Publication
International year of the family report (phase 1): an overview of academic attempts to define the family
Summary
1. Introduction
Family life has re-emerged not only as an area of growing academic interest, but also as both a fit symbol for political slogans and a subject of public interest. The political nature of the family is manifest in the inability of different interest groups to agree on what the institution is and/or what are the correct forms of family life.
Academic debate throughout the 1940s and 50s was dominated by structural functionalist views of the family. These works sought to understand the family in terms of the functions that the institution plays within industrial society. Inherent in the functionalist models were consensual views of interpersonal and family relationships. Later feminist works have questioned these assumptions and pointed out that family life often involves conflict and the exercise of power by men over women and adults over children (Oakley 1982; Brannen 1987; Finch 1989 & 1993). On the theoretical level, feminists suggest that patriarchal values are inculcated in families, but they also permeate and influence all levels of society: political, economic and ideological. They argue that historically the form of patriarchy has been variable - religious, medical, scientific - but the essence remains the same and lies in a concept of a social order premised upon a male, and particularly paternal authority.
2. Social policy and the family
Political interest in the family is often closely tied to debates about public expenditure in the fields of welfare, health and social security (Finch 1989). For Van Every (1991), the common lack of a clear definition of the family in areas of public debate serves to mask an ideological construction. She argues that at ideological and practical levels many social policies (ranging across social security, housing, health and community care), encourage the belief and aim to promote the view that the most desirable and natural family type consists of “a heterosexual, married couple and their own (genetic) children, conceived 'naturally' ” (Van Every 1991 p 63). Finch and Mason (1993) point out that many family oriented policies are premised upon the belief that within families there is a natural division of labour (based upon gender) wherein women provide care for dependent family members (1991). Close analysis of many social policies suggests that when hard and fast boundaries are created between the ‘responsibilities of the state’ and the ‘responsibilities of the family’, there is a tendency for the state to deny more than minimal responsibility.
Health care professionals view of the family
The limited academic literature relating to doctors, heath visitors and social workers suggests that during their daily practice all use a particular common-sense view of what is a correct family type. This is normally the heterosexual nuclear family, consisting of husband, wife and child(ren). Most commonly this model comes to the surface when issues of child care and protection are raised. However, rhetorically most health care professionals claim not to engage in moral judgements and appear unaware of the influences of their common-sense knowledge upon their daily activities.
3. The changing family in Scotland
In reality there are a multiplicity of family types in Scotland. The last twenty years have seen falling fertility rates, with women completing their families younger. In 1970 there were 88,569 births, in 1980 there were 69,355 births and in 1992 there were 66,145 births. Marriage rates have also been decreasing during the last 20 years: between 1971 and 1975 there were on average 41,605 marriages per year; between 1976 and 1980 the average was 37,801 per year; and between 1986 and 1990 the average number per year was 35,400. However in 1992 there were still 35,057 new marriages. Marriage remains popular. At the same time divorce rates have risen. Between 1971 and 1975 there were on average 6604 divorces and nullities per year; between 1981 and 1985 the average divorce rate per year was 11,942; in 1991 and 1992 there were 12,399 and 12,479 divorces respectively. Births to unmarried parents have risen from 7.7 per cent of all births in 1970, to 11.3 per cent in 1980 and 30.3 per cent in 1992. Lone parenthood has also been rising. In 1986 63,000 Scottish families were receiving lone parent benefit by 1991 this had risen to 87,000 families. Most lone parents are women who have become divorced. Over half of all lone parents are economically inactive (61%), probably reflecting the lack of affordable and adequate child care.
The role of the family in maintaining and creating health
Families play a crucial role in creating and maintaining individuals health. In the best situations families provide tremendous emotional and physical support. However, families do not exist and live within a social vacuum and the opportunities open to families are affected by the level of public resources (MacIntyre 1993) as well as their private financial and social resources. An adequate understanding of people’s health promoting and health damaging behaviours requires that their actions be located within the context of their daily lives. From an individual’s perspective a single activity may be both health promoting and health damaging (Graham 1987). Individuals do not always see health damaging behaviours (e.g. smoking, excessive alcohol consumption, high fat diets) as equally bad at all stages of the life cycle (Backett & Davison 1992). People’s perceptions of what health is and how it should be promoted are related to age, gender and culture.
Health promotion, health education and the family
At the level of ideology there is an important distinction to be drawn between health education and health promotion (Tones 1993). Health education tends to stress the medical model, professional assessments of health status and the responsibility of individuals and families to look after their own health. By contrast, health promotion favours community participation in assessments of health needs and a community development path to improving health. Environmental issues such as the effects of bad housing, low incomes, unemployment and available public resources are stressed and related to the opportunities open to individuals and/or families. Inherent in the health education model is the tendency to stress individual and or family responsibility. The inherent danger in targeting families whilst using the health education ideology lies in the fact that it is all too easy to fall into ‘victim blaming’ (MacIntyre 1993) and to de-politicise health issues. This is particularly the case with regard to families as opposed to individuals because the family is often seen as the archetypal private domain.
A review of health promotion/education policies and initiative oriented towards the family
The Scottish Office, Health Boards (including HEBS), Health Councils and major voluntary sector organisations, were contacted and their central policy statements and initiatives reviewed. The inventory at the end of the main report provides a comprehensive list of the organisations contacted, as well as details of the documents reviewed. The central finding was that very few health education/promotion initiatives focus specifically upon the family. However, as most people live within what might be broadly defined as a family unit all health promotion/health education policies and initiatives have implications for family life. Health Boards tend to categorise their health promotion/education initiatives as being either settings based or topic based. Interestingly, the family is never cited as worthy of settings based initiatives. This may well reflect their recognition of the multiplicity of family types in Scotland. When families and households are mentioned in policy statements it is most commonly in relation to ‘parenting’ and the spheres of ‘child development’ and ‘child safety’.
Recommendations for stage two of the HEBS International Year of the Family Project
It is recommended that health visitors, their senior managers (and if resources allow their front-line managers), and health visitors’ clients are targeted for the second stage of the IYF project. This is because health visitors appear to be the health care professionals who spend most time working directly with families. Good research practice recognises that front-line workers often make policy through the exercise of their discretion. Importantly, however this is always within their organisational context. This is why it is recommended that, if resources allow, senior and front-line managers should also be included in the study.
The review of family health promotion initiatives in Scotland suggests that there are variations between Regions. It would therefore be interesting to take at least two geographical locations. This will allow for comparative analysis and a more adequate understanding of the ways in which organisational and managerial contexts affect health visitors’ daily practices.
4. References
Backett K & Davison C (1992) Rational or reasonable? Perceptions of health at different stages of life. Health Education Journal vol 52/1 pp 55-59.
Brannen J & Wilson G (eds) (1987) Give and Take in Families. London Allen & Unwin
Finch J & Mason J (1993) Negotiating Family Responsibilities London Tavistock and Routledge
Finch J (1989) Family Obligations and Social Change. London Polity Press.
Graham H (1987) Women’s smoking and family health. Social Science and Medicine Vol 25 No1 pp 47-56.
MacIntyre S MacIver S & Soomans A (1993) Area, Class and Health: should we be focusing on places or people? Journal of Social Policy Vol 22, 2, pp 213-234.
Oakley A (1982) Subject Women. Glasgow, Fontana.
Tones K (1993) Changing theory and practice: trends in methods, strategies and settings in health education. Health Education Journal Vol 52/3 pp 125 139
Van Every J 1991 Who is ’the family’? The assumptions of British social policy Critical Social Policy pp 62-75.
1. What is the family?
Introduction
Recently, family life has re-emerged not only as an area of growing academic interest, but also as both a fit symbol for political slogans and a subject of popular public interest. The political nature of the family is manifest in the inability of different groups to agree on what it is, what it means, and what it should be. Some argue that the family is the foundation of society, indeed of civilisation itself. Others maintain the institution is the source of most of our problems and unhappiness. The New Right of the 1980s has seized upon the family as the salvation of society and have increasingly looked to draw upon the institution’s strengths and resources to aid their restructuring of welfare services. Feminists see the family as the locus of women’s and children’s oppression in a patriarchal society.
Early structural functionalist definitions of the family
Much academic effort has been spent in trying to define the family. Early attempts divided families into two main types: nuclear and extended. Murdock (1949), was one of the first to use the term nuclear family which he defined as consisting of parent(s) and child(ren). This he juxtaposed with the extended family taken to consist of parent(s), child(ren), and grand-parent(s) or other kin. The suggestion was that prior to industrialisation the majority of families were of the extended type; largely as a result of low levels of geographical and social mobility. For Murdock (1949), Parsons (1964) and others, from about 1750 onwards rapid population growth, urbanisation and above all industrialisation, resulted in a change in family structure and the creation of the modern nuclear family. The nuclear family being seen as better suited to the needs of industrial society.
More recently, however, demographic and historical works have challenged these earlier accounts and theories, and proved most of their assumptions to be misguided. Laslett (1972) for example, supplies evidence to the effect that prior to industrialisation, many people actually lived in relatively small households. Most of these households - but by no means all - corresponded quite closely to nuclear families.
Throughout the 1950s and 60s most sociological studies of the family were dominated by structural functionalist definitions of what the family is and what ‘needs’ it fulfils within society. At a basic level, functionalists such as Murdock and Parsons argued that the family is a universal institution that performs certain specific functions which are essential to society’s survival. Thus Murdock defined the family as:
a social group characterised by common residence, economic co-operation, and reproduction. The four basic functions of the family being common residence, economic co-operation, reproduction and sexuality (Murdock 1949).
In reality, as Gittens (1985) points out, the more one considers the historical and anthropological evidence the more striking it becomes that there are always a variety of household types within any given society. Thus she argues that Murdock’s definition does not take adequate account of the diversity of ways in which co-residence, economic relations, sexuality and reproduction can be and are organised.
The feminist challenge to the ideology of the family
One of the strongest challenges to the structural functionalist view of the family comes from feminism. From the late 60s feminist academics have offered increasingly strong challenges to the consensual view of family relationships which are inherent in functionalist works. They have argued that families are often repressive, involve conflict, and are based upon a particular set of power relationships. For Finch (1989) the symbolic importance of the family cannot be underestimated, for it goes beyond political allegiances to the left or right and is arguably the most important institution of modern industrial society.
For feminists the locus of inequality between men and women and adults and children lies quintessentially within the family (Oakley 1974, 1976, 1982: Brannen 1982 1987, 1989: Gittens 1985). They argue that at the ideological level the concept of the Western nuclear family contains notions of male and, specifically, paternal dominance over others. The husband and father is the patriarch, literally the father and ruler of the tribe. Patriarchy is defined as both a gender and an age relationship, based upon power. Thus, almost by definition, the family is an unequal institution premised on paternal authority and dominance.
Our traditional family model of the married heterosexual couple with children- based on a sexual division of labour where the husband as breadwinner provides economic support for his dependent wife and children, while the wife cares for both husband and children- remains central to all family ideology (Segal, 1983, p 13).
Although patriarchal values are inculcated in families, from a feminist perspective, they also permeate and influence society at all levels: political, economic and ideological. It is argued that historically the form that patriarchy has taken has been variable - religious, medical, scientific - but the essence remains the same and lies in a concept of a social order premised upon a male, and particularly paternal authority. At the root of patriarchy are notions of inequality, subordination and dependence. By definition this involves the dependence and service of women and children. For Gittens (1985) the pressures of the patriarchal ideology are clearly seen and acted out- and reacted against- in our inter-personal relationships, in marriages and non-marriages, in love and hate, having children and not having children. In short, much of our social behaviour occurs in, and is judged on the basis of, the ideology of the family.
For Braten (1983) one of the most striking aspects of modern society lies in the way in which the nuclear family has claimed a ‘model monopoly’. He suggests that this results when only one perspective on a complex reality is seen and acknowledged. In turn this narrows the range of available perspectives and denies that alternative possibilities exist. Levin (1993), takes up the idea of the nuclear family having a model monopoly and argues that its dominance at the level of ideology has meant the near invisibility of other family forms. To illustrate the point he recounts the story of a young school girl who informs her teacher that eleven of her siblings are coming to her tenth birthday party. The teacher is puzzled by this and does not believe the girl. Understanding her story as a symptom of other problems the teacher then refers his pupil to the school psychologist. However, the schoolgirl was not fantasising. She lived in a step-family and had eleven siblings, half siblings and step-siblings. For the teacher, her family structure did not exist, and her story made her a deviant (Levin, 1993).
Gittens (1985) suggests that many of the problems experienced by academics and others in defining the family lies in the very concept itself and the apparent determination to conceive of the family always in the singular; thereby implying that there can only ever be one correct type of family. She argues, both forcibly and persuasively, that in reality there is actually no such thing as the family - only families (Gittens, 1985). The concept of there being families rather than the family allows us to recognise that in reality people living in various types of household structure.
The family and social policy
Since the mid-1970s, it has been possible to detect, amongst all mainstream political parties, a growing rhetorical emphasis upon supporting the family (Morgan, 1985). Often this has been closely tied to debates about public expenditure in the fields of welfare, health and social security (Finch 1989). What is noticeable, however, is that what is meant by the family is rarely explicitly defined.
The basic ties of the family at the heart of our society are the very nursery of civic virtue. It is on the family that we in government build our own policies for welfare, education and care. You recall that Timothy was warned by St. Paul that everyone who neglects to provide for his own house (meaning his own family) has disowned the faith and is worse than an infidel (Lady Thatcher quoted in the Observer newspaper, 22 May, 1988) italics added.
In the 1980s the Conservative government became increasingly explicit about their wish to encourage families to take responsibility for their members. These themes were arguably most clearly spelled out in John Moore’s speech to the party conference in 1987. In the speech, which was largely concerned with the reform of social security, he spoke passionately of the need to move from a dependency culture to one of enterprise and individual and family responsibility.
For Van Every (1991), the common lack of a clear definition of the family in areas of public debate serves to mask the ideological construction which lies behind many policies. She argues that at the ideological and practical levels many social policies ranging across social security, housing, health and community care, are implicitly (and occasionally explicitly) aimed at promoting the view that the most desirable and natural family type consists of “a heterosexual, married couple and their own (genetic) children, conceived 'naturally' ” (Van Every 1991 p 63).
Finch and Mason (1993) have extended Van Every’s arguments by pointing out that along with the ideal composition of the family there also exists an ideologically constructed division of labour with responsibilities based upon gender differences. These relationships are seen to commonly involve: women becoming economically dependent upon men; women being responsible for the emotional support of their husband and children and engaging in the direct physical tending of dependent relatives; whilst at the same time men remain in a position of power and authority over both women and children (Van Every 1991 p 66). Similarly, for Oakley (1974; 1976) all too often social policies aimed at ‘supporting the family’ in effect mean supporting a particular type of household and a certain set of inter-personal relationships. In this type of household and kinship group, women provide the unpaid labour which secures the reproduction of the population and the care of the sick and elderly.
Both Van Every and Finch cite the recent reforms in community care as a good example of a social policy which promotes the responsibility of the family to care at the expense of state responsibility. Within the Griffiths Report (1988) and later NHS and Community Care Act, it is expressed unequivocally that ‘families friends and neighbours’ should continue to be the cornerstone of support for people who cannot fully care for themselves.
Publicly provided services constitute only a small part of the total care provided to people in need. Families, friends and neighbours and other local people provide the majority of care in response to needs which they are uniquely well placed to identify and respond to. This will continue to be the primary means by which people are enabled to live normal lives in community settings (Griffiths, 1988, para. 3.2).
Equally, the September 1988 reforms of Social Security for 16-17 year olds can be cited as a recent policy explicitly aimed at promoting family responsibility (in this case promoting parental responsibility for their teenage children). Under the 1988 regulations 16 and 17 years olds have no automatic right to state benefits (except in very exceptional circumstances). Rather, if a young person can not find work, their income is tied to attendance at a Youth Training Programme. Within the scheme the Training Allowance is set at a level which assumes that the young person will live with their family. Thus although the allowance varies with age it is never more than £40 per week. Further, when a 16-17 year old is not on a scheme (and there are a shortage of available places) they are only entitled to a £15 per week Bridging Allowance. The ideology behind this policy is clear, young people should live at home and parents have an obligation to support them. What has arguably not received sufficient attention is the fact that many young people leave home because of parental abuse or because their family can not afford to keep them (Roll 1990).
Pascall has made the crucial point that as the family stands for the private sphere and in juxtaposition to the public sphere of many areas of daily life, when the state pushes responsibility onto the family it is at the same time in effect abdicating responsibility.
The real meaning of supporting the family is supporting family responsibility, as distinct from supporting state responsibility, for dependants old and young (Pascall, 1986, p.38).
For Finch (1989), writing in relation to community care, the message is clear. It is assumed that the state’s responsibility is essentially discharged if a person lives with a relative. The question of what support is provided, its cost to the family carers, or the quality of care which an elderly, disabled, mentally-ill or mentally-handicapped person receives, are not matters with which state services need seriously be concerned. Langan (1990) has charted the history of community care in post war Britain and argued that resources have always lagged behind the political rhetoric.
The important point to emerge here is that when hard and fast boundaries are created between the responsibilities of state and the responsibilities of the family, and where certain issues and activities are located within the private sphere of the family rather than the public sphere of the state, there is an inherent danger that the state may deny its responsibilities and associated accountability. In other words, public domain issues may become privatised and presented and seen as the responsibility of individuals and families.
2. Health care professionals views of the family
Gaining an understanding of the ways in which the front-line health care professionals conceive of the family is of significant importance. It has long been recognised in the field of social policy that in order to adequately understand and evaluate policy outcomes it is necessary to give attention to the ways in which front-line staff actively interpret and opperationalise the policies handed down from the higher bureaucratic echelons (Lipsky 1980, Sabatier 1986). This theme is developed further in the final section of this report dealing with suggestions for the second stage of HEBS IYF Project.
However, having noted the importance of this section, it is necessary to report that repeated computer aided literature searches have identified very few works related to medical professionals’ views of what the family is or should be. This may in itself be a reflection of the power and prestige of the medical profession within our society. The one area where there is literature looking at doctors’ views of the family is in the expanding field concerned with assisted human reproduction.
In this area the recent work of Donavan (1993) is of particular interest. Donavan conducted in depth qualitative interviews with doctors working in fertility clinics. Her explicit aims were to gain an understanding of the ways in which the doctors made decisions concerning an applicant’s suitability for assistance with conception and more generally, made judgements about who should or should not become parents. Donavan reports that nearly all of the doctors in her study maintained that they tried to refrain from moral non-medical judgements during their practice. Her analysis reveals, however, that in reality this proved near impossible and doctors were forced to draw upon their own personal belief systems and what they perceived to be public opinion. This led to a situation whereby, in the main, the doctors aimed to reproduce the heterosexual nuclear family.
the majority of the respondents ... (sought) to reproduce the heterosexual nuclear family. A third of the respondents also preferred heterosexual couples to be married. Over half showed some allegiance to middle class norms in relation to financial, living and material resources and paid employment. The result of donor recruitment practices is that white people find it easier to attain access to parenthood through the use of DI (donor insemination). Women with disabilities and genetic conditions will also find the question of their access comes under scrutiny because of belief that genetic conditions should not be propagated (Donavan 1993 p 171) (brackets added).
Abbott and Sapsford (1990) offer insights into the role and practice of health visitors and their views of the family. This work is of particular interest because in the final section of this report it is suggested that health visitors should be included in the second stage of the HEBS IYF project. As Clarke (1982) notes, although health visitors are often charged with the care of elderly people in addition to children and mothers, in reality the majority of their time is spent working with families. For Abbott and Sapsford, although health visitors claim to engage in family health education and promotion rather than the policing of child care, and attempt to adopt a non-judgmental approach to their practice, they invariably resort to a common-sense notion of the ideal type of family in which to rear children. The authors argue that the common-sense notion of family most often used by health visitors is one that is essentially ‘patriarchal and middle class’ (Abbott & Sapsford 1990 p120). Rigler (1982) argues that the employment context of health visitors (often general practices) has important implications for their practice. Abbott and Sapsford, in searching for the reasons behind the ways that health visitors view and relate to families, look to the child development theories which are learnt during training. As they write:
We suggest that this tendency to work with an individualistic perspective is compounded by child development knowledge which health visitors learn on their specialist training courses ... and the stress that midwives and health visitors place on mother-child bonding and ‘normal’ mother-child interaction. Furthermore, psychological theories of child development tend to assume the ‘normal’ family, even if this is not made explicit (Abbott and Sapsford p 131).
Orr (1986) has provided an explicitly feminist analysis of health visitor training and practice which draws heavily upon the concept of patriarchy. Abbott and Sapsford summarise her arguments when they write:
health visitor training reinforces middle-class values, patriarchal attitudes to the family already held by trainees - that is, they are taught that the ideal-typical nuclear family is biologically given and socially necessary as the context for normal child development. She argues that rather than helping women to care for their own and their children’s health, the health visitor’s interactions are designed to reinforce/maintain/create the patriarchal nuclear family (Abbott & Sapsford 1990 p 131 referring to Orr 1986).
In relation to social work McLeod and Saraga (1988) provide evidence to suggest this professional group also commonly work with a particular model of the ideal family. The authors argue that social workers tend to focus more upon ‘unnatural’ families (single parents, step-fathers etc.), and their interventions reflect their views that the worst thing for any child is family break-up.
To summarise, academic work in relation to medical doctors, health visitors and social workers suggests that within all of these professions there is a tendency to work with a particular model of the ideal family type. Most commonly this appears to be the nuclear heterosexual family, wherein there are clear gender divisions and related responsibilities. Often, however, the professionals involved do not appear to be aware of the ways in which these common-sense notions of the family guide their practices. The following section will turn to look at the reality of the varying family types in Scotland.
3. The Changing Family
3.1 Introduction
Major demographic and sociological changes have taken place with regard to family composition this century, with the pace of change accelerating in the past two decades. Almost all developed countries have experienced changes of four principal types: a decline in fertility rates, the ageing of the population, an erosion of the institution of marriage, and a rapid increase in births outside of marriage. For Sorrentino (1990), each of these four trends have played a major part in the transformation of the family. Here statistical data is presented in order to elaborate the most significant demographic changes which have affected Scottish families in recent years and to demonstrate the multiplicity of family types.
3.2 Fertility rates in Scotland
The average size of British families has decreased during this century. Women are completing their families much sooner than in the past - most by their late 20s instead of nearly 40 (Anderson, 1985). As Lewis (1980) points out, the reduction in the number of births and pregnancies has had a dramatic effect on women’s health and their experience of motherhood (pregnancy, childbirth and child care). In the 1930s the average number of children per family in Britain was between five and six, today it is just over two. Table One below presents precise information on the changing fertility patterns in Scottish families over the period from 1970 to 1992.
Table 1
Births in Scotland 1970 to 1992
| 1970 |
1980 |
1990 |
1991 |
1992 |
||
| All births |
No |
88,569 |
69,355 |
66,322 |
67,393 |
66,145 |
| Rate 1 |
17.0 |
13.4 |
13.0 |
13.2 |
12.9 |
|
| Rate 2 |
88.0 |
63.7 |
59.1 |
60.1 |
60.0 |
|
| Live Births |
No |
87,335 |
68,892 |
65973 |
67,024 |
65,789 |
| Rate 1 |
16.8 |
13.3 |
12.9 |
13.1 |
12.9 |
|
| Still Births |
No |
1,234 |
463 |
349 |
369 |
356 |
| Rate 3 |
13.9 |
6.7 |
5.3 |
5.5 |
5.4 |
Rate 1-Per 1,000 population: Rate 2- Per 1,000 females aged 15-44: Rate 3- Per 1,000 total births including childbirth.
(source: Annual Report Registrar General for Scotland 1992)
The change in average family size has had important implications for the institution of the family and individual family members. In particular smaller families have meant fewer relatives to care for young children or other dependent members (Sorrentino, 1990). Lower fertility rates have also created the opportunity for women to participate to a greater extent in the labour market. And conversely, increased participation in the labour market has also led to lower fertility rates. The period from 1970 to 1990 saw a rise of 3 million in the number of women in Britain who are economically active. In Britain in 1971 approximately 50 per cent of married women were economically active by 1990 this figure had risen to 70 per cent (Social Trends 1992).
3.3 Marriage and Divorce in Scotland
Marriage rates for single persons aged 16-29 have been falling since 1970. In 1938, the percentages of males aged under 20 and 25 who were married were 2.1 and 28.0 respectively. The figure for those aged under 20 rose to a high of 12.7 in 1973 and has fallen in each subsequent year to 1.3 in 1992. For those aged under 25 the figure reached a high of 65.4 in 1970 and fell each year to 26.0 in 1992. The number of married females under 20 years rose from 12.5 per cent in 1938 to 30.6 per cent in 1966 before falling back to 4.5 per cent in 1992. The figure for females under 25 who were married rose from 49.2 per cent in 1938 to 78.0 per cent in 1969 but has since fallen and now stands at 38.7 per cent. The statistical trend over the last twenty years has been towards generally lower of marriage.
Table 2
The Number of Marriages in Scotland 1970-92
| 1971-5 Average |
1976-80 Average |
1981-85 Average |
1986-90 Average |
1990 |
1991 |
1992 |
| 41,605 |
37,801 |
35,755 |
35,400 |
34,672 |
33,762 |
35,057 |
(Source: Annual Report Registrar General Scotland, 1992)
However, although marriage rates are declining there were still 35,057 new marriages in Scotland in 1992, 1,295 more than in 1991. This 1992 figure being 23 higher than the five year average. The rate of marriage per 1,000 population was 6.9 for 1992, compared with a rate of 6.6 per 1,000 of the population in 1991. The average marriage rate for 1987-1991 was 6.9 per 1000 of the population.
Haskey (1993b) has calculated that if British divorce rates continue at the 1987 level, then almost four in ten marriages (37 per cent) will end in divorce. However, Haskey argues that the divorce rate is in fact likely to rise since divorce is taking place earlier, more marriages are remarriages (for at least one partner) and these are at the greatest risk of ending in divorce. The risk of divorce is also related to social class, especially for men. Those in social class V and the unemployed are most likely to experience divorce and least likely to re-marry (Haskey, 1984).
As table Three below shows the number of divorces in Scotland has risen steadily since 1970. The total number of dissolved marriages in 1992 was 12,479. This was a small increase of 80 on the 1991 figure. The highest number of divorces ever recorded in one year was 13,373 in 1985 (Annual Report Registrar General for Scotland 1992). In 1992 there were 9,376 children under 16 affected by divorces. Since 1980, the total number of children involved in divorces has fallen by 15 per cent. (Annual Report Registrar General for Scotland 1992).
Table 3
The number of divorces over time in Scotland (including nullities).
| 1971-5 Average |
1976-80 Average |
1981-85 Average |
1986-90 Average |
1990 |
1991 |
1992 |
| 6604 |
9067 |
11942 |
12067 |
12272 |
12399 |
12479 |
(Source: Annual Report Registrar General Scotland 1992)
3.4 Lone Parents
According to the General Household Survey 1991, the proportion of households in Britain conforming to the nuclear family type fell from 31 per cent in 1979 to 25 per cent in 1991. In the same period the proportion of families headed by lone parents increased from 8 per cent to 19 per cent (OPCS 1993). The number of lone parent families rose from 570,000 in 1971 to 1.3 million in 1991. At the same time the number of dependent children living in one parent families increased from 1 million to 2.2 million (Haskey, 1993a). The rise has been relatively steady year on year. Married couples with dependent children now account for just over eight in ten or four in five of families with children.
At the Scottish level, recent figures for lone parent households as a percentage of the number of households with children (aged 0-15) stands at 15.8 per cent (Census Report for Scotland 1991). This gives us a figure of 90,937 households (with children 0-15) in Scotland headed by a lone parent.
Table 4
Economic activity: lone mothers with child(ren) 0-15, Scotland 1991
| Number | percentage | |
| Full-time | 11,844 | 14 |
| Part-time | 13,264 | 15.7 |
| Self Employed | 933 | 1.1 |
| Other | 6,094 | 7.3 |
| Economically active students | 143 | 0.2 |
| Economically inactive | 52,107 | 61.7 |
| Total | 84,385 |
(Source: Census for Scotland 1991)
Lone parents are overwhelmingly women and not men. Therefore, at a Scottish level, we find that out of 90,937 lone parent households, 84,385 (92.8%) are headed by women (1991 Census). Importantly, they are also predominantly women who have had serious relationships with their children’s fathers but which have subsequently broke down. It is clear that marriage break-down is the major cause of lone parenthood. As the table below shows in 1992 the vast majority of births were to married couples
Table 5
(source: Annual Report Registrar General for Scotland 1992).
Live Births, Numbers by age of mother and marital status.
| Married |
| Year |
All ages |
<20 |
20-24 |
25-29 |
30-34 |
35-39 |
40-44 |
45> |
| 1992 |
45,839 |
757 |
8150 |
18786 |
13595 |
3979 |
530 |
18 |
| Unmarried |
| 1992 |
19950 |
4449 |
7255 |
4785 |
2378 |
808 |
144 |
5 |
However, the increase in the numbers of single mothers (i.e. unmarried and not cohabiting) has been especially marked since 1986, whilst the numbers of divorced lone mothers has stabilised (Haskey, 1993a). In this sense there are grounds for current claims that the recent steep upward curve in single parenthood result from changes in the behaviour of young, single women.
Table 6
Births to unmarried parents in Scotland 1970-92
| 1970 |
1980 |
1990 |
1991 |
1992 |
|
| Number |
6286 |
7760 |
17985 |
19662 |
20088 |
| Percentage |
7.7 |
11.3 |
27.1 |
29.1 |
30.3 |
(Source: Scottish Health Statistics 1993)
Among lone mothers it is those who are single (never married, not cohabiting) who have the highest proportions of young, especially very young children (Haskey, 1993a). Sixty per cent of their children are pre-school age compared with 25 per cent of the children of all lone parents (Brughes, 1993).
Table 7
Total children in families receiving one parent benefits by size of family, 1986-1991
| 1986 |
1987 |
1988 |
1989 |
1990 |
1991 |
|
| No. children in family |
||||||
| 1 |
39,000 |
44,000 |
47,000 |
48,000 |
50.000 |
53,000 |
| 2 |
19,000 |
21,000 |
22,000 |
22,000 |
24,000 |
25,000 |
| 3 |
4,000 |
5,000 |
5,000 |
6,000 |
6,000 |
7,000 |
| 4 or more |
1,000 |
1,000 |
1,000 |
1,000 |
2,000 |
2,000 |
| All |
63,000 |
71,000 |
75,000 |
77,000 |
82,000 |
87,000 |
(Source: Scottish Abstract Statistics 1992)
One parent families are not the only alternative to what has been described above as the nuclear family, although they are probably statistically the most significant. The numbers of single people living alone has also risen sharply in recent years, largely because of the ageing population and the fact that women outlive men (Arber & Gin 1992).
To summarise, in Scotland during the last 20 years marriage rates and fertility rates have both fallen. Statistical trends show an increase in divorce and marriage breakdown. Lone parenthood has risen significantly since 1971. The majority of lone parents are women whose relationships with the fathers of their children have broken down. Most lone mothers are economically inactive, possibly due to a shortage of adequate child care. It is statistics such as those presented that ring alarm bells in supporters of the family and traditional marriage patterns. For other commentators these statistics stand as evidence of the re- or de-construction of the family.
4. The role of the family in creating and maintaining health
Within the preceding sections it has been shown that, although there are important variations in the make up of households living in Scotland, the vast majority of people still live within what can be broadly termed a family unit. Moreover, as Cresson and Pitrou (1991) argue, the family remains a primary social institution which promotes and/or impairs the physical and emotional development and well-being of its members.
Habits of cleanliness, hygiene and nutrition are forged in the home. Individuals learn to relate to their bodies and the daily and annual rhythms of life are inculcated; knowledge of the many forms of self-medication are acquired in the home, and relationships with specialists are developed (Cresson and Pitrou 1991 p 213).
On a practical and empirical level, Graham (1987) notes that mothers provide vital and considerable informal health care to their families through many of their daily living activities. These include:
the daily routines of cooking and cleaning, washing-up and washing clothes, shopping, tidying and serving meals. ... the physical care of (children) bathing and changing nappies, settling to sleep and coping with wakeful nights and the social care of comforting, playing and supervising and disciplining. Finally informal health care ... (covers) the range of activities which bring mothers into contact with the providers of professional health care: visiting the doctor, dentist and child health clinic and caring for children and partners during times of sickness (Graham 1987 p 50) (brackets added).
It would, however, be incorrect to see families as living and acting within a social vacuum and as being completely free to promote and maintain their own health. Conversely, it is equally wrong to present a narrowly deterministic view of family life. The role of the families in health promotion and maintenance is therefore probably best seen as one which is active but also embroiled within particular broader social and cultural contexts.
The link between socio-economic circumstances and morbidity/mortality rates has been well documented (see Townsend, Davidson & Whitehead 1988 for statistics at a national level; Carstairs & Morris 1989 for comparative analysis between England, Scotland and Wales; Carstairs & Morris 1991 for data pertaining solely to Scotland; and Lothian 1989 for data pertaining to Lothian region). In short, for many common diseases and illnesses morbidity and premature death rates are higher for people in the lower social classes.
Recently, MacIntyre et al. at the Medical Sociology Unit (Glasgow) have attempted to go beyond merely proving a statistical relationship between social class and morbidity and mortality rates and have provided important insights into the ways in which geographical features and other structural factors place limits upon the ways families can actively promote and maintain their health (MacIntyre et al. 1989, MacIntyre et al. 1993, Sooman et al. 1993). As part of The West of Scotland Twenty-07 Study, MacIntyre and her colleagues provide a detailed comparative analysis of two contrasting areas of Glasgow (one affluent containing predominantly middle class people, the other deprived with mainly working class residents). The team showed, that irrespective of individual characteristics, the opportunity structure in the poorer area was less conducive to promoting and maintaining health than was the case in the better-off area (MacIntyre et al. 1993 p 223). As they comment:
Even for individuals who are similarly situated in terms of their personal circumstances (for example, with the same income, family size, and tenure of house), it seems likely that living in the NW would be more conducive to good health than living in the SW; healthy foodstuffs are more available, and cheaper, locally, there are more sporting recreation facilities within easy reach, better public transport, more extensive primary health services, and a less threatening local environment (MacIntyre et al. 1993 p 229).
On a more micro level, work in the area of lay-health-beliefs has sought to locate individuals’ and families’ health promoting and health damaging behaviours within their socio-cultural context. As Offer (1989) points out, from a medical point of view people’s lay theories and explanations of health and health promoting behaviours may often seem inadequate, muddled or even contradictory, but it is vital to understand them in order elucidate the factors affecting people’s openness or resistance to health education material and campaigns.
Here, in order to draw out some of the central findings of the lay-health beliefs literature, a sample of recently reported studies are reviewed. Within the following brief review the precise methods used in each of the cited studies are deliberately not spelled out. This is because the intention here is not to produce an annotated bibliography but rather to introduce the central themes relating to the need to locate health enhancing and health damaging behaviours within social and cultural contexts.
Watson (1993) in a recent article concerned with the male body image and health beliefs explored the male experience of health in the context of family responsibilities. He notes that:
Focusing on men who had children and were or had been married, or were otherwise in a stable relationship, was felt to be important for exploring the issue of how self and body image might be affected by life-course transactions such as marriage and parenthood (Watson (1993 p 247).
Watson argues that his participants most commonly saw health as a resource which enabled them to work and support a family. However, he notes that respondents also saw health as involving: emotional, mental and physical well-being; the absence of disease; and as being related to appearance and being a product of behaviour. These lay views concerning what constitutes health bear significant similarities to those reported by Williams (1983) in an earlier study of 70 Aberdonians.
Whilst recognising the limitations involved in generalising from a small scale study, Watson suggests that when men (re)enter the private domain of the home, fatherhood and marriage they also often leave behind the ‘public health morality’ (Crawford 1985) which implores them to actively maintain their health. He suggests that this public health morality becomes fragmented by:
a) the necessity to fit in with and satisfy a number of domestic imperatives such as family relationships, security, play and rest, and
b) by the fact that certain health behaviours begin to assume primacy derived from the way they are locked into everyday life, such as eating and food (Watson 1993 pp 251).
The theme of an individual’s stage in the life cycle affecting their health beliefs and behaviours is more explicitly addressed in the work of Backett & Davison (1992). The authors begin by noting that much health education material concerning diet, exercise, smoking and alcohol consumption is aimed at a broad spectrum of the community (although different mediums are often used). They point out that the underlying logic behind such an approach is that certain behavioural norms promote health irrespective of one’s age or sex. Backett and Davison argue that their combined data (some gathered in South Wales and some in Edinburgh, covering an age range from 5 to 75 years, n= 264), points to the fact that their respondents did not share the belief that certain behaviours were health producing or health damaging irrespective of age. Thus for example, their respondents suggested that when young an individual’s body can cope with certain levels of toxins and that such behaviours as smoking, having a bad diet, excessive alcohol consumption etc. could, in youth, be life enhancing activities. During adolescence such behaviours could be tolerated because they were seen as unlikely to persist into later life. Respondents also suggested that many of the unhealthy behaviours of youth were balanced by other healthy actions such as sport and other rigorous activity.
By contrast, Backett and Davison’s data relating to adults with young children suggested that this group felt that they had more of a responsibility to actively maintain their health because of their family caring responsibilities. Whilst at the same time, respondents pointed to the way in which caring for their children took up the time, money and energy which previously they had spent on leisure activities. For this group smoking and excessive alcohol consumption were seen as largely unacceptable because they were expensive and potentially disruptive to family life.
The work of Graham (1987a), offers interesting insights into how smoking (often cited as an archetypal health damaging behaviour) was seen and used by women actively engaged in caring for children with limited material resources. Graham takes as her starting point the fact that for women ‘to live with’ invariable also means ‘to caring for’ (see Graham 1987b) and sets out to:
explore the everyday world of informal health care in households with pre-school children. ... particular concern was with the impact of poverty and single parenthood on the way in which mothers perceived and tackled their health care responsibilities (Graham 1987 p 50).
Graham argues that most of the participating women had developed a two-tier strategy to cope with their considerable child care responsibilities. First, at moments of stress the mothers sought to create space, symbolically if not physically, by switching on the radio or television, leaving the room or by putting the child in another room. Second, the respondents described how they filled this space with self-directed rather than child-direct activities. For 63% of the mothers this involved either making a cup of tea/coffee or having a cigarette. Two-thirds of the smokers identified smoking as one of the most helpful strategies that they had for re-establishing the capacity to cope with their children (ibid p 54). Moreover, Graham suggests that for the women involved in caring for children on a full-time basis and living on Supplementary Benefit (now Income Support):
Smoking emerged as their only luxury and their only leisure activity. It was a moment of self-caring which, unlike a cup of tea or coffee, needed no preparation. ... In a life-style stripped of new clothes, make-up, hair-dressing, travel by bus and evenings out, smoking can become an important symbol of one’s participation in an adult, consumer society (Graham 1987 p 55).
Further support for Graham’s central arguments is provided in the work of Calnan and Williams (1991). Interestingly, however, Calnan and Williams suggest that there may also be a gender difference in relation to smoking behaviours. The authors argue that within their study working class men’s accounts of smoking stressed its habitual and social nature rather than the stress relieving qualities highlighted by women (ibid p 518).
What emerges from the brief review in this section is the necessity of recognising that families live within concrete socio-economic and environmental situations. The level of material resources which are available within the immediate environment, both public and private, necessarily affect the opportunities available to individuals and families to promote and maintain their health. Thus the work of MacIntyre and her colleagues provides a concrete example of the ways in which public resources can limit or enhance the health promoting opportunities open to families.
Further, the work in the area of lay-health beliefs draws attention to the fact that the family is by definition a group living situation and provides a micro social environment within which individuals engage in many types of social behaviour. In order to gain an adequate understanding of both health enhancing and health damaging actions, it is necessary to locate such behaviours within the context of the family’s daily life. In fact health enhancing and health damaging behaviours are only understandable when seen in the context of everyday life and people’s ideas about such things as involvement in paid work, domestic work, caring responsibilities and leisure activities. The situation is further complicated by the fact that from an individual’s perspective any one concrete action may be both health promoting and health damaging. Thus, in Graham’s work, whilst smoking clearly damaged the women’s physical health, they viewed the habit as promoting their psychological health in the sense of their ability to cope with their children. From this perspective insight is offered into how many people can simultaneously recount health education messages in ‘public accounts’, whilst engaging in health damaging behaviours during their everyday lives (Backett 1990).
5. The theoretical distinction between health education and health promotion and its relationship to the family
Within the original brief for this project the terms health education and health promotion were used in a way which suggested that they were near equivalents, (‘health education/promotion’). The work completed during the project suggests that this is to oversimplify a complex area. In a recent article to commemorate the 50th year of the Health Education Journal Tones (1993) reviewed the history of health education and health promotion in post war Britain. He argued that historically there have been important ideological differences between proponents of health education and health promotion, which have in turn led to them favouring different policies and strategies when attempting to improve the nation’s health. The term ideology is used by Tones solely to refer to:
that constellation of values and associated beliefs which provide people with meaning in their personal and professional lives and which would, inter alia, influence their preferred ways of working (Tones 1993 p 126).
For Tones health education has traditionally been conservative in nature and based squarely within the medical model of disease. Here policies and intervention strategies have traditionally been ‘top-down’ and authoritarian in their approach. Within this model specialists provide knowledge to non-expert audiences; with the needs of the community seen as best determined by the medical profession who subsequently instruct individuals and families in the correct way to promote their health. This view of health education leads Watson (1993) to comment:
The practice of traditional health education, concerned as it is with promoting ‘healthy’ behaviours (healthy eating, exercise, drinking sensibly, and managing stress), and seeking to eliminate unhealthy behaviours (eating to excess, smoking and drinking to excess), has been likened in recent sociological enquiry to society seeking to impose control over individuals and ‘order’ populations through specific forms of health behaviour aimed at controlling bodies (Watson 1993 p 251).
By contrast health promotion, which Tones argues came increasingly to the fore in the 1970s, can be seen to be the ‘militant wing’ of public health. For Tones the ideological essence of health promotion can be captured under five central points: first, there is an emphasis upon de-medicalisation; second, there is an explicit acknowledgement of the importance of socio-economic and environmental (rather than individual or medical) influences on health; third, there is a call for the consideration of health issues in all areas of public policy; forth, the need for inter-sectional collaboration between informal, voluntary ‘not-for-profit’, commercial and statutory sectors is acknowledged and finally, and above all else, the need to remedy inequalities is advocated. Within the health promotion ideology the emphasis is upon ‘bottom-up’ strategies which attempt to empower the community and involve them directly in the determination of their own health needs and the ways in which they are best addressed. Here then there is more emphasis upon ‘felt needs’ as opposed to the professionally ascribed needs in health education. Tones draws a parallel between the ideology of health promotion and wider community development approvingly quoting the Gulbenkian Foundation:
Community development ... is concerned with the worth and dignity of people and (the) promotion of equal opportunity ... (it) ... is most needed in communities where social skills and resources are at their weakest ... (it) ... involves working with those most affected by poverty, unemployment, disability, inadequate housing and education and with those who for reasons of class, income, race or sex are less likely than others to be, or to feel, involved and significant in local community life (Calouste Gulbenkian Foundation 1984, quoted in Tones 1993 p 131).
A recent editorial commentary in Health Education Research (1992) makes a similar point to that of Tones in calling for research contributors to take explicit account of the impact of the wider socio-economic and socio-political contexts when reporting both the design and implementation of health education and health promotion programmes.
The WHO defines health promotion as ‘a unifying concept for those who recognise the need for change in the ways and conditions of living, in order to promote health’ (WHO 1986) and identifies five principles which reflect health promotion.
- Involving the population as a whole in the contexts of their everyday lives, (rather than the populations at risk for certain diseases).
- Being directed towards action on the determinants of, or causes of health
- Being diverse in methods and approach
- Involving effective and concrete public participation
- Not being a medical specialism
(WHO 1986).
Clearly the model constructed by Tones (and others) is one of ideal-types and he is the first to acknowledge that in reality many strategies aimed at the improvement of the communities health cannot be divided neatly into ‘politically correct’ bottom-up community empowering projects and blatant top-down manipulative or controlling programmes. Moreover, as Fieldgrass (1992 p 8) has argued health education has always had, and will continue to have, a pivotal role within wider health promotion strategies. This point is illustrated nicely by Clark (1993) who, in a recent discussion of the ethical issues faced by nurses engaged in health education, extends the concept of health education to include nurses in developing their clients’ decision making and assertiveness skills:
The health educator is required to be aware of these (ethical) issues and of the need to respect and develop personal autonomy with his/her clients ... This can only be achieved if the health educator begins to educate clients not just in the do’s and don’ts to promote and maintain health but also in the development of health-related life skills such as personal awareness and decision-making and assertive skills that will be helpful in their self-development (Clark 1993 p 535) brackets added.
Moreover, in reality in addition to the ideology lying behind the type of intervention programmes which are initiated to promote a community’s health it is also necessary to recognise the effect of such considerations as cost and the issues surrounding the striking of a balance between the extensiveness of a particular programme’s coverage and the intensiveness of the work.
Although the difference between health education and health promotion is in practice often clouded, the distinction is important when we consider the role of families in the promotion and maintenance of their health. As has be suggested in previous sections ideologically the family is often portrayed as the archetypal private domain and as juxtaposed to the public domain of many other areas of modern life. Almost by definition within the ideology of health education the aim is to change individual behaviours. The locus of health problems are squarely within individuals’ behaviours and there exists a built in tendency to stress aspects of ‘individual responsibility’. Often this is to the exclusion of adequate consideration of the environmental and structural constrains faced by individuals and families and the ways in which health damaging and health promoting behaviours exist within the cultural contexts of people’s daily lives (see section on lay-health beliefs). The danger then within the health education ideology is that it is all too easy to de-politicise health issues and lapses into what has often been termed ‘victim blaming’ (MacIntyre 1993). This potential danger would appear to be increased if health education is tied to or targeted at the family because ideologically the family stands for and is a private domain social institution. As MacIntyre writes:
...many health promotion or public health policies focus on individuals and their behaviours (DH 1992: SOHHD 1992: Reid 1992) A large proportion seem to be based on the principle that if working class 'people' could only become more like middle class 'people', then their rates of illness and premature death would become more like those of middle class people. An alternative approach would be to try to make working class 'areas' more like middle 'class' areas by improving the social and physical environment (MacIntyre 1993 pp 229-30)
6. A review of health promotion / education policies and intiatives oriented towards the family
6.1 Introduction
A considerable amount of time was directed towards the collection and review of health education and/or promotion initiatives and policy statements. I targeted, in the first instance, policy statements that issued from various tiers of the formal health structure in Scotland, and also the policy documents produced by bodies contributing to the development of policy in this area. The Scottish Office, Health Boards, Health Councils and major voluntary sector organisations, amongst others, were approached. The inventory at the end of this document provides a more comprehensive list of the organisations contacted, as well as details of the documents reviewed.
Due to the volume of policy documents and information about specific initiatives received it is necessary to impose a structure on this review. Accordingly, central policy documents are reviewed under headings reflecting their point of issue. However, in the case of some voluntary sector initiatives the ‘issue area’ forms the heading. A section is also included on ‘Joint Working’ initiatives. At the outset it must be noted that the aim here is not to recount the content of all the policy documents and initiatives, but rather to give a flavour of what is happening in Scotland with regard to family health education and/or health promotion. Therefore, in the case of Health Boards only four regions policies are reviewed; these are chosen to illustrate the variation in current approaches. A bullet point summary is provided at the end to this section.
6.2 The Scottish Office
None of the Scottish Office policy statements relating to health education and/or health promotion refer explicitly to the family. Its publications over the last few years have set national targets for health improvements which are predominantly oriented around the individual opting for what are variously termed ‘lifestyle changes’ or moving to a ‘positive lifestyle’.Scotland’s Health: a challenge to us all sees such changes as being achievable through ‘individual decisions’ supported by government groups and ‘communities’. The family, as a diverse social group to which most people belong, is not mentioned. The emphasis remains upon individual responsibility.
Targets and initiatives are important but ultimately the improvements in health we all seek will only be brought about by the determination of each one of us to give effect to necessary changes in our lifestyles and habits. The forms of personal behaviour which most contribute to ill-health are smoking, poor diet, excessive use of alcohol and lack of physical exercise (Scotland’s Health: a challenge to us all, p12).
Similarly, the leaflet Scotland’s health: a challenge to you, is designed for the individual to read with a view to making a ‘lifestyle change’. It lists guide-lines for ‘sensible living’ which refer to the family implicitly in ‘Tips for the Home’ and the sphere of accident prevention. However, most of its contents flow from the assertion that ‘personal behaviours contribute to ill health’, though other contributory factors external to individual behaviour, such as ‘housing, unemployment and socio-economic circumstances in general’ are mentioned very briefly (in one sentence).
The 1993 Report The Scottish Diet considers the main obstacles to dietary change as ‘motivational’, and whilst it never refers directly to the family, it does identify the ‘household management of food provision’ as the forum in which diets can be improved, ‘especially amongst low income groups’ (p76).
Health Education in Scotland (1991) stresses the importance of collaboration between Health Boards and Social Work Departments in areas of ‘multiple deprivation’, and espouses what it terms a ‘broader health perspective’ based on a ‘recognition’ that health promotion involves issues of the environment, housing, and urban renewal, amongst other things.
The statement also recognises that ‘Health Education will also have to adapt to changing family structures’, and includes amongst its objectives the elevation of public awareness of the ‘problem of accidents in the home’ (particularly amongst the young and the elderly), and the desirability of drawing parents, as well as young people, professionals and volunteers, into ‘drug education’ programmes. Much of the success of such aims it sees as dependent upon the involvement of communities in the development and implementation of health education programmes which, the document emphasises, ‘can have a powerful influence on their success through the sense of ownership this brings’ (p18).
The report notes that Social Work departments are often engaged in programmes with families in socio-economic groups where ‘illness and unhealthy lifestyles are often a particular feature’ (p19). There are opportunities, it concludes, for health care professionals, working in co-operation with social workers, to ‘promote good health in providing for families with young children’ (p19). As will be shown below, Fife is one region that has produced a strategic document in which health promotion is discussed in the context of the changes in Community Care.
6.3 Health Boards
Within Health Boards’ literatures and activities there is a tendency to categorise activities as either topic-based or settings-based (for example, see Greater Glasgow Health Board). Hence, campaigns against smoking, drug abuse, bad diets and the promotion of safe sex can be seen as topic-based programmes, whilst safety at work or community development initiatives are programmes that are settings-based. Inevitably there is a great deal of overlap between these two broad classifications and topic-based issues need to be operationalised within specific settings. Similarly settings-based initiatives normally address a range of specific topics. Interestingly, however, the family is never cited as being a forum for settings-based initiatives, except insofar as the ‘household’ is a context of accident prevention policy. Rather, when the family is mentioned it is normally in relation to topic-based projects, such as the role parenting can play in early health ‘education’ (see below). This may well reflect Health Boards’ recognition of: the wide variety of family structures; the fact that families live in different geographical settings; and that the needs of individual family members differ according to their age and sex.
One curiosity is that the ‘workplace’ is frequently discussed in terms of a health setting, but recognition that the family, or at least the household, might also be a place of work is not forthcoming. For instance, the Operational Plan of Greater Glasgow’s Department of Health Promotion aims to ‘cultivate the workplace as a setting for health promotion, through developing health policies and providing opportunities for lifestyle changes in the key worksites’. In conducting this part of the research, no evidence of policy-makers giving consideration to the work done, mainly by women, in the household, was evidenced.
The original brief for this report requested information on whether family health promotion/education initiatives utilised a broad view of health (including emotional, social and environmental elements) or whether they were working with a narrower ‘physical illness’ model. The answer to this question is complex. Most literature produced by Health Boards espouses broad definitions of health, often citing the World Health Organisation (WHO) when setting out aims and objectives (see, for example, the Annual Report of the Director of Public Health in Lothian, 1992). Health Boards tend to readily acknowledge the relationship between socio-economic and geographical situations and their population’s health.
Health Boards also often stand between the low level, bottom-up, community development initiatives and the top-down health education-oriented policies found in Scottish Office materials. It would be wrong, however, to give the impression that all of the Health Boards are following broadly similar policies with regard to health education and health promotion. Although all Health Boards are producing local health targets as required by the Scottish Office's Challenge to us all, their rhetoric and methods for achieving these vary considerably. The approaches of Glasgow and Lothian, for instance, are significantly different from those of Argyll and Clyde. The policies and initiatives of these three Regions are briefly reviewed below.
6.4 Lothian
The Annual Report of Lothian's Director of Public Health (1992) contains a section entitled Social Environment within the Family (pp 24-7) which notes the importance of emotional relationships and parenting and the problems (such as unemployment) facing families. It notes that because of the physical dangers to which children are increasingly vulnerable to when playing outdoors, ‘parents are keen to encourage children to follow indoor pursuits such as TV and video games’. This was the only example in the search of consideration being given to aspects of emotional health bound up with family relationships, which also considered how changing patterns in the leisure activities of families, particularly children, may be related to issues of health promotion. The subsequent section on ‘Poverty’ notes that ‘Low income also increases the chances of families having poor access to health care and to social and recreational facilities’ (p33), but that despite this ‘research shows that all parents...place a high priority on health and set high standards for the health of their children’. Finally it recommends that ‘each of us should do all we can to support and help others - in our families, in the neighbourhood, at work and in the wider community - particularly for children and families’ (p 138).
Health in Lothian: Annual Report (1992) , despite recognising the importance of life-style issues, places a strong emphasis upon a broad range of environmental influences on health (ranging from ecology, through unemployment, to the influence of television and the impact of poverty). The report draws upon the themes within Facts of life (a joint UNICEF, WHO, UNESCO AND UNFPA document) and in an appendix is found the World Declaration on the Survival, Protection and Development of Children. Within the document there is a clear wish, at least at the level of rhetoric, to place Lothian’s health issues and initiatives within a broad global context. Attention is drawn to international issues and solidarity is sought of, and requested from, other nations.
6.5 Greater Glasgow
Greater Glasgow’s Health Promotion Strategy begins by asking ‘who should be involved?’ (p3) and lists ‘health education, medicine, nursing, teaching, housing, social work and environmental health’. Subsequently, the report notes that:
The task for professionals is to enable individuals and communities to live healthy lives. Therefore to be successful, health promotion depends on community participation but to achieve this, comprehensive programmes of health promotion need to be established in key community settings (primary health care, hospitals, schools, and other educational institutions, the work-place, deprived communities etc.) and developed with key community groups (e.g. children, women, expectant parents/parents of babies and young children, ethnic minorities, etc.)
What is noticeably absent is any explicit mention of the family, apart from more oblique references to ‘agencies which influence health’. In fact, it is not until the list of various programmes in the appendix that families are discussed, and then it is in relation to a programme aimed at the Promotion of Child Health and Safety (p 15). Here three of the central objectives are noted as being:
- To equip parents to be family health promoters
- To prevent accidents in the home by promoting home safety
- To pilot the use of a parent-held record as a tool for health promotion
6.6 Argyll and Clyde
Argyll and Clyde’s Health Promotion Strategy (1993) whilst quoting the WHO’s definition of health on its cover, focuses almost totally upon the life-style factors which affect health. The document sticks closely to the national targets set by the Scottish Office and notes that, in line with the strategy advocated by HEBS, four settings will be targeted: Health Service, Schools, Workplace and Community and Voluntary Groups.
Noticeable by its absence is any reference to the family as a setting. Within the region a ‘life-style’ survey has been conducted and this is used to guide initiatives and programmes to help promote health. Socio-economic issues such as the effects of poverty upon health in both its physical and emotional/psychological dimensions, are not explicitly addressed. The emphasis within the Argyll and Clyde’s Health Promotion Strategy (1993) is captured well in the following quotation relating to work-place initiatives:
A senior Health Promotion Officer has been appointed to assist workplaces to develop ‘health promoting premises’. This will include policies on topics such as smoking, nutrition, stress and alcohol aimed at providing a working environment which supports people making healthy choices, offering support mechanisms to staff to help them make changes and supplying information to increase awareness (Argyll and Clyde’s Health Promotion Strategy 1993 p 18).
6.7 Joint working
A further important and recurrent theme during conversations with workers within the health education/promotion field (at all levels) was their frustration at the perceived lack of co-ordination between various agencies (statutory, voluntary ‘not-for-profit’, commercial and informal). Many people working in health education/promotion appear to believe that for objectives to be realised, it is necessary for all sectors to work together. The need for co-operation between various sectors is something explicitly recognised in recent Scottish Office literature (e.g. Health in Scotland 1991). Most of the workers who I have spoken to do not think that this is happening at present. The notable exceptions to this being Fife’s policy document ‘Towards 2000’ which is a joint strategic document between the Health Board and Regional Council: and the work in Glasgow through the Healthy Cities and the Glasgow 2000 initiatives.
6.8 Fife
Fife’s Towards 2000 is a good example of how health promotion and community care policy has been linked. It takes the view that ‘social and health needs are so enmeshed amongst client groups (e.g. children and families) that joint planning and joint operational activity are essential’. To this end, a ‘multidisciplinary’ approach to the provision of services to client groups has been adopted, where the Social Work Department and the health Board co-operate with Housing and Education Departments and the independent sector. Amongst its goals, notably, is a commitment to ‘create a healthy environment at home (my emphasis), work, and leisure’.
Fife has also adopted the recommendations made in Health Care and Travelling People: A Charter for Health for Travelling People, produced by the Scottish Association of Health Councils in September 1992. This report arose from, amongst other things, a concern over the extent to which Health Needs Assessments take account of travelling families. Since 1988, the community care unit of Fife Health board has allocated 50 per cent of one Health Visitor’s time specifically to Travelling People in the Health Board’s area. The Board has issued Parent Held Child Health Care Records and has developed a Traveller Held Health Care Record.
Another important jointly produced document is the Lothian Children’s Family Charter (1991). This document was developed jointly between the Social Work Department, the Education Department and the Health Board and, in its statement of principles, affirms ‘the central importance of the child and the primacy of the family and accepts the obligation to listen directly and carefully to their wishes and feelings affecting the quality of life’. It notes that it is ‘firmly committed to putting the family at the centre of (its) endeavours’ (p3). Under the section relating to Health: safety and security thirteen principles are laid down. Four of these principles are noted to be entitlements under the terms of the charter.
1) Opportunities for their parents to seek advice and comment on their health and educational development. This advice should be shared in ways appropriate to understanding, sensitivities, background and culture of the individuals involved.
2) A school curriculum which should help children to protect themselves, e.g. against bullying or physical/emotional/sexual abuse: awareness of the importance of environmental conservation.
8) Help to overcome the effects of any harm which has already been experienced.
13) Transitions of health care from hospital to home, and between other forms of care, e.g. home to school or from school to school, being discussed and agreed by themselves and parent(s).
Health Education, according to the Charter, ‘should be provided in schools and by parents at home’, and ought to include issues such as nutrition and diet, decisions about smoking, advice about responsible relationships, family planning, sex education and the risks of HIV and AIDS. Overall, then, there is a concern that wherever possible, ‘parents and children should be involved in decisions about their health’.
6.9 Community level
The top-down medically oriented and bottom-up community development approaches have been discussed in a previous section of this report. This section will concentrate on the WHO’s Healthy Cities Projects and how they relate to families. The Drumchapel Community Health Project, as one example, works on a very much ‘bottom-up’ community development model. Thus the vehicle of producing a community health profile was utilised in order to enable local people to identify their own health needs and to facilitate collaboration between statutory agencies and the local community. The key principles behind the initiative are stated as being ‘empowerment, participation and collaboration’ (ibid. p 32).
One crucial way of empowering local people is to give them access, on an equal basis, to professionals representing different local agencies. To be on first names terms with these people and feel able to get in touch with them with a query or request. ... But it is not only barriers between workers and residents that were broken down; involving representatives from Housing, Social Work and the Local Volunteer Project in defining the local health agenda, had a very powerful effect on these agencies’ attitudes to local health issues (Kennedy 1992 pp 32-33)
What the Glasgow Healthy City Project terms the ‘whole person approach’ takes account of all the inter-related social and economic factors which affect health yet, perhaps surprisingly, family formation and family structures are not mentioned in the discussion about individuals identifying their own health needs.
Within Lothian the ‘Health Hut’ in Greater Pilton runs a ‘Good Food Project’ which operates through ‘fruit and vegetables’ co-operatives in the area.
traditionally, health education messages have tended to urge people to eat good, healthy food without taking account of how expensive and often difficult this can be for people on low incomes of income support...against this background, a planning group was recently established to review the ways in which this service could develop on a more secure footing...The group looked at a variety of ways in which food could be provided more cheaply in the area and practical ways of encouraging more discussion about healthy food.
The Pilton initiatives stands as a good example of the ways in which a local community might attempt to improve local health, yet the family or the household are not cited as sites where people collectively eat, or where information is exchanged. Rather, the concentration is on attracting local people to become directly involved through engaging the interest of community groups, such as women’s groups.
6.10 Accident Prevention
Although most policy documents reviewed above discuss the importance of accident prevention, and the role parenting plays in this process, it is worth considering the Child Accident Prevention Trust’s Basic Principle of Child Accident Prevention - A Guide to Action for its more detailed consideration of the factors at play in this sphere of health. In discussing the location of responsibility for accident prevention, this document is keen to point out that parents and children can play a role by ensuring a safe environment and safe products. However, it also notes the links between social class and deaths caused by accidents - ‘Children from economically deprived backgrounds have a markedly higher death rate from accidents’ (p16). It is keen to stress the advantages of local action which ‘lie in the possibility of affecting policies and priorities by raising public awareness, educating parents and children, heightening the individual’s and community’s sense of responsibility to care for and protect children’. Furthermore, it concludes that ‘District health authorities and local councils are the starting point for action’ (p19).
The Trust suggests that this is most likely to happen through the contact between health service personnel (health visitors, district medical officers, GPs, practice staff, midwives, nurses, accident and emergency staff, paediatricians, community physicians, health promotion workers etc.) and parents and/or children, either in their general health promotion work or by influencing local policies. Parents, carers, childminders and children themselves are on the list of ‘who to target’, along with the health service personnel mentioned, the media, industry and commerce and education, but in terms of the ‘home’, most emphasis is placed on the ‘design and construction of the environment’ rather than education within its confines.
Summary of central findings
- Few policy initiatives are aimed explicitly at the family.
- However, most health education and health promotion policies have implications for people living in families.
- Most policy statements which are directed towards families concentrate on ‘parenting’ and its importance in the field of accident prevention and child development.
7. Recommendations for stage two of HEBS International Year of the Family Project
Within the original brief for this report recommendations were requested regarding the second phase of HEBS IYF project. More specifically, I was asked to provide some suggestions concerning which policy makers and practitioners it would be most appropriate to include in the empirically based second stage of the project.
First, it necessary to think carefully about the ways that the terms policy makers and practitioners are being used. This is more than just a semantic point. When undertaking any piece of evaluative research it should always be recognised that the evaluation is taking place from a specific perspective (most commonly that of the organisation’s management). However, it is naive to assume that all members of the organisation share common goals and perspectives and are always pulling in the same direction. As Barrett and Fudge (1981), Lipsky (1980) and Sabatier (1986) have all shown, an adequate evaluation requires gaining an understanding of the ways in which ground level workers interpret and operationalise the mandates and directives received from above. Lipsky has gone so far as to argue that ‘street level bureaucrats’ actually make policy in many governmental organisations through the exercise of discretion in their dealings with the general public.
Sabatier (1986) has called for evaluative research to take account of both ‘top-down’ and ‘bottom-up’ approaches when attempting to understand policy making, policy implementation and policy outcome. Like Lipsky, he argues that an adequate analysis requires an understanding of front-line workers’ actions and the meanings that they attach to them. However, he also argues that it is necessary to locate the actions of front-line professionals within their broader organisational context. He makes the point that the directives and available resources from the bureaucratically higher parts of the organisation place important limits upon what front-line workers can and can not do.
In many ways the most obvious group of professionals to include in the second stage of this project would appear to be health visitors, due to their daily contact with families. As DeAth (1982) writes:
The health visitor appears to have a pivotal role in the life of the community and of her clients which has been well recognised by the caring professions as well as numerous select committees. She stands at the interface between ‘institutional’ knowledge (with her understanding of hospitals and medical providers, health and hygiene, drugs and technology gained during SRN training) and ‘community’ child-rearing patterns and expectations, life-styles and ‘life-chances’, local folklore and the range or lack of neighbourhood services ( DeAth p 283: quoted in Abbott & Sapsford 1990 p 127)
The importance of the work of Sabatier, Lipsky, Barrett and Fudge and others, lies in the way that they draw attention to the fact that front-line workers (in this case health visitors) in many ways actively create policy, but importantly, within the constraints of particular contexts. As noted in a preceding section, Abbott and Sapsford (1990) suggest that the fact that many health visitors work within or from a General Practice affects the opportunities available to them. Some support for this assertion is also found in the literature relating to the activities of practice based nurses. Thus Bradford and Winn (1993), in a recent study of General Practice based nurses, found that whilst many respondents agreed with the basic ideas of more radical health promotion, the medical-models they employed in their daily work were invariably conservative.
The implication of this may be that while many practice nurses recognise that health promotion has socio-political implications, the concept appears to be far removed from their working practice. ... although 22 per cent ranked the social change model highest, only two per cent said that it was the model they used in practice. Thus it seems that there is some agreement in principle with more radical approaches to health promotion, but their application in practice nursing is at present limited (Bradford & Winn 1993 p 95).
Interestingly, though, the review of work being undertaken in Glasgow for the Healthy Cities Project suggests that, in that Region at least, some health visitors are attempting to engage in health promotion as well as health education. The Community Development Strategy, therefore, includes a statement from a health visitor engaged in community development in Drumchapel. As she writes:
The health issues in an area like Drumchapel are many and complex, and there can be no one way to address the health needs. In working with the Project I have had the opportunity to use my health visiting training to the full- in the process of identification of health needs; increasing community participation in health activities and in decision-making forums; breaking down barriers between the agencies with input to community health work; and empowering local people to have more control of personal and local issues (Craige P in ‘Community Development Strategy: community support unit Glasgow health city project’-Draft July 1993).
As noted, there is limited recent academic work looking specifically at health visitors’ views of family life. Given the multiplicity of family types in Scotland, information would be useful on the ways in which health visitors view and interact with various forms of family and their views of correct and/or inappropriate gender roles. It would also be very interesting to know how the organisational context within which heath visitors work affects their views of their roles, in terms of health education and health promotion or some combination of the two. These are all areas worthy of empirical investigation and would make a valuable contribution to the International Year of the Family.
In order to gain an understanding of the contexts in which health visitors work it would appear necessary to ask them directly how they perceive the contextual pressures upon them. If resources allow it would also seem advisable to interview their daily line managers. This will provide data on the role that front-line team leaders expect health visitors to fulfil (this may involve interviewing General Practitioners but the situation appears to vary between areas and regions).
Equally, an adequate understanding of the role of health visitors engaged in health promotion and health education work with families requires speaking to their clients. It is only through meeting and talking with families that the implications of the worker’s advice and/or actions can be understood and located the within the context of the family’s daily life.
In addition to gathering these front-line views, following Sabatier, I would also advise that data be collected from health visitors’ senior managers (senior members of Health Promotion Departments might also be appropriate here). In this way it will be possible to gain an understanding of the role that these policy makers play in shaping the context within which health visitors work.
Within the preceding review of current (and recent) policies, programmes and initiatives aimed at the promotion of family health, it was noted that there are significant variations in the approaches taken by different Health Boards. For example, in the previous section it was suggested that the approach of Glasgow (particularly in the context of the Healthy Cities initiative) is significantly different to that of Argyll and Clyde. Within the empirical part of this project the taking of two contrasting regions or areas would appear sensible, as it would allow for comparative analysis and ultimately more understanding of the ways in which different policy contexts affect the work of front-line workers (in this case health visitors).
Clearly, whether the line of enquiry suggested is feasible will depend, in large part, on the available resources and the time schedule for the completion of the project. If it is not possible to take account of all of the suggestions made here, it is hoped that the issues raised will at least be of use when considering the direction of the second stage the project.
8. References
Abbott P & Sapsford R (1990) Health visiting: policing the family? in Abbott & Wallace (eds) The sociology of the caring professions Basingstoke, Falmer.
Anderson, M (1985) The Emergence of the Modern Life-cycle in Britain. Social History 10 (1): p.69-87.
Arber, S & Ginn, N (1992) Gender in Later Life London Routledge.
Audit Commission for Local Authorities in England and Wales (1985) Managing Social Services for the Elderly More Effectively. London: HMSO.
Backett K & Davison C (1992) Rational or reasonable? Perceptions of health at different stages of life. Health Education Journal vol 52/1 pp 55-59.
Backett K (1992) Taboos and excesses: lay health moralities in middle class families. Sociology of health and illness Vol 14 No2 pp 255-273.
Backett K (1992) The construction of health knowledge in middle class families. Health Education Research Vol 7 No4 pp 497-507.
Barry, J (1994) Caring in the Context of Older People's Lives. Paper to Centre for Family Research. University of Cambridge.
Barrett S. & Fudge C. (1981) Policy and action: essays in the implementation of public policy, Methuen, London.
Bernardes, J (1993) Responsibilities in Studying Postmodern Families. Journal of Family Issues, Vol. 14 No.1, March p. 35-49
Brannen, J & Collard, J (1982) Marriages in Trouble: The Process of Seeking Help. London Tavistock.
Brannen, J & Wilson, G (eds) (1987) Give and Take in Families. London Allen & Unwin
Braten, S (1983) Dialogens vilk ar i datasamfunnet. Oslo, Norway: Universitetsforlaget
Calnan M & Williams (1991) Style of life and the salience of health: an exploratory study of health related practices in households from differing socio-economic circumstances. Sociology of Health and Illness Vol 13 No 4 pp 506-529.
Calouste Gulbenkian Foundation (1984) A National Centre for Community Development: Report of a Working Party. London Gulbenkian Foundation.
Campbell, B (1993) Goliath: Britain's Dangerous Places. London, Methuen.
Carstairs V & Morris R (1989) Deprivation: explaining differences in mortality between Scotland, England and Wales, British Medical Journal 299 pp 886-9.
Carstairs V & Morris R (1991) Deprivation and Health in Scotland, Aberdeen, Aberdeen University Press.
Cheal, D (1991) Family and the State of Theory. New York, Harvester Wheatsheaf.
Clark J (1993) Ethical issues in health education British Journal of Nursing Vol 2 no.10 pp 533-538.
Clarke J (1982) A way to get organised Nursing Times Vol 68 No 31 pp 287-97.
Collins, R (1985) 'Horses for Courses': Ideology and the Division of Domestic Labour. in Close P & Collins, R. (eds) Family and Economy in Modern Society Macmillan Press.
Crawford R (1985) A cultural account of health control, release and the social body In McKinlay J (eds) Issues in the political economy of health London Tavistock.
Cresson G & Pitrou (1991) The role of the family in creating and maintaining healthy lifestyles. In Badura and Kickbusch (eds) Health Promotion Research: towards a new social epidemiology WHO Regional Publications European Series No. 37
DeAth E (1982) A preventive approach to family life: the role of the health visitor Health Visitor 55 pp 282-4.
Denscombe M (1993) Personal health and the social psychology of risk taking. Health Education Research Vol 8 No. 4 pp 505-517.
Donavan C (1993) Keeping it in the family PhD thesis University of Edinburgh.
Fieldgrass J (1992) Partnerships in health promotion and collaboration between the statutory and voluntary sectors, Health Education Authority.
Finch, J (1989) Family Obligations and Social Change. Polity Press.
Finch J & Mason J (1993) Negotiating Family Responsibilities London Tavistock/Routledge
Flandrin, J-L (1979) Families in Former Times. Cambridge University Press, Cambridge.
General Household Survey (1991) HMSO
Gittens, D (1985) The Family in Question: Changing Households and Familiar Ideologies. Basingstoke, Macmillan.
Graham H (1987a) Women’s smoking and family health. Social Science and Medicine Vol 25 No1 pp 47-56.
Graham H (1987b) Women’s poverty and caring. In Glendinning C & Millar J (eds) Women and poverty in Britain Wheatsheaf Books Brighton.
Griffiths, R (1988) Community Care: Agenda for Action. A Report to the Secretary of State for Social Services. London HMSO
Gubrium, J F & Holstein, J A (1990) What is Family? Mountain View, CA Mayfield.
Hareven, T (1982) Family Time and Industrial Time, Cambridge University Press, New York.
Haskey 1993 Trends in the numbers of one parent families in Great Britain. Population Trends 72 pp 26-33.
Haskey, J (1993a) Trends in the Numbers of One-parent Families in Great Britain. Population Trends 71:26-33.
Haskey, J (1993b) First Marriage, Divorce and Remarriage: Birth Co-hort Analyses. Population Trends 72:24-33.
Health Education Research (1992) Editorial- ‘health education research: theory and practice-future directions’ Vol 7 No. 1.
Hunt S, McKenna S, McEwen J, Backett E, Williams J & Papp E. A Quantitative approach to perceived health status: a validation study Journal of Epidemiology and Community Health Vol 34 pp 281-286.
Kennedy A (1992) Local Voices, Local Lives: the story of the Kendoon community health profile Glasgow, Drumchapel Community Health Project.
La Fontaine, J S (1985) Anthropological Perspectives on the Family and Social Change in Anthropology: The Family and Social Change.
Langan, M. (1990) Community Care in the 1990s: the community care white paper: ‘caring for people Critical Social Policy, August, 58-69.
Laslett, P (1972) The History of the Family in Laslett and Wall (eds) Household and Family in Past Time, Cambridge University Press, Cambridge.
Levin, I (1993) Family as Mapped Realities. Journal of Family Issues, Vol. 14, No. 1, March p.82-91.
Lewis, J (1980) The Politics of Motherhood. Croom Helm, London.
Lipsky, M. (1980) Street-level bureaucracy: dilemmas of the individual in public services, Russell Sage foundation, New York.
Liss, L (1987) Families and the Law. in Sussman, M B and Steinmetz, SK (eds) Handbook of Marriage and the Family. New York: Plenumn Press.
Lothian Regional Council Health Committee 1990 Health and Social inequalities in Lothian; an atlas of social indicators Lothian Regional Council.
MacIntyre S, Annadale E, Ecob G et al. (1989) The west of Scotland twenty-07 study: health in the community. In Martin C & MacQueen D (eds) Readings in a new public health Edinburgh Edinburgh University Press.
MacIntyre S, MacIver S & Soomans A (1993) Area, Class and Health: should we be focusing on places or people? Journal of Social Policy Vol 22, 2, pp 213-234.
McLeod M & Saraga E 1988 Challenging the orthodoxy: towards a feminist theory and practice Feminist review No. 28 pp 16-55.
Morgan D H 1985 The family: politics & social theory Routledge Kegan and Paul, London.
Morgan, D H J (1985) The Family, Politics and Social Theory. London Routledge and Keegan Paul.
Morris, L (1990) The Workings of the Household: a US-UK Comparison. Cambridge, Polity.
Murdock, G (1949) Social Structure. Macmillan, New York.
Oakley, A (1974) The Sociology of Housework. Oxford, Martin Robertson.
Oakley, A (1976) Housewife. Harmondsworth, Penguin.
Oakley, A (1982) Subject Women. Glasgow, Fontana.
Observer Newspaper, 22nd May, 1992
Offer J (1989) Lay theories and health education: people’s beliefs versus experts’ diagnoses. Health Education Journal Vol. 48 No.3 pp 136-139.
OPCS (1993) Birth Statistics, Series FM1, Office of Population Censuses and Surveys.
Orr J (1986) Feminism and health visiting In Webb C (eds) Feminist Practice in Women’s Health Care Chichester, Wiley.
Parsons, T (1964) The Social System. London Routledge and Kegan Paul.
Pascall, G (1986) Social Policy: A Feminist Analysis. London Tavistock.
Roll J (1990) Young People: growing up in the welfare state, London, Family Policy Studies Centre.
Reid M (1992) Long live Glasgow Greater Glasgow Health Board and Evening Times, Glasgow.
Rigler M (1982) Tomorrows health visitor can she change our attitudes to health? Health Visitor Vol 55 pp 107-8.
Sabatier, P. (1986) Top-down and bottom-up approaches to implementation research; a critical analysis and suggested synthesis Journal of Public Policy 6, 1, 49-72.
Segal, L (1983) What is to be Done About the Family? Handsworth, UK:Penguin.
Settles, B H (1987) A Perspective on Tomorrow's Families. in Sussman, H B and Steinmetz S K (eds) Handbook of Marriage and the Family. New York: Plenum Press.
Sooman A, MacIntyre S, Anderson A (1993) Scotland’s health- a more difficult challenge for some? the price and availability of healthy foods in socially contrasting localities in the West of Scotland. Health Bulletin 51 (5) pp 276-283.
Sorrentino, C (1990) The Changing Family in International Perspective. Monthly Labour Review, March.
Stone, L (1977) The Family, Sex and Marriage in England 1500-1800. Weidenfeld and Nicolson.
Tones K (1993) Changing theory and practice: trends in methods, strategies and settings in health education. Health Education Journal Vol 52/3 pp 125 139
Townsend P & Davidson N 1982 Inequalities in health Harmondsworth, Penguin.
Townsend P, Davidson N & Whitehead M (1988) Inequalities in Health and the Health Divide London Penguin.
Trost, J (1993) Family from a Dyadic Perspective. Journal of Family Issues, 14, p.92-104.
Van Every J 1991 Who is ’the family’? The assumptions of British social policy Critical Social Policy pp 62-75.
Watson J M (1993) Male body image and health beliefs: a qualitative study and implications for health promotion practice. Health Education Journal Vol 52/4 pp 246-252
WHO (1986) Health Promotion: Concepts and Principals in Action: a policy framework. Copenhagen WHO Regional Office for Europe.
Williams R (1983) Concepts of health: an analysis of lay logic Sociology Vol 17 No2 pp 185-205.
Young M & Willmott P (1973) The Symmetrical Family Harmondsworth Penguin.
Appendix: Inventory of health education and health promotion materials and initiatives
INVENTORY OF HEALTH EDUCATION AND HEALTH PROMOTION MATERIALS AND INITIATIVES
SCOTTISH OFFICE
'Scotland's health: A Challenge to us all'
THE SCOTTISH DIET. Report of a Working Party to the Chief Medical Officer for Scotland.
Scottish Home & Health Department
HMSO, December 1993
'Scotland's health: A Challenge to us all'
A POLICY STATEMENT
The Scottish Office
HMSO, 1992
'Scotland's health: A Challenge to you'
The Scottish Office
HMSO, 1992
'The Patient's Charter: A Charter for Health'
The NHS in Scotland
1991
'Health education in Scotland'
A NATIONAL POLICY STATEMENT
Scottish Home & Health Department
HMSO, 1991
'The Parents' Charter in Scotland'
The Scottish Office
HMSO, 1991
HEALTH BOARDS
Argyll & Clyde Health Board
Health Promotion Strategy March 1993
'An apple a day...?' A Study of Lifestyles and Health
Health Behaviours of Young People in Argyll and Clyde - 1992
Health Promotion in Argyll and Clyde FIRST ANNUAL REPORT 1992
Fife Health Board
Local health Strategy Review 1993
Towards 2000: Health and Welfare Strategies for Fife: A Joint Strategic Statement (1993) Fife Health Board & Fife regional Council
Greater Glasgow Health Board
The Annual Report of the director of Public health 1991/2
Health Promotion Strategy
January 1990
Greater Glasgow Health Board (continued)
Department of Health Promotion OPERATIONAL PLAN 1993-4
Health Education Board Scotland
Annual Report 1992/3
Strategic Plan 1992-97
Health Behaviours of Scottish School children:
Report 1: National and Regional Patterns
Report 2: Family, Peer, School and Socio-economic Influences (1993)
Highland Health Board
HIGHWAY TO HEALTH 1992
Annual Report 1992/3
Lothian
Lothian Health Education Department PROFILE 1993-4
Lothian Health Board ANNUAL REPORT 1992-3
Lothian Health Board ANNUAL REPORT: (DIRECTOR OF PUBLIC HEALTH) 1992
Lothian Health LOTHIAN ACUTE SERVICES STRATEGY: Hospital Services for the 21st Century
Lothian Health Promotion Department ANNUAL REPORT 1993
Lothian Health Board YOUR CHARTER FOR HEALTH
Lothian Regional Council LOTHIAN CHILDREN’S FAMILY CHARTER
Lothian Health PURCHASING AND CONTRACTING PROSPECTUS 1994-7
OTHER GROUPS
Child Accident Prevention trust
Basic principle of Child Accident Prevention - A Guide to Action, 1989.
Children in Scotland
Annual Report 1992-3
Drumchapel Community Health Project
'Local Voices, Local Lives': The Story of the Kendoon Community Health Profile 1992
Glasgow Healthy City Project
'Community Development strategy' Community Support Unit, July 1993 (Draft only)
'The Health of the City, a shared concern: the GHCP four years on' (1992)
The Health Hut
'Who is listening to local voices?': Changes in the NHS
Lothian Health Council
Annual Report 1992-93
Pilton Partnership
'Fighting Poverty in Greater Pilton: A Report on the first two years of the Pilton Partnership' December 1992
Public Health Alliance
'Poverty: The Forgotten Health Concern' FOURTH ANNUAL REPORT 1992-3
Public Health Alliance in Scotland
Report on 'Health Care and Travelling Families' 1993?
Report on 'Housing and health in Scotland' 1993
Scottish Association of Health Councils
Health Care and Travelling People: A Charter for Health for travelling People
September 1992.
Scottish Convention of Women
Review of Health Education in Scotland October 1989
Strathclyde Poverty Alliance
'Youth Destitution in Strathclyde' June 1992