Publication
International year of the family report (phase 1): an overview of academic attempts to define 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).