lecture 1: family structure

1. L1: Social Determinants of Family
Health
Dr Rahmah Mohd Amin
Family Health Unit
Department of Community Health
Medical Faculty, UKM
16th June 2006

2. Family- Defined
• Is a social institution, found in all societies
• An important basic unit in a society
• It unites people in cooperative groups to oversee the
bearing and raising of children.
• Family ties = kinship. This is a social bond based on
blood, marriage or adoption.
• Normally based on a legally sanctioned relationship
involving economic cooperation as well as sexual
activity and childbearing.

3. Family-Defined
• A single person cannot be a family
• Family members are dynamic – can increase in
number, interact, communicate, teach, love etc
• Perception as to what is a family differs by attitude,
values, beliefs

4. Family structure
• Various structure depend on
– Number of members
– Who the family members are
– Perception in terms of power
– Living arrangement
– Where they live

5. Fig 1: Family ‘Core’ Family as a unit
Nucleus
Extended
Modified
extended
Single parent

6. Family: based on living arrangement
 Nuclear family  Extended family
• A social unit • A social unit
composed of one or including parents,
two adults and children and other
children. kin.
• Also called conjugal • Also called
family = based on consanguine family
marriage

7. Family: based on living arrangement
 Single parent  Modified extended
family
• Either father or
mother alone raising • Core family,
the child because of grandparents, uncle
divorce/separation/ or aunties
death

8. Family: based on marriage pattern
• Monogamy
– Marriage joining two partners
• Polygamy
– Marriage joining three or more people.
– Has two form i.e Polygyny (many women) and
Polyandry (many men).
– E.g of Polyandry is in Tibet
• Most of the world societies have, at some
time, permitted more than one marital
pattern.
• Most actual marriage has been
monogamous.

9. Family: based on marriage pattern
• Endogamy
– Marriage between people of the same
social category. Same age, village, race,
religion
• Exogamy
– Marriage between people of different
social categories
In India for e.g a person suppose to marry people
from same caste (endogamy but from a different
village (exogamy). Endogamy because people of
similar position pass along their standing to
children. Exogamy to encourage cultural diffusion
and build alliance.

10. Family: based on where they live
• Matrilocality • Neolocality
Married couples live Lives apart from
with or near the both sets of
wife’s family. parents. More in
industrial society.
• Patrilocality
Married couples live • Ambilocality
with or near the Alternately living as
husband’s family. matrilocal and
patrilocal

11. Family in terms of power
Malay adat is divided into two
• Matriarcal law (Adat Pepatih)
• Patriarchal law (Adat Temenggung)
Compared with Adat Pepatih, the social institution of
Adat Temenggung is more patrilineal in character.
Its inheritence rules are in accordance with what is
stated in the Quran, and the practice of Adat
Temenggung is more prominent and acceptable in
Malay society. Adat Pepatih is practiced only in the
state of Negeri Sembilan. In adat Pepatih, inheritence
is towards females.

12. Family in terms of power
• Father has the power in a family,
Patrilineal, patriarchal
• Aborigines – follow “batin” –
• Sheikh of a tribe-
• powerful and influential person in their
community

13. Other arrangements…
• Families of affinity – unmarried but committed
partners.
• Cohabitation – heterosexual or homosexual
• Accepting them as family unit excluding them from
health care or other benefits.
• “Elton John & David Farnish”
• Doubting the impact of rearing children in
homosexual partners / cohabitation among
heterosexual partner

14. Family and Health Impact
• Care giving
• Responsibility – gender, or chronology
• Health seeking behaviours – older
members, Sheikh, husband
• Consent, decision making

15. Functions of family
• Family performs many task
• Family is the backbone of a society to care
for its members
1) Biological
2) Socialization
3) Regulation of sexual activities
4) Social placement
5) Emotional / psychological security
6) Economic / material security
7) Physical security
8) Education

16. • Biological function • Safety and love
– Sexual function and – Protection and love. Over
needs or under protection. Over
compensate with material.
Moderation is always the
best.
• Physical function
– Safety, survival. Place
• Reproductive
to stay, eat, sleep.
– Children are needed.
Without them a family is
considered as ‘not
• Socialization complete’. Wealth, family
– Personality developed name. son or daughter.
Test tube babies,
in family. Attitude, surrogate mothers.
idea, values. Parents
as role model

17. • Economy • Giving status
– Working for salary to – Give legal status,
support family. respect.. Out of
Knowledge and skills in wedlock child.
home economics.
• Education
• Psychological / pleasure – Illiteracy is a major
– Interact with spouse and barrier for those
children. Positive home seeking improvement
condition. in health status and
– Feel happy to be at quality of life
home. Spacious. Flats – Functional literacy
with two rooms. Privacy. – (Life skill & specific
Loitering. knowledge). Not just
primary education

18. The Family
• Has greatest impact on socialization
• Plays a major role in family/societal
building and stability
• Advocates and maintains the health of
family members and society.

19. Poor Anna…
On a cold winter day in 1938, a social worker
walked quickly to the door of a rural
Pennsylvania farmhouse. Investigating a
case of possible child abuse, the social
worker soon discovered a five-year-old girl
hidden in a second-floor storage room. The
child whose name was Anna, was wedged
into an old chair with her arms tied above her
head so that she couldn’t move. She was
wearing filthy clothes, and her arms and legs
were as thin as matchsticks.

20. Anna’s condition could be described as tragic. She
was born in 1932 to an unmarried and mentally
impaired woman of twenty-six who lived with her
strict father. Enraged by his daughter’s “illegitimate”
motherhood, the grandfather did not even want the
child in his house. For the first six months of her life,
Anna was shuttled among various welfare agencies.
But when her mother was no longer able to pay for
her care, Anna returned to the hostile home of her
grandfather. To lessen the grandfather’s anger,
Anna’s mother put the child in the storage room,
giving her just enough milk to keep her alive. There
she stayed – day after day, month after month, with
almost no human contact – for five long years.

21. How a sociologist described Anna when he
saw her at a county home…
• I was appalled by the emaciated girl, who
could not laugh, speak or even smile. Anna
was completely unresponsive, as if alone in
an empty world.
Taken from Macionis, J.J. (2000) Society the Basic, Prentice-Hall
International: New Jersey.

22. Social interaction: the key to socialization and humanity
• Anna was deprived of social contact.
• Although physically alive, Anna hardly seemed
human
• Without social experience, a child is incapable of
thought, emotion or meaningful action – more an
object than a person.
• Unlike other species whose behavior is biologically
set, human need social experience to learn their
culture and to survive.
• Social experience is also the basis of personality (a
person’s fairly consistent patterns of acting, thinking
and feeling.
• Without social experience, as Anna’s case shows,
personality does not emerged at all.

23. Responses to “Annas” in different societies
• Anna in Pennslyvania USA in 1932
• Anna in Pennslyvania USA in 2008?
• Anna in Malaysia?
• Anna in Hadramout?
• Anna in Sanaa?

24. Other Examples of dysfunctional families
• Example I- Economic deprivation and poverty
• Example II- Divorce and single parenthood
• Example III- Illegitimate
• Example IV- “Neo” families- single sex
• Example V- Violence and abuse
• Example VI-

25. Family Health
From MCH to Family Health

26. Fig 1: Family Life Cycle
Family as a unit
Elderly Marriage
Men Maternal
Adulthood
Perinatal/
Women infancy
Gender sensitivity
Children Program
Adolescent/
Youth
Toddlers
Schoolers Pre-schoolers

27. What is Health?

28. Health
• The preamble to the Constitution of the WHO
(adopted in 1946) stated that;
“Health is a state of complete physical, mental and
social well-being and not merely the absence of
disease or infirmity”
• 50 years later this definition was updated with the
addition of two words;
“Health is a dynamic state of complete physical,
mental, spiritual and social well-being and not
merely the absence of disease or infirmity”

29. The broadening of the original definition
of health to include dynamic
demonstrates the flexibility of the concept
of health and the manner in which it is
prone to change under various human
and environment influences.
The addition of the word spiritual
indicates the influence of values and
beliefs derived from the diversity of
cultural norms and practices.

30. Family health and environment
Physical Social
Environment environment
-geography, Family -SES,
workplace, Culture, Beliefs,
study place Religion, Values
Mental
Environment
-emotion,
psychology

31. Family and treatment
Comprehensive care

32. Health Services
• Maternal and child health
• Family health

33. SERVICE DEVELOPMENT
1950s
National
Rural Health
Services
Maternal
Maternal & Child
Child
Health
Dental services
services
Out-patient
services

34. SERIAL VITAL STATISTICS M ALAYSIA
45
40
35
Per 1000 LB 30
25
20
15
10
5
0
1970 1980 1990 2000 2004
IMR 39.4 23.8 13.1 6.8 5.6
CBR 32.4 30.6 27.9 22.6 21.3
PMR 31.2 23.5 13.2 6.6 *
10.2
NMR 21.4 14.2 8.5 3.9 4.9*
CDR 6.7 5.3 4.6 4.5 4.5
MMR 1.4 0.6 0.2 0.3
*
0.5
* - Year 2002 Source: Ministry of Health Malaysia

35. 1995
SERVICE DEVELOPMENT ONWARDS
FAMILY
Primary Health
Nutrition DEVELOPMENT
Care
Branch DIVISION
Branch
Family Health
Maternal &
Branch Elderly
Perinatal
Unit Health
Child
Health Mental
Unit Health
Women’s
Rehabilitation Adolescent
Health
Health
Unit

36. Social determinants of family health

37. Culture
Fig 2: Social determinants
of Family Health
Race,
Social class,
Age,
Gender
Lifestyle
Health Bio-genetic
and
non-health
related
social Socio-
policies Economic Family
status Nutrition Health
Outcome
Accessibility
to HCS
Non-
modifiable
Occupational
factors
Modifiable Environment
factors

38. Determinants of health: an e.g from the UK
• In relation to the determinants of health, the
National Health Service (NHS) of the United
Kingdom stated that;
“The worst health problems in our country will not be
tackled without dealing with their fundamental
causes. This means tackling disadvantage in all its
forms – poverty, lack of educational attainment,
unemployment, discrimination and social exclusion”
(DOH, 2000: 106)

39. Determinants of health…
Several policy documents in the UK such as The
Black Report (1980); The Health Divide (1987) &
The Acheson Inquiry (1998) highlighted the
apparent class gradient between health and
illness, and point to the link between deprivation
and health status.
Socio-economic factors associated with
variations in health and illness include income
and employment and housing condition.

40. Determinants of health…
Poverty and ill health go hand in hand.
Unemployed people tend to have worse
health than people who are employed.
e.g ethnic minorities, older people, older ethnic
minorities

41. Even historically…
• The Greeks, Romans and Victorians had more or
less identified such associations and their impact on
health, and had sought to address the causes of
health inequalities;
“…the Ancient Greeks recognized the links between
location, environment, nutrition and the health of the
community. The Romans too were aware of these
factors, and sought to improve public health through
large scale engineering works such as water supply
systems and sewers. Centuries later, the Victorians
established a legislative and administrative
framework which led to improvements in health
through better housing, sanitation and a cleaner
environment”
(Baggott, 1998: 270)

42. Culture
Fig 2: Social determinants
of Family Health
Race,
Social class,
Age,
Gender
Lifestyle
Bio-genetic
Health-
related Family
social
policies Socio- Health
Economic Outcome
status Nutrition
Accessibility
to HCS
Non-
modifiable
Environment
factors
Modifiable Occupational
factors

43. Health related social policy

44. Health related social policies…(Malaysia context)
• New Economic Policy (1971)
• Vision 2020 (1991)
• National Mission

45. The National Mission (2006 – 2020)
 The five key thrusts :
1. Moving the economy up the value chain;
2. Raising the capacity for knowledge and
innovation, and nurturing “first class
mentality”;
3. Addressing persistent socio-economic
inequalities constructively and productively;
4. Improving the standards and sustainability of
the quality of life; and
5. Strengthening the country’s institutional and
implementation capacity
 The Ninth Malaysia Plan (2006-2010) ~ the first
step in the National Mission

46. Enhancing Human Capital . . .
 Policies and New Emphasis :
 Develop holistic human capital
Nurturing ‘First Class Mentality’
Thrust 2 : Raising The Capacity
 Strengthen national schools to become the
For Knowledge & Innovation, &
school of choice
 Enhance the quality of institutions of higher
education to be at par with renowned universities
 Increase the supply of highly skilled human
resource, particularly at diploma and advanced
diploma levels
 Accelerate lifelong learning for individuals to add
value to themselves
 Promoting self-employment and fostering
entrepreneurship
 Increase participation of persons with disabilities
to engage in productive economic activities and
to be self-reliant

47. Advancing Women in Development . . .
 Policies and New Emphasis :
 Special window in existing financial
Nurturing ‘First Class Mentality’
programmes to enable women to obtain loans
Thrust 2 : Raising The Capacity
For Knowledge & Innovation, &
 Home office concept
 Programme for poor women in urban areas
Special emphasis on single mothers through
formulation of strategic action plan
 Inkubator Kemahiran Ibu Tunggal (I-KIT)
programme, a skills training programmes for
single mothers
 Program Anak Angkat, financial assistance for
the education of children of single mothers
 Measures to meet the 30 per cent quota for
women in decision-making positions in public
sector

48. Empowering Youth for the Future . . .
 Policies and New Emphasis :
 Enhancing their role in society
Nurturing ‘First Class Mentality’
Thrust 2 : Raising The Capacity
For Knowledge & Innovation, &
 Formulation of National Youth Act
 Empowering youth to foster national unity & nation
building
 Developing youths with good leadership qualities &
entrepreneurial skills
 Creating wholesome individuals with spiritual and
high moral values
• Focused programmes for youths in the 15 – 24 age
group
• Establishment of National Youth Research Institute
within existing facility
• Skills training and enterpreneurial development
• Enhancing training programmes to promote self-
employment

49. Fostering Family & Community
Development . . .
 Policies and New Emphasis :
 Building resilient families and creating a more
Nurturing ‘First Class Mentality’
Thrust 2 : Raising The Capacity
For Knowledge & Innovation, &
caring society
 Enhancing community participation
 Increasing the role of civil society and NGOs
through partnerships and joint programmes
 Foster national unity and closer integration
 Strengthening family unit
 Formulation of National Family Policy
 Strengthen family support mechanism to facilitate
child welfare, protection, development and
participation
 Capacity building of personnel and upgrading of
facilities
 Early Childhood Care and Development Policy
 People with Disabilities Act

50. Focus Of Federal Government Development
 Soft infrastructure
Programme . . .
The 9th Malaysia Plan, 2006-10
 Human capital ~ education and training
 Poverty reduction
 Rural development
 Revitalise the agriculture sector
 Restructuring of society
 Enhance capacity of S&T and R&D
 Curb crime and drug abuse
 Address infrastructure problems :
- water supply
- public transportation
- flash flood
- quality electric supply
 Scheduling of project expenditure to take into
consideration election year 2008/09

51. Pg 1-Highlights
THE 9 CHALLENGES :
1. The establishment of a united Malaysian nation made up of
one Bangsa Malaysia;
2. The creation of a psychologically liberated, secure and
developed Malaysian society;
3. The fostering and development of a mature democratic
society;
4. The development of a moral and ethical society;
5. The creation of a mature, liberal and tolerant society.
6. The transformation to a scientific and progressive society;
7. The realization of a fully caring society;
8. The development of an economically just society, in which
there is a fair and equitable distribution of wealth; and
9. The establishment of a prosperous society with an economy
that is fully competitive, dynamic, robust and resilient. Pg 14 Next
15

52. TOWARDS VISION 2020 Challenges V2020
Highlights . . .
The First Fifteen Years, 1991-2005
 The Malaysian economy experienced credible growth with strong
fundamentals.
 Structure of the economy approaching that of a developed nation
 Substantial achievements in infrastructure development at par with
developed economies
 Significant progress in poverty eradication and improvements in the
quality of life
 More needs to be done to develop technology, especially
indigenous technology and competitive entrepreneurs as well as
inculcate the required mindset
The Next Fifteen Years, 2006- 2020
 Build upon the strengths that were developed
 Internalizing of the universal principles of Islam Hadhari
 Launching of new initiatives to enhance human capital

53. Malaysia’s Health Vision
Malaysia is to be a
nation of healthy
96 individuals, families
19 and communities
Health system Emphasis
• Equitable • Quality
• Affordable • Innovation
• Efficient • Health promotion
• Technologically appropriate • Respect for human dignity
• Environmentally adaptable Promotion
• Consumer friendly • Individual responsibility
• Community participation
towards an enhanced quality of life

54. National Policy of older people – its objectives
• 1) to enhance the respect and self-worth of
the elderly in their family, society and nation
• 2)to improve the potential of older people so
that they continue to be active and
productive in national development and
create opportunity to assist them to live
independently
• 3) to encourage the creation and availability
of specific facilities to ensure the care and
protection of older people to enhance their
well-being

55. Culture…
• From the definition of health by WHO, health is
as much a social as a biological issue.
• Cultural patterns define health – ideas about
health are a form of social control that
encourages conformity to cultural norms
• Cultural standards of health change over time
• Health relates to a society’s technology
• Social inequality affects health

56. Age and gender…
• Death is now rare among young people.
• But young people do fall victim of accidents, AIDS
• Life expectancy is much higher in most countries
• Across life course, women have better health
compared to men
• Women live longer than men
• Men because of aggressiveness and individualistic
are more prone to accidents, violence

57. Even lifestyle…
• Research also point to the influence of lifestyle
factors at the level of individual. Lifestyle factors are
identified in policy documents. In this context, the
Saving Our Lives white paper (DOH, 1999: 1.4)
stated;
“…the four main killers – the illnesses which
together with accidents, play the greatest part in
causing preventable deaths and ill-health: cancer,
coronary heart disease and mental health. Together
they account for more than 75 percent of all people
who die before the age of 75 years.”

58. Social class and race…
• Infant Mortality is twice as high for disadvantage
children in the US compared to those from privilege
family.
• Studies have shown that those from higher social
class think that their health is excellent compared to
the lower social class.
• African Americans are two and one half times as
likely as whites to be poor, which helps explain why
they are more likely to die in infancy and to suffer ill
health and effects of violence as adults

59. Culture
Fig 2: Social determinants
of Family Health
Race,
Social class,
Age,
Gender
Lifestyle
Bio-genetic
Health-
related Family
social
policies Socio- Health
Economic Outcome
status Nutrition
Accessibility
to HCS
Non-
modifiable
Environment
factors
Modifiable Occupational
factors

60. Conclusion
• Health of family are multi-factorial.
• Understanding of family concept and
development
• Comprehensive care