, such as midwives. Where these connections do occur there tends to be an even greater dominance by medical professionals over lay practitioners. This is the context in which the first attempt at developing a rural detection and self-help program for hypertensives was begun in 1984 in the Croatian village of Belec. This mountain fanning community of 2,643 persons living in 681 widely dispersed households contains a rapidly aging population with 15.1% over age 65 in 1981 (Lukovi6 and Ivankovi6 n.d.). Health screenings indicated that more than one in three adults had significantly high blood pressure and that less than half of those individuals were receiving any treatment for this condition. 326 JAY SOKOLOVSKYET AL. Having experienced incredible devastation during W o r d War H, rural villagers in places such as Belec were still highly suspicious of outsiders. In 1984, for example, when the physicians from the ~tampar School of Public Health came to Belec to initiate the first hypertensive prevention program, the general reaction of the village leaders was, "What do they want from us?" As a response, the basics of the program were laid out in a lengthy public meeting. The idea was to start with a hypertensive "initiative" and thereby set the structure for other programs of sanitation and diet. A house-to-house survey was taken, screening people to see if blood pressures measurements had been obtained by medical personnel. If not, pressures were taken two times by medical students. All those individuals with clear or even marginal cases of hypertension were selected out and invited to participate. However, only four people came to the first meeting, and for many months only two or three persons showed up. Participation grew gradually toward the end of the first year, from 10-12 persons at each meeting to an average of 30--40 individuals by the end of the second year. However, a number of problems developed. One of these was that women in Belec were more likely to be available for home health screening and to respond to the self-help initiatives. Almost 90% of the targeted women in Belec participated in some way in the self-help program, compared to only 50% of the men. One factor was certainly the high rate of men working outside of the village, many of whom resided there only on weekends. Another factor was the substantial drinking problem among the males; some thought that if they were examined and discovered to be hypertensives the doctors would try to stop them from drinking. A more basic problem was that due to the very dispersed, low density nature of this area, the club model from urban areas did not work effectively. During the second year of the project it was decided to switch to a system of lay health representatives from the local neighborhoods, trained by the public health physicians to use their own blood pressure measuring devices and to keep a registry of blood pressures and body weights of hypertensives in their neighborhood. This "board for health" composed of 25 individuals came to function as an informal community network of local physicians, government and lay health monitors to deal not only with hypertension but with other pressing health care needs. Although the community was initially suspicious and antagonistic to the program, after it got underway the "board for health" actually pressured the Public Health School to expand its interventions to deal with other specific medical and social problems. These ranged from the support of handicapped children to the care of disabled, homebound and isolated aged. Over the course of a year (1985-6) the "health monitors" worked with the Stampar Public Health School and successfully dealt with eight difficult cases of medical and social need. More recently, the "board for health" has even asked for help in setting up a program to treat alcoholism. This was noteworthy because the health board included a number of members with significant drinking problems. SELF-HELPHYPERTENSIVEGROUPSIN YUGOSLAVIA 327 WHAT CAN BE LEARNED FROM THE EXPERIENCE OF HYPERTENSIVE MUTUAL AID IN YUGOSLAVIA The evidence about mutual aid hypertensive groups from the United States and Yugoslavia indicates that they are generally effective. Success is most clearly seen in maintaining regulated blood pressures, promoting healthier lifestyles and promoting longevity. Enhancing the social closeness of those acting together to control hypertension has been identified as a key measure of success among differing medical interventions directed at controlling high blood pressure. Measuring "success" by the percent of participants controlling their blood pressures, a study in rural Mississippi (Frate 1983) compared the effectiveness of three intervention strategies: (1) the hypertension health counselor-single client relations; (2) high blood pressure management self-help groups; (3) community-wide detection, referral and educational activities. These were compared with a control group in a control county where no intervention measures were being taken. Using a six-month evaluation based on six measurements, it was found that "over 90% of the 128 individuals participating in the family based self-help groups had achieved a controlled blood pressure and over 70% of individuals participating in community (church) based self-help groups similarly had achieved a controlled pressure" (ibid: 212). All three interventions were successful when compared to national studies showing that for doctors giving medication alone, only 34.1% are achieving controlled pressures. Preliminary studies by the Stampar School of Public Health in Yugoslavia indicate similar results: the best clubs attain a 90% controlled blood pressure rate and a weight reduction in about 70% of the cases. Also, in following 165 participants from the first hypertensive clubs over an eleven year period, it was found that for those who participated in the club and followed prescribed treatment procedures, life expectancy was 4.0 years longer (72.8 years) than for those who did not treat their hypertension (68.8 years), and 2 years longer (70.8) than for those persons who used irregular treatment patterns (Grahovac 1985). Another common benefit derived from such self-help groups is empowerment with regard to health care. One potential problem of group members in dealing with health issues is the discrepancy in education, knowledge and social status between the givers of service (doctors/health care workers) and the users of the service (patients). This difference is amplified among the elderly, who grew up during a time when Yugoslavia had one of the lowest standards of living and education in Eastern Europe. Thus the mutual aid groups can be thought of as a mechanism which can empower the elderly to understand and manage their own health care. This is reflected in the fact that the most successful groups make their needs for extra services and training known to the professionals and use this help topromote increased independence from the formal health care system. 328 JAY SOKOLOVSKYET AL. CONCLUSIONS It is far too easy to be optimistic about self-help and mutual aid groups functioning as a panacea for the problems of health care systems in developing countries. While hypertensive control support groups seem, in fact, to be effective in stabilizing blood pressure, there are some cautions that should be noted based on the Yugoslav experience: (1) Real results in terms of a long term change in diet and other aspects of a healthy lifestyle take a long time. It was found that at least two to three years was needed to effect these types of changes in the participating populations. Moreover, participation in the groups must be long term because if regimens are discontinued, the benefits will disappear. (2) It can be anticipated that in addition to initial resistance from target populations, there are also likely to be roadblocks set up by general practitioners. In some instances they can strongly resent the intrusions on their power to make decisions on health matters, but in most cases they are simply not trained in working with groups in primary care and in the transmission of health information. The likely result of this would be poorly trained groups which do not receive the kinds of professional support necessary for long-term effective functioning. (3) It should be anticipated that a variety of organizational options for mutual aid formations must be available to meet differences based on community and cultures within a given polity. These cautions noted, it is crucial to realize that even in nations with "young" populations hypertension can represent a major health threat that can lead to the premature onset of chronic disease that can exact high costs in lives and funds from already scarce resources. The level of appreciation of the hypertensive groups by the participants was summed up in a speech by the President of a club in a rural area on the outskirts of Zagreb. Looking around at the audience, he stated "Well, the good members are here and the bad members are in the cemetery!" NOTES The research for this paper combined the anthropological fieldwork of Sokolovsky in various self-help groups and interviews by him of key personnel involved with initiating these organizations. It also includes the continuing research of the other authors, Zvonko So~i6 and Gordana Pavlekovi~ in the process of working with and evaluating the functioning of such groups. 2 For a discussion of how the structure of medical care is changing in relation to recent changes in the country, see Oluji6 1990. REFERENCES Borman, L. 1983 Self-Help Groups, Professionals, and the Redefinition of Pathological States. In Clinical Anthropology: A New Approach to American Health Problems. D. Shimkin and P. Golde, eds. Pp. 99-118. Lanham, MD: University Press of America. SELF-HELPHYPERTENSIVEGROUPSIN YUGOSLAVIA 329 Caplan, G. and M. Killilea, eds. 1976 Support Systems and Mutual Help: Multidisciplinary Explorations. New York: Grune and Stratton. Defilipis, B. and M. Havelka 1984 Stari Ljudi (Old People). Zagreb: Stvamost. Diessenbacher, H. 1988 Self-Help Initiatives Among the Elderly and Their Contributions to a Social Culture for Later Life. Bulletin on Aging 2:1-5. Frate, D. 1983 The Operation of a Community Based Project: The Second Phase, 1982-83, of the Community Control of Hypertension in Central Mississippi. In Clinical Anthropology: A New Approach to American Health Problems. D. Shimkin and P. Golde, eds. Pp. 205-219. Lanham, MD: University Press of America. Frate, D., E. Logan, and C. Wade 1983 The Organization and Implementation of a Community Based Research Project: The Initial Phase, 1980-81. In Clinical Anthropology: A New Approach to American Health Problems. D. Shimkin and P. Golde, eds. Pp. 179-192. Lanham, MD: University Press of America. Grahovac, V. 1985 Hypertensives, Self-Help and Mutual Aid in the Zagreb Health Station Area. Paper presented at the seminar on Self-Help and Mutual Aid in Health, at the InterUniversity Center for Post-Graduate Study, June 3, Dubrovnik, Yugoslavia. Gussow, Z. and G. Tracy 1976 The Role of Self-Help Clubs in Adaptation to Chronic Illness and Disability. Social Science and Medicine 10:407-414. Halpem, J. and B. Kerewsky-Halpem 1986 A Serbian Village in Historical Perspective. Prospect Heights, II1: Waveland. Hammel, E. 1968 Altemate Social Structures and Ritual Relations in the Balkans. Englewood Cliffs, N.J.: Prentice-Hall. Jakgi6, Z., ed. 1984 Experiences in Primary Health Care: Selected Case Studies from Yugoslavia. Zagreb: Andrija Stampar School of Public Health. Kavar-Vidmar, A., B. Mesec, V. Milosevid, and M. Tanaskovi6 1980 Open Care for the Elderly in Yugoslavia. In Open Care for the Elderly in Seven European Countries. A. Amann, ed. Pp. 155-180. New York: Pergamon. Kul6ar, Z., D. Bijeli6, V. Grahovac, S. Matega, D. Drozdjek, A. Barath, A. Hartman, and A. Hecimovi6 1984 Controlling Hypertension: Community Care and Mutual Aid Through Neighborhood Clubs. In Experiences in Primary Health Care: Selected Case Studies from Yugoslavia. Z. Jakgi6, ed. Pp. 141-142. Zagreb: Andrija Stampar School of Public Health. Kunitz, S. 1979 Health Care and Worker's Self-Management in Yugoslavia. International Journal of Health Services 10(4):587-609. Lang, S., S. Woolhandler, and D. Himmelstein 1982 Development of the Yugoslav Health Care System. World Health Forum 3(4):407-408. Lukovi6, G. and D. Ivankovid, n.d. Demographic Features of the Belec Population. Zagreb: Andrija Stampar School of Public Health. Olujid, M. 1990 Political Economy of Reform: Changing Face of Socialism and Health Care in Yugoslavia. Paper presented at the American Anthropological Association Meetings in New Orleans, December 1. Parmelee, D. 1985 Whither the State in Yugoslav Health Care? Social Science and Medicine 21:719-727. Pavlekovi6, G. 1985 Self-Care and Mutual Aid Programs in a Rural Community - The Belec Study. Paper presented at the seminar on Self-Care and Mutual Aid in Health, June 3, Dubrovnik, Yugoslavia. Robinson, D. and S. Henry 1979 Self-Help and Health: Mutual Aid for Modem Problems. London: Martin Robertson. Simi6, A. 1990 Aging, World-View, and Intergenerational Relations in America and Yugoslavia. In The Cultural Context of Old Age: World-Wide Perspectives. J. Sokolovsky, ed. Pp. 89-108. New York: Bergin and Garvey. Smoli6-Krkovi6, N. 1976 Longitudinalna Studija Socijalno-Ekonosmkog Stanja Starih Ljudi u Seoskim Podrucjima SR Hrvatske. Zagreb: Republicki Zavod Za Socijalni Rad. 330 JAY SOKOLOVSKY ET AL. Yugoslavia: National Answers to the Questionnaire 1984 Conference of European Ministers Responsible for Family Affairs, Strasbourg, June 6, 1983. Jay Sokolovsky Department of Sociology and Anthropology University of Maryland Baltimore County Catonsville, MD 21045 U.S.A. Zvonko ~ogi( and Gordana P avlekovi( Andrija ~tampar School of Public Health Rockfellerova 4 41000 Zagreb Yugoslavia