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The social approach to family health studies
THE
SOCIAL
APPROACH
TO FAMILY
HEALTH
STUDIES
PETER .I. M. MCEWAN* Feardar House. Crathie. Aberdeenshire, AB3 5TQ Abstract-An rxamination of the psycho-social perspectives relevant to the study of family health. and a discussion of the importance of the subject supported by a condensed review of recent evidence.
OBJECTIVES
The purpose of this paper is to provide a psycho-sociological perspective to the consideration of how the concept of the family as a unit might be used in health studies. The general problem has been divided into five principal areas of attention .rll.< These are: of possible sources of information (a) an examination approach to the study of for a health and disease : (b) an examination of the implications of recent .developments in statistical methods and techniques which facilitate and improve the gathering of information relevant lo a family-based approach to the study of health problems: of guidelines and recommenda(c) the formulation tions for the revision of standard vital and medical records. so as to include information relating these events to the family; (d) the discussion of various types of statistical studies and surveys required for expanding knowledge of the familq as regards health status and patterns; and (e) the identification of major gaps in statistical techniques and information needed for the development and formation of an epidemiology of family disorders and diseases. SOME
INlTlAL
PROBLEMS
It is necessar! to draw attention at the outset to three kinds of difficult!. The first ma\ be called the semantic difficulty. There are at least two concepts with which we shall be dealing that readill cause semantic confusion: health and farnil! health. I am not referring to the problem of defimtion. which will be discussed later. but to the implicit nature of these concepts. It is a curious fact that b! the stud! of health is general!! meant the stud! of disease. the stud! of the latter being more immediateI> understood and more urgentI!- required. There is the further problem that the absence of disease does not nccrssaril! impl! the presence of health. if by the latter * At the time this \\as tvritten the author \vas Director of the Ccntre fol- Social Research at the Uni\ersit\ of Sussex.
is connoted well-being. The boundary that separates good from bad health is tenuous and can be difficult to detect precisely. The difficulty is compounded by the necessary distinction between physical and mental health. a dichotomy based more upon convenience than science. The ensuing inaccuracies can be minimized most effectively if the concepts of health and disease are rigorously defined. The notion of family health is ambiguous. It may denote the health (i.e. absence or presence of disease) of family members or it may denote the condition of the family itself. In each case the criteria of “health” are different, for only individuals have diseases. It is true that the notion of a “healthy” family. meaning an effectively functioning unit, implying the possibility of its opposite. is yet comparatively little used. but it is growing in currency and. therefore. should not be neglected. The second initial difficulty may be called the technical, or statistical, problem and as such will not be considered in this paper. The third difficulty is of a conceptual kind. Although it is true that the nature of the present exercise is concerned primarily with quantifiable data. it depends for its success on a bold and radical departure from some hallowed epidemiological concepts and their replacement by new ones. Our task is therefore not so much the rendering of old categories in a revised manner as the development of revised categories. In this sense the magnitude of the task may be measured not in terms of greater demographic or analytical sophistication. important though these undoubtedly will be. but in terms of the organic and social processes we seek to relate and the methods by which these relationships can be tested. We have a thought barrier to cross. Since the notion of a healthy family refers specifically to the social functioning of a group, the use of the word “healthy” is misleading. A group can be effective and, or functional or ineffective and/or disfunctional. It has to be decided whether the phrase “healthy family” is to be encouraged and developed on the grounds that it is already in common usage or whether a more accurate substitute can be agreed in the interests of future clarity. The criteria used to assess health are ver) different in these different notions of a healthy family. 487
P. J. M. McE\v~s
488 THE SOCIAL
SCIENCES
IS MEDICINE
It is almost 50 yr since Grotjahn enunciated his six principles for the systematic social approach to disease [2]. These are: (a) the significance of a disease from the social viewpoint accords first. to itsfi.rqtrenc.v; (b) it then becomes necessary to know the forr~ in which any particular disease most often occurs; (c) there are four ways in which the etiological relationship between social conditions and organic disease can be expressed. Social conditions may predispose toward the disease. may cause the disease directly, may transmit the causes of disease or may influence its course; (d) not only are the origin and causes of diseases determined by social factors. but these diseases may in turn influence social conditions ; (e) medical treatment. which itself is affected by social conditions. can exert an appreciable influence on the prevalence of a disease and successful therapy may be socially important;. (fj the prevention of disease or influencing its course by social means, requires attention to the patient’s social and economic environment. The most common social factors in the etiology of disease are variables relating to (a) the family; (b) ethnic background; (c) socio-economic status; and (d) religion. Each of these implies characteristic patterns of socially determined behaviour and since the family is the prime unit of socialization, in terms both of time and influence. it may be said that the family is the single most important social factor in the etiology of organic disease. The causal relationship between family variables and organic disease may take a variety of forms depending upon the way in which the disease is contracted. It may concern a characteristic mode of behavior. For example. practices of child rearing either peculiar to families or to larger social groups (of which the family is the prime agent) may protect against or facilitate disease, while the influence of dietary behaviour on various diseases is well documented [3.4]. The causal relationship may be genetic in character. the family providing the necessary etiological connexion. One in two hundred births has a serious defect. genetically conveyed. The screening of factors is an important tcchniquc among those now being used in negative medical eugenics. Again. the causal relationship may be a function of both social and genetic factors, each operating in varying proportions [4, 51. Social factors may have a reciprocal influence with the course of disease, each affecting the other. Illness may reduce the effective functioning of an individual in his society. When this occurs, the first group to be alrccted will be the immediate family. This may trigger a chain of reactions within the family and even in the community beyond. which can itself change
the level of health of its members. Most societies have developed mechanisms for reducing the necessar> social adjustments to the occurrence of illness. the most important of which is the sick role. The sick role has rights and duties. It is generalI! held that in industrialized societies there are two socially sanctioned rights and two duties. The rights are esemptions from normal social responsibilities and the recognition that the patient is not to be blamed for his condition. The obligations are continuous effort to recover and the acceptance of competent help to be cured. The manner in which an individual plays the sick role and the nature of familial response may influence the course of the patient’s condition as well as the health and happiness of the family. It has been argued that the vulnerability of the small nuclear family to the stresses imposed bq the illness of one of its members. particularly the main breadwinner, is partly responsible for the dramatic extension of hospital facilities [6]. The emotional strains will be minimized if the patient is treated outside the family. The eflect of illness on a family will be related to a number of social factors. Among these factors are the allocation of roles within the fa;ly. the extent of emotional support available and occupational vulnerability (i.e. the extent to which financial affairs and/or promotion are placed in jeopardy). These. in turn. are related to ethnic variations and class ditrerences within and between societies. Although its forms are similar. the relationship between social and health variables is more extensive and more complex in the field of mental illness than in the case of physical disease. The form of residence mav assume importance. In advanced industrial societies-it is common for men to leave the household of their parents upon marriage and to live in the neighbourhood of the wife’s family [7]. The degree of the detachment of husband and wife from their respective parental homes. which varies according to cult;ral and sub-cultural ditrerences. can be an important factor in the etiology and treatment of schizophrenia. This disease is significantly more common in cases where the nuclear familq is incompletely formed owing to the primary attachment of one or both parties to a parent or sibling [Xl. There is a tendency in industrial societies for more wives to seek employment outside the home. In some cases. this may lead to the setting up of ;I separate place of residence. The quality of the relationship between parents, although difficult to measure. may have an important bearing upon the mental health of the family [9]. There is the sociological aspect of the relationship, having to do with role allocations within the family [IO], and the psychological aspect. involving emotional interactions and person:d dynamics. The attachment of a child between the seventh and thirtieth month of its life to its mother has been shown to IX critical 10 hc;dth dc\clopmcnt [I I. 12. 131. This has important implications for the collection of useful statisticaldata. Incnscsofadoption. for example. theage
The
social
approach
of the infant at the times of renioval and arrival are critical. Furthermore. in cases of parental loss. the ages of the children are important. Loss of a mother &fore five years of age may be related to psychoneurosis Cl43. To determine the influence of any changes in the family environment affecting the quality of human relationships is a complex.qucstion. but there is evidence linking major changes not only with psychosomatic disturbances but also with accidents and other apparently unconnected misfortunes [I 5-211. When genetic as well as environmental factors are involved in the realm of mental illness. it is particularly difficult to unravel their respective etiological salience. There is a correlation. for example. between mental retardation without organic defect and mentally inferior parents. but the precise nature of the causative factors remains unclear. Much more information is required. but it is important to note that cross-generational data is essential as well as an adequate degree of diagnostic comparability [23-251. There is mounting evidence connecting birth order with personality characteristics and related matters such as marital adiustment [26]. Physical conditions in the environment relevant to the contraction and prevention of disease are in part socially determined. Such determinants include tradition. taboo. values. dietary habits. personal interactions. methods of trade and agriculture and the modes of social sanctioning. All of these are transmitted through the agency of the family [37.X]. DEFISITIONS
If the distinction already noted between family health and a “healthy family” is accepted. then for our present purposes it 1s sufficient that b>; -‘health” we mean the absence of any disease or impairment. physical or mental. The impairment may only be imaginary, or at least lacking in objective confirmation (as by a physician) but an imaginary impairment remains an impairment. But it is to be noted that even such a general definition as this has cultural undertones. PaGents vary not only in their tolerance of symptoms and in their standards of normalit!, and dysfunctioning according to differing social standards and values. but also in the choice of symptom presented [29]. There are occasions \vhen medical intervention is appropriate although neither disease nor impairment is directly involved. Intervention of this kind may be preventive or supportive. An example of the first would be a public health authorit!, initiating action to prevent or restrict an epidemic: an example of the latter would be psychiatric consultation with a community that had suffered a natural disaster. The concept of famil! ma! be defined as a group of two or more persons. related to each other b) blood. marriage or adoption and liying together. According to this definition a brother and sister liv-
to family
health
4x9
studies
ing together is a family but an unmarried man and woman living together without children though a household is not a family. If in the latter case. a child is born, they become a family. To avoid some of the semantic confusions mentioned earlier it is necessary to distinguish between the “healths” of members of a family and familial health. The former is concerned with the prevalence and incidence of disease within a given family; the latter describes the functioning of the family as a structural unit. It is proposed that since the term “family health” has established usage it be used exclusively in the former sense, to describe exclusively the comparative health status within a family, and that the term “familial health” be used in the latter sense, as an evaluative description of functions and structure. THE
FAMILY
The family is not only the basic unit of human social organization. but it is also the one that is most accessible for preventive and therapeutic intervention. The health of a family goes beyond the physical and mental conditions of its members to the extent that it provides a social environment for the natural development and fulfilment of all who live within its ambience. Apart from religion. the family is the only social institution which is formally developed in all societies. The family is the principal mediating agent between the individual and his society. Through its teachings. sanctions and examples the young are socialized into the customs, habits, manners, values and beliefs of their culture. The family unit of socialization is the family of orientation. This is in distinction to the family of procreation, the reproductive family unit. The family varies in form from one culture to another. There are four basic forms. The conjugal or nuclear family comprises husbarid, wife and children. When a nuclear family group shares the living quarters with a relative. who is a primary family head and maintains a household, this smaller unit is sometimes referred to as a sub-family. The extended family consists of several generations living together. The stem family is a specialized version of extension, common in parts of the United States of America and Japan. Under this system only one child, usually the eldest son, inherits the family property which, together with family title and responsibility is unilaterally administered. The joint family of India consists of co-percerers, these being people sharing property rights within the family, generally all the brothers in each generation in a direct line. so long as the farnil) unit remains cohesive. In many cultures family location is predetermined. Neolocality. in which the bride and bridegroom move away from both their parental neighbourhoods reduces the influence of elders. When a woman moves
190
P. J. M. McEw~s
to the location of her husband’s family there is patrilocality. and if he moves to her neighbourhood there is matrilocality. Which of these is followed in any instance will largely determine the frequency of social interaction between the kinship networks. The nuclear family passes through four natural stages of development. the duration of each being variable. These phases, each of which presents characteristic opportunities and strains, represent periods of expansion. dispersion. independence and replacement. As families pass through these identifiable stages of development. crises may be experienced. These are generally classified as being of two kinds. transitional crises which have to do with problems posed by severe role change as is created, for example, by marriage, the birth of the first child, retirement and bereavement. Non-transitional crises have been further classified as illustrated in Table 1. Table
I. Classification
of family crises [30]
Dismemberment Death of a child, spquse or parent Hospitalization of spouse War separation Accession Unwanted pregnancy Return of deserter Stepfather/stepmother returns War reunions Some adoptions, aged grandparents, orphaned kin Demoralization Non-support lnfidelitv Alcohol&m Drug Delinquency and events bringing disgrace Demoralization + Dismemberment or Accession Illegitimacy Runaways Dcscrtlon Divorce imprisonment Suicide or Homicide Institutionalization for mental illness or mental retardation
In addition to crises, seven main types of change in the life-style have been identified. Although often less scvcrc in their demands upon individual and familial adjustment than the transitional crises. the status shifts involved can be major factors in the etiology of mental illness and perhaps also in the contraction of certain organic diseases [3 I]. Thcsc arc: (a) sudden impoverishment; (bj prolonged unemployment: (c) sudden wealth or fame; (d) rcfiigec migration: (c) natural disasters:
(f) wartime deprivations: (g) political declassing. Hansen and Hill [Y] identif; four themes that run through most attempts to classify family stressors. These are: (a) the effect of presence or absence of physical features of stress: (b) the tensions or hardships that. precede impact of the stressor or evidence of strain: (c) the presence or absence of factors that allow members to blame one another for the stress: and (d) the probable effect on the family of community response and resources. There is evidence that western societies are passing through a transitional stage in which values are changing. The gradual revision of legitimacy involves a period of increased deviation (illegitimacy). In the family this means an increase in the number. and to this extent at least the importance. of illegitimacy. the uncompleted family unit. The most common forms are consensual unions. casual relationships prior to marriage and adulterous relationships within marriage. Difficulties in establishing these facts make them elusive categories for the demographer. but their signiticance for health studies warrants greater care in establishing these categories than has been shown in the past. The strains placed upon the institution of marriage by contemporary western societies. associated with evidence of changing values. have led some people to believe that marriage m its present form may be undergoing dissolution. Evidence for this belief is still somewhat slight. but the fact remains that the effects of these influences upon the patterns of family life are considerable. This factor of contemporary change does not make the planning of long-term goals of the kind with which we are concerned easy. but nevertheless these issues have to be faced. The nuclear family may dissolve as a viable structure without any formal dissolution (death. divorce, legal separation). There may be desertion. voluntary separation, the unwilled absence of one partner and the “empty-shell” family in which communication is non-existent although the members continue to live under the same roof. The concept of the nuclear family as a basic social institution and a inajor determinant of personality. good health and behaviour. is also undergoing changes. Short-term trends that have been identified include a greater dependence in the matter of getting married upon economic and political Huctuations. a younger age at marriage. changes in child-spacing (with a propensity toward the bunching of offspring). the re-allocation of sex rolesand a departure from parallel roles in marriage toward a monadic-diadic relationship [32]. Longer-term trends may be more important in as far in planning future as they can be anticipated demographic surveys. Those that seem most likely and which relate most to health are mentioned below. The increased mobility of families. making community relations more dilhcult (in the United States of America. for example. one family in five moves
491
The social approach to family health studies
annually and one in three of these crosses county lines every year). There is a reduction in the number of services supported by the family. In the past the nuclear family has provided medical care, general and religious instruction and recreation. These are being placed more and more in the hands of specialized agencies. Age and sex roles within family life are changing. As the family becomes less self-sufficient, the role of the father grows less authoritarian. Prosperity becomes more dependent upon external forces, if things go wrong the blame, as well as the responsibility, is directed increasingly to forces outside the family. Households are becoming smaller and mate selection is more independent of parental influence. There are fewer arranged marriages in the world. The decrease in the overall proportion of extended families is reflected in a corresponding increase in the proportion of nuclear families. This decline of the consanguineous family system may be due, not only to the effects of industrialization, but also to the internal strains upon the system imposed by the often delicate relationship between women in joint households [33]. There is a strong movement throughout the world toward tht social and economic equality of women. Working wives whose occupation takes them away from home have greater difficulty in reconciling their career with their role in the family than do men. This trend reduces the comparative authority of the male and tends toward greater equalitarianism, although often at the expense of producing greater role strain as functions within the family are readjusted. There is an increased separation between sex and procreation, more sexual intercourse and fewer children. This reduction in the procreative function remains. at least for the moment, contained within the family. although the separation itself has obvious consequences for sexual morality. for the position of women in society and for patterns of pre-marital sexual behaviour. Divorce is becoming more common. Nimkoff has this to say [34]: “Increasing industrialization and urbanization are correlated with rising divorce rates because of their influence on the family and its setting. The industrial-urban complex results in a diminution of economic interdependence of married persons. They need each other less in the struggle for existence than do couples’in pre-industrial rural society. Women can support themselves and men can find substitute sources of satisfaction of their domestic needs. If their economic interdependence is less, their psychological interdependence is greater than before. for the possibilities of loneliness are greater in the mass society. But sentiment is more ephemeral than survival. and marriage based on love is more vulnerable than one based on economic need. So modern marriages break up more readily. although those that endure are generally more
satisfying because they are based on psychological compatibility. The trend toward equality in the relationship between husbands and wives, replacing the earlier patriarchalism, is also a potent source of difficulty. A relationship of equality is more difficult to maintain than one of inequality. There is only one point at which a pair of scales will balance and many points at which it will not. The urban setting contributes to marital instability because there is less effective social control in the mass society than in the smaller. simpler folk society”.
THE FAMILY
AS FOCUS
OF MEDICAL
CARE
Information regarding patterns of health in families although often proposed has been seldom implemented [35,36,37]. It has been suggested that the family can be regarded as a unit of health behaviour with its own patterns of morbidity, responses to symptoms and utilization of medical facilities [38]. This is true. but only as long as it is recognized that a family as a concept cannot itself do these things, they are done by individuals acting in the name of. or through the influence of a group called the family.
METHODOLOGICAL
CONCERNS
Data regarding family health may be collected through conventional census channels, satisfactory for comparatively crude demographic data but insufficiently sensitive for detailed studies, from medical records maintained by medical personnel, applicable only when members of a single doctor share the same medical advisers, or by seeking more intensive, longitudinal assistance from families. The reliability of family health information, particularly in cases of mothers with low educational achievements, is extremely difficult to obtain. Incidents of health behaviour are complex, arbitrary and sometimes difficult to recall. Kosa found that what he called two kinds of normative ideas-medical relevance and social desirability-tended to bias reports. Suchman and his colleagues compared the assessments of health status made by a lay panel with those made regarding the same subjects by a group of physicians [39]. They found considerable variations. but health behaviour conformed more closely with the selfevaluations. When patients are asked to report on their use of physicians they tend to reduce the number of occasions [36,40] but to increase the amount of hospitalization [41.42,43]. This reduction is not exclusively attributable to lapses of memory C44-473. It is generally held that the best source of information within the family is the mother [48-533. The most consistent and carefully designed attempt in the field
492
P. J. M M~EWAN
is that made by Kosa [37] but his experience was generally most disappointing. There is great danger that inaccurate data will be collected when details of actual medical treatment and characteristics are gathered from patients. even when the characteristics are physically apparent [54]. One problem in the use of epidemiological data is the insidious characteristic of categories. It is always tempting to restrict information to categories that are clearly defined and unambiguous. But this can mask important connections. It is therefore of the utmost importance to consider most carefully the purposes of a survey before making a choice of the categories to be used. A further refinement is desirable when two or more variables are thought to have a casual relationship such that x implies y, but y need not imply x. In such cases the use of sub-categories should be employed separating x and y at the time the data is collected. What is needed when embarking upon any study of the family in relationship to disease and its prevention are the formulation of firmly based hypotheses, the selection of indicators of the health behaviour to be examined, a definition of the concepts employed and an unequivocal understanding of the logistic support available.
REFERENCES
on Statistical Aspects of the Study of the Family as a Basic Unit in Public Health. WHO, Private Memorandum 197 I. Grotjahn A. So.-iale Patholoyie. (2nd Edition.) pp. 9-18, Hirschwald, Berlin, 1915. Levin M. L. et al. Nursing, Fertility and 0th~ Factors in the Epidemiology of Cancer of the Breast. Paper presented at the American Public Health Ass. Meeting, Miami. 1962. Graham S. and Lilienfeld Abraham M. Genetic studies of gastric cancer in humans: Appraisal. Cuncer 11, 945 1958. Graham S. Social Factors in Relation to the Chronic Illnesses. In Hundhook of MAcal Socioloyy (edited by Howard and Freeman it ul.). Prentice Hall 1963. (Adopted from Winkelstein and Warren in a personal communication). Parsons T. and Fox R. Illness, therapy and the modern urban American family. J. Social. (8). 3 I. Young M. and Wilmot P. Fnnlily and Kinship in Easf Lortdon. Routledge. London. 1957. Fleck S. Family dynamics and origin of schizophrenia.
I. Consultation
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6. 7. 8.
Psychosotn.
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relationship in cases of puer9. Lomas P. Husband-wife peral breakdown. Br. J. Med. Psychdl. 32, 117. IO. Lidz T. et (I/. The intrafamilial environment of schizophrenic patients. II. Marital schism and marital skew. Am. J. Psychiut. 114, 241. I I. Schaffer H. R. Ob,jective observations of personality development in early infancy. Br. J. Med. Psychol. 31. 174.
I 2. Schatfer H. R. and Callender W. M. Psychological effects of hospitalization in infancy. Purdiutrics 24, 528.
13. Bowlby. John. .4rttrch~rrm Vol. I. Hogarth Press. Lendon. 1970. 14. Barr! H. and Lindemann E. CrItical ages for maternal bereavement in psychoneurosis. P.s~chosor~~. .\Ic,,/. 22. 166. 4~r. J. 15. Eisenberg L. The autistic child in adolescence. Ps!~chint~. 112. 607-l 2. 16. Bowlbv J. YI (I/. The effects of mother child seuaration: follow&p study. Br. J. .Clrd. Psjx+ro/. 29, 21 I. i900. 17. Barry H. Si@icance of maternal bereavement before age of eight m psychiatric patients. 4rch. .Ve~rro/. P.s!,chiatr.
62, 630.
18. Levy D. M. Oppositional Syndromes and Oppositional Behaviour in Ps~~cl~optrtl~oloy~~ o/ Chi/dhoot/. (Edited by Hoch P. H. and Zubin J.) Grune and Stratton. N.Y. 1955. 19. Penrose L. S. T/X, Bioloy!, of .If~ml/ DL’/~~I~I.L,.s.2nd Edition. Sidgwick and Jackson. London. 1954. 20. Stein Z. and Susser M. Families of dull children I.I. Identifying family types and subcultures. J. wt?t. Sci. 106, 1296. 21. O’Gorman G. Psychosis as a cause of mental defect J. mrnt. Sci. 100, 934. 22. Bourne H. Protophrenia: A study of perverted rearing and mental dwarfism. Larwt 269, 1156. 1900. 23. Davis D. R. A disorder theory of mental retardation. J. wnr. Suhnormul. 1, 13. 24. Miller F. J. W. rt ul. Gro\ri~l~/ L;p in .I’crvcu.srlr-upo+ ryr~e. Oxford University Press. London. 1960. 25. Charles D. C. Ability and achievement of nersons earlier judged mentally deficient. J. Grnrr. Ps&~ol. Mouo~~~. 47, 3. 26. Toman,Walter Yt (II. Fmnilv Comtrllutior7. 2nd Revised Edition. Springer. N.Y.. 1969. 27. Jelliffe D. B. Social culture and nutrition. Prrrdiurrics 20. 128.
28. Keys. Ancel. The diet and the development of coronary heart disease. J. Clzrorr. Dis. 4, 364. 29. Zola. Irving. How Sick is Sick’! Working notes and reflections on the Cross Cultural Studv of Illness. WHO . Consultative document 1970. 30. Eliot T. D. Familv crises and wavs of meetine them. In Murriuyr and thcvFuwi/~~. (edited-by Becker g and Hill R.), pp. 489.-536. Heath. Boston, 1942. 31. Hill R. Grnwic Feutwcs of Ftrvlilies L~r~t/er Stwss. Social casework 39. pp. 139- 150. 32. Hill R. The American family today. In Herr/t/l nnd the Commrr~ir~. (edited bv Katz A. H. and Felton J. S.), The Free Press. N.Y.. 1962. M. F. Compururrve Furnil!, S\xterns. pp. 33. Nimkoff 346-347. Houghton Mifflin. Boston. 1965. 34. fhid. pp. 355-6. P. S. Chronic illness and socioeconomic 35. Lawrence status. Prrhl. Hlth. Rep. WU.S/I. 63, 1507. 36. Haggerty R. J. Family diagnosis: Research methods and their reliability for studies of the medical social unit. the family. ,1n1. J. p&l. H/t/z. 53. 1521. 37. Kosd John et ul. On the Reliability of Family Health Information. Sot. Sci. & Med. I, (2). pp. 165%81. 38. Kosa, John et (11.Crisis and stress m family Ilfe: A reexammatlon ot concepts. Wiac. Sociolo~qist 4, I 1. 1900. 39. Suchman E. A. et ul. An analysis of the validity of health questionnaires. Sot. Forces 36, 223. 40. Solon J. A. et al. Patterns of medical care: validity of interview information on use of hospital clinics. J. Hlth.
hum. Brhac. 3, 21.
The social approach 41. l!.S. National Health Survey. Rrpwrimq of Hospiru/isuriorr rn t/n, Hrulrl~ Inrcvric,\~ S~rrw~~ (Vital and Health Statistics. PHS Publ. 1000.Series ~-NO. 6). P.H.S. Wash. DC. 1965. 42. U.S. National Health Survey. Compuriswl ctf Hospitulistrrion Reprrirq (Vital and Health Statistics. PHS Publ. 1000. Series 2 No. X). P.H.S. Wash. DC. 1961. 1.3. Sanders H. S. How good arc hospital data from a household survey. AIII. J. pub/. Hlth. 49, 1596. 44. Commission on Chronic Illness. Chronic IIlr~rss in the L’rlitrd Srate.s. (4 vols.). Harvard University Press. Cambridge. Mass.. 1967. 45. Elinson J. and Trusscll R. E. Some factors relating to degree of correspondence for diagnostic information as obtained by household interviews and clinical evaluations. Am. J. pub/. Hlrh. 47. 31 1. 46. Krueger D. E. Measurement of prevalence of chronic disease by household interviews and clinical evaluations. 4rn. J. prrhl. H/t/?. 47, 953. -17. Trussell R. E. 1’1trl. Comparisons of various methods of estimating the prevalence of chronic disease in a community. .4ru. J. puhl. H/~/I. 46. 173.
to family health
493
studies
48. Mechanic. David and Newton M. Some problems in the analysis of morbidity data. J. Chron. Dis. 18, 569. 49. Cartwright M. Sornc Mclltodolocti~ul Pwhlrm EIICOL~IIrcwd WI u Furnil~~ Surw~. Ph.D. Thesis. London tinivcrsity. 1961. intcrvicw survey as a tech50. Feldman J. J. The household nique for the collection of morbidity data. J. Chron. Di.!. 11,535. D. The influence of mothers on their chil51. Mechanic dren’s health attitudes and behaviour. Purdiutrrc.s 33, 444.
David. Perception of parental responses to 52. Mechanic, illness. J. Hlth. hum. Brhuc. 6, 253. nursing 53. Alpert J. J. et al. Medical help and maternal care in the life of low-income families. Purdiatrics. 1968.
cir54. Lilienfeld A. and Graham S. Validity of determining cumcision status by questionnaire as related to cpidemiological studies of cancer of the cervix. J. n&n. Cancer 1nsr. 21, 713.
.
SOCIAL
APPROACH
TO FAMILY
HEALTH
STUDIES
PETER .I. M. MCEWAN* Feardar House. Crathie. Aberdeenshire, AB3 5TQ Abstract-An rxamination of the psycho-social perspectives relevant to the study of family health. and a discussion of the importance of the subject supported by a condensed review of recent evidence.
OBJECTIVES
The purpose of this paper is to provide a psycho-sociological perspective to the consideration of how the concept of the family as a unit might be used in health studies. The general problem has been divided into five principal areas of attention .rll.< These are: of possible sources of information (a) an examination approach to the study of for a health and disease : (b) an examination of the implications of recent .developments in statistical methods and techniques which facilitate and improve the gathering of information relevant lo a family-based approach to the study of health problems: of guidelines and recommenda(c) the formulation tions for the revision of standard vital and medical records. so as to include information relating these events to the family; (d) the discussion of various types of statistical studies and surveys required for expanding knowledge of the familq as regards health status and patterns; and (e) the identification of major gaps in statistical techniques and information needed for the development and formation of an epidemiology of family disorders and diseases. SOME
INlTlAL
PROBLEMS
It is necessar! to draw attention at the outset to three kinds of difficult!. The first ma\ be called the semantic difficulty. There are at least two concepts with which we shall be dealing that readill cause semantic confusion: health and farnil! health. I am not referring to the problem of defimtion. which will be discussed later. but to the implicit nature of these concepts. It is a curious fact that b! the stud! of health is general!! meant the stud! of disease. the stud! of the latter being more immediateI> understood and more urgentI!- required. There is the further problem that the absence of disease does not nccrssaril! impl! the presence of health. if by the latter * At the time this \\as tvritten the author \vas Director of the Ccntre fol- Social Research at the Uni\ersit\ of Sussex.
is connoted well-being. The boundary that separates good from bad health is tenuous and can be difficult to detect precisely. The difficulty is compounded by the necessary distinction between physical and mental health. a dichotomy based more upon convenience than science. The ensuing inaccuracies can be minimized most effectively if the concepts of health and disease are rigorously defined. The notion of family health is ambiguous. It may denote the health (i.e. absence or presence of disease) of family members or it may denote the condition of the family itself. In each case the criteria of “health” are different, for only individuals have diseases. It is true that the notion of a “healthy” family. meaning an effectively functioning unit, implying the possibility of its opposite. is yet comparatively little used. but it is growing in currency and. therefore. should not be neglected. The second initial difficulty may be called the technical, or statistical, problem and as such will not be considered in this paper. The third difficulty is of a conceptual kind. Although it is true that the nature of the present exercise is concerned primarily with quantifiable data. it depends for its success on a bold and radical departure from some hallowed epidemiological concepts and their replacement by new ones. Our task is therefore not so much the rendering of old categories in a revised manner as the development of revised categories. In this sense the magnitude of the task may be measured not in terms of greater demographic or analytical sophistication. important though these undoubtedly will be. but in terms of the organic and social processes we seek to relate and the methods by which these relationships can be tested. We have a thought barrier to cross. Since the notion of a healthy family refers specifically to the social functioning of a group, the use of the word “healthy” is misleading. A group can be effective and, or functional or ineffective and/or disfunctional. It has to be decided whether the phrase “healthy family” is to be encouraged and developed on the grounds that it is already in common usage or whether a more accurate substitute can be agreed in the interests of future clarity. The criteria used to assess health are ver) different in these different notions of a healthy family. 487
P. J. M. McE\v~s
488 THE SOCIAL
SCIENCES
IS MEDICINE
It is almost 50 yr since Grotjahn enunciated his six principles for the systematic social approach to disease [2]. These are: (a) the significance of a disease from the social viewpoint accords first. to itsfi.rqtrenc.v; (b) it then becomes necessary to know the forr~ in which any particular disease most often occurs; (c) there are four ways in which the etiological relationship between social conditions and organic disease can be expressed. Social conditions may predispose toward the disease. may cause the disease directly, may transmit the causes of disease or may influence its course; (d) not only are the origin and causes of diseases determined by social factors. but these diseases may in turn influence social conditions ; (e) medical treatment. which itself is affected by social conditions. can exert an appreciable influence on the prevalence of a disease and successful therapy may be socially important;. (fj the prevention of disease or influencing its course by social means, requires attention to the patient’s social and economic environment. The most common social factors in the etiology of disease are variables relating to (a) the family; (b) ethnic background; (c) socio-economic status; and (d) religion. Each of these implies characteristic patterns of socially determined behaviour and since the family is the prime unit of socialization, in terms both of time and influence. it may be said that the family is the single most important social factor in the etiology of organic disease. The causal relationship between family variables and organic disease may take a variety of forms depending upon the way in which the disease is contracted. It may concern a characteristic mode of behavior. For example. practices of child rearing either peculiar to families or to larger social groups (of which the family is the prime agent) may protect against or facilitate disease, while the influence of dietary behaviour on various diseases is well documented [3.4]. The causal relationship may be genetic in character. the family providing the necessary etiological connexion. One in two hundred births has a serious defect. genetically conveyed. The screening of factors is an important tcchniquc among those now being used in negative medical eugenics. Again. the causal relationship may be a function of both social and genetic factors, each operating in varying proportions [4, 51. Social factors may have a reciprocal influence with the course of disease, each affecting the other. Illness may reduce the effective functioning of an individual in his society. When this occurs, the first group to be alrccted will be the immediate family. This may trigger a chain of reactions within the family and even in the community beyond. which can itself change
the level of health of its members. Most societies have developed mechanisms for reducing the necessar> social adjustments to the occurrence of illness. the most important of which is the sick role. The sick role has rights and duties. It is generalI! held that in industrialized societies there are two socially sanctioned rights and two duties. The rights are esemptions from normal social responsibilities and the recognition that the patient is not to be blamed for his condition. The obligations are continuous effort to recover and the acceptance of competent help to be cured. The manner in which an individual plays the sick role and the nature of familial response may influence the course of the patient’s condition as well as the health and happiness of the family. It has been argued that the vulnerability of the small nuclear family to the stresses imposed bq the illness of one of its members. particularly the main breadwinner, is partly responsible for the dramatic extension of hospital facilities [6]. The emotional strains will be minimized if the patient is treated outside the family. The eflect of illness on a family will be related to a number of social factors. Among these factors are the allocation of roles within the fa;ly. the extent of emotional support available and occupational vulnerability (i.e. the extent to which financial affairs and/or promotion are placed in jeopardy). These. in turn. are related to ethnic variations and class ditrerences within and between societies. Although its forms are similar. the relationship between social and health variables is more extensive and more complex in the field of mental illness than in the case of physical disease. The form of residence mav assume importance. In advanced industrial societies-it is common for men to leave the household of their parents upon marriage and to live in the neighbourhood of the wife’s family [7]. The degree of the detachment of husband and wife from their respective parental homes. which varies according to cult;ral and sub-cultural ditrerences. can be an important factor in the etiology and treatment of schizophrenia. This disease is significantly more common in cases where the nuclear familq is incompletely formed owing to the primary attachment of one or both parties to a parent or sibling [Xl. There is a tendency in industrial societies for more wives to seek employment outside the home. In some cases. this may lead to the setting up of ;I separate place of residence. The quality of the relationship between parents, although difficult to measure. may have an important bearing upon the mental health of the family [9]. There is the sociological aspect of the relationship, having to do with role allocations within the family [IO], and the psychological aspect. involving emotional interactions and person:d dynamics. The attachment of a child between the seventh and thirtieth month of its life to its mother has been shown to IX critical 10 hc;dth dc\clopmcnt [I I. 12. 131. This has important implications for the collection of useful statisticaldata. Incnscsofadoption. for example. theage
The
social
approach
of the infant at the times of renioval and arrival are critical. Furthermore. in cases of parental loss. the ages of the children are important. Loss of a mother &fore five years of age may be related to psychoneurosis Cl43. To determine the influence of any changes in the family environment affecting the quality of human relationships is a complex.qucstion. but there is evidence linking major changes not only with psychosomatic disturbances but also with accidents and other apparently unconnected misfortunes [I 5-211. When genetic as well as environmental factors are involved in the realm of mental illness. it is particularly difficult to unravel their respective etiological salience. There is a correlation. for example. between mental retardation without organic defect and mentally inferior parents. but the precise nature of the causative factors remains unclear. Much more information is required. but it is important to note that cross-generational data is essential as well as an adequate degree of diagnostic comparability [23-251. There is mounting evidence connecting birth order with personality characteristics and related matters such as marital adiustment [26]. Physical conditions in the environment relevant to the contraction and prevention of disease are in part socially determined. Such determinants include tradition. taboo. values. dietary habits. personal interactions. methods of trade and agriculture and the modes of social sanctioning. All of these are transmitted through the agency of the family [37.X]. DEFISITIONS
If the distinction already noted between family health and a “healthy family” is accepted. then for our present purposes it 1s sufficient that b>; -‘health” we mean the absence of any disease or impairment. physical or mental. The impairment may only be imaginary, or at least lacking in objective confirmation (as by a physician) but an imaginary impairment remains an impairment. But it is to be noted that even such a general definition as this has cultural undertones. PaGents vary not only in their tolerance of symptoms and in their standards of normalit!, and dysfunctioning according to differing social standards and values. but also in the choice of symptom presented [29]. There are occasions \vhen medical intervention is appropriate although neither disease nor impairment is directly involved. Intervention of this kind may be preventive or supportive. An example of the first would be a public health authorit!, initiating action to prevent or restrict an epidemic: an example of the latter would be psychiatric consultation with a community that had suffered a natural disaster. The concept of famil! ma! be defined as a group of two or more persons. related to each other b) blood. marriage or adoption and liying together. According to this definition a brother and sister liv-
to family
health
4x9
studies
ing together is a family but an unmarried man and woman living together without children though a household is not a family. If in the latter case. a child is born, they become a family. To avoid some of the semantic confusions mentioned earlier it is necessary to distinguish between the “healths” of members of a family and familial health. The former is concerned with the prevalence and incidence of disease within a given family; the latter describes the functioning of the family as a structural unit. It is proposed that since the term “family health” has established usage it be used exclusively in the former sense, to describe exclusively the comparative health status within a family, and that the term “familial health” be used in the latter sense, as an evaluative description of functions and structure. THE
FAMILY
The family is not only the basic unit of human social organization. but it is also the one that is most accessible for preventive and therapeutic intervention. The health of a family goes beyond the physical and mental conditions of its members to the extent that it provides a social environment for the natural development and fulfilment of all who live within its ambience. Apart from religion. the family is the only social institution which is formally developed in all societies. The family is the principal mediating agent between the individual and his society. Through its teachings. sanctions and examples the young are socialized into the customs, habits, manners, values and beliefs of their culture. The family unit of socialization is the family of orientation. This is in distinction to the family of procreation, the reproductive family unit. The family varies in form from one culture to another. There are four basic forms. The conjugal or nuclear family comprises husbarid, wife and children. When a nuclear family group shares the living quarters with a relative. who is a primary family head and maintains a household, this smaller unit is sometimes referred to as a sub-family. The extended family consists of several generations living together. The stem family is a specialized version of extension, common in parts of the United States of America and Japan. Under this system only one child, usually the eldest son, inherits the family property which, together with family title and responsibility is unilaterally administered. The joint family of India consists of co-percerers, these being people sharing property rights within the family, generally all the brothers in each generation in a direct line. so long as the farnil) unit remains cohesive. In many cultures family location is predetermined. Neolocality. in which the bride and bridegroom move away from both their parental neighbourhoods reduces the influence of elders. When a woman moves
190
P. J. M. McEw~s
to the location of her husband’s family there is patrilocality. and if he moves to her neighbourhood there is matrilocality. Which of these is followed in any instance will largely determine the frequency of social interaction between the kinship networks. The nuclear family passes through four natural stages of development. the duration of each being variable. These phases, each of which presents characteristic opportunities and strains, represent periods of expansion. dispersion. independence and replacement. As families pass through these identifiable stages of development. crises may be experienced. These are generally classified as being of two kinds. transitional crises which have to do with problems posed by severe role change as is created, for example, by marriage, the birth of the first child, retirement and bereavement. Non-transitional crises have been further classified as illustrated in Table 1. Table
I. Classification
of family crises [30]
Dismemberment Death of a child, spquse or parent Hospitalization of spouse War separation Accession Unwanted pregnancy Return of deserter Stepfather/stepmother returns War reunions Some adoptions, aged grandparents, orphaned kin Demoralization Non-support lnfidelitv Alcohol&m Drug Delinquency and events bringing disgrace Demoralization + Dismemberment or Accession Illegitimacy Runaways Dcscrtlon Divorce imprisonment Suicide or Homicide Institutionalization for mental illness or mental retardation
In addition to crises, seven main types of change in the life-style have been identified. Although often less scvcrc in their demands upon individual and familial adjustment than the transitional crises. the status shifts involved can be major factors in the etiology of mental illness and perhaps also in the contraction of certain organic diseases [3 I]. Thcsc arc: (a) sudden impoverishment; (bj prolonged unemployment: (c) sudden wealth or fame; (d) rcfiigec migration: (c) natural disasters:
(f) wartime deprivations: (g) political declassing. Hansen and Hill [Y] identif; four themes that run through most attempts to classify family stressors. These are: (a) the effect of presence or absence of physical features of stress: (b) the tensions or hardships that. precede impact of the stressor or evidence of strain: (c) the presence or absence of factors that allow members to blame one another for the stress: and (d) the probable effect on the family of community response and resources. There is evidence that western societies are passing through a transitional stage in which values are changing. The gradual revision of legitimacy involves a period of increased deviation (illegitimacy). In the family this means an increase in the number. and to this extent at least the importance. of illegitimacy. the uncompleted family unit. The most common forms are consensual unions. casual relationships prior to marriage and adulterous relationships within marriage. Difficulties in establishing these facts make them elusive categories for the demographer. but their signiticance for health studies warrants greater care in establishing these categories than has been shown in the past. The strains placed upon the institution of marriage by contemporary western societies. associated with evidence of changing values. have led some people to believe that marriage m its present form may be undergoing dissolution. Evidence for this belief is still somewhat slight. but the fact remains that the effects of these influences upon the patterns of family life are considerable. This factor of contemporary change does not make the planning of long-term goals of the kind with which we are concerned easy. but nevertheless these issues have to be faced. The nuclear family may dissolve as a viable structure without any formal dissolution (death. divorce, legal separation). There may be desertion. voluntary separation, the unwilled absence of one partner and the “empty-shell” family in which communication is non-existent although the members continue to live under the same roof. The concept of the nuclear family as a basic social institution and a inajor determinant of personality. good health and behaviour. is also undergoing changes. Short-term trends that have been identified include a greater dependence in the matter of getting married upon economic and political Huctuations. a younger age at marriage. changes in child-spacing (with a propensity toward the bunching of offspring). the re-allocation of sex rolesand a departure from parallel roles in marriage toward a monadic-diadic relationship [32]. Longer-term trends may be more important in as far in planning future as they can be anticipated demographic surveys. Those that seem most likely and which relate most to health are mentioned below. The increased mobility of families. making community relations more dilhcult (in the United States of America. for example. one family in five moves
491
The social approach to family health studies
annually and one in three of these crosses county lines every year). There is a reduction in the number of services supported by the family. In the past the nuclear family has provided medical care, general and religious instruction and recreation. These are being placed more and more in the hands of specialized agencies. Age and sex roles within family life are changing. As the family becomes less self-sufficient, the role of the father grows less authoritarian. Prosperity becomes more dependent upon external forces, if things go wrong the blame, as well as the responsibility, is directed increasingly to forces outside the family. Households are becoming smaller and mate selection is more independent of parental influence. There are fewer arranged marriages in the world. The decrease in the overall proportion of extended families is reflected in a corresponding increase in the proportion of nuclear families. This decline of the consanguineous family system may be due, not only to the effects of industrialization, but also to the internal strains upon the system imposed by the often delicate relationship between women in joint households [33]. There is a strong movement throughout the world toward tht social and economic equality of women. Working wives whose occupation takes them away from home have greater difficulty in reconciling their career with their role in the family than do men. This trend reduces the comparative authority of the male and tends toward greater equalitarianism, although often at the expense of producing greater role strain as functions within the family are readjusted. There is an increased separation between sex and procreation, more sexual intercourse and fewer children. This reduction in the procreative function remains. at least for the moment, contained within the family. although the separation itself has obvious consequences for sexual morality. for the position of women in society and for patterns of pre-marital sexual behaviour. Divorce is becoming more common. Nimkoff has this to say [34]: “Increasing industrialization and urbanization are correlated with rising divorce rates because of their influence on the family and its setting. The industrial-urban complex results in a diminution of economic interdependence of married persons. They need each other less in the struggle for existence than do couples’in pre-industrial rural society. Women can support themselves and men can find substitute sources of satisfaction of their domestic needs. If their economic interdependence is less, their psychological interdependence is greater than before. for the possibilities of loneliness are greater in the mass society. But sentiment is more ephemeral than survival. and marriage based on love is more vulnerable than one based on economic need. So modern marriages break up more readily. although those that endure are generally more
satisfying because they are based on psychological compatibility. The trend toward equality in the relationship between husbands and wives, replacing the earlier patriarchalism, is also a potent source of difficulty. A relationship of equality is more difficult to maintain than one of inequality. There is only one point at which a pair of scales will balance and many points at which it will not. The urban setting contributes to marital instability because there is less effective social control in the mass society than in the smaller. simpler folk society”.
THE FAMILY
AS FOCUS
OF MEDICAL
CARE
Information regarding patterns of health in families although often proposed has been seldom implemented [35,36,37]. It has been suggested that the family can be regarded as a unit of health behaviour with its own patterns of morbidity, responses to symptoms and utilization of medical facilities [38]. This is true. but only as long as it is recognized that a family as a concept cannot itself do these things, they are done by individuals acting in the name of. or through the influence of a group called the family.
METHODOLOGICAL
CONCERNS
Data regarding family health may be collected through conventional census channels, satisfactory for comparatively crude demographic data but insufficiently sensitive for detailed studies, from medical records maintained by medical personnel, applicable only when members of a single doctor share the same medical advisers, or by seeking more intensive, longitudinal assistance from families. The reliability of family health information, particularly in cases of mothers with low educational achievements, is extremely difficult to obtain. Incidents of health behaviour are complex, arbitrary and sometimes difficult to recall. Kosa found that what he called two kinds of normative ideas-medical relevance and social desirability-tended to bias reports. Suchman and his colleagues compared the assessments of health status made by a lay panel with those made regarding the same subjects by a group of physicians [39]. They found considerable variations. but health behaviour conformed more closely with the selfevaluations. When patients are asked to report on their use of physicians they tend to reduce the number of occasions [36,40] but to increase the amount of hospitalization [41.42,43]. This reduction is not exclusively attributable to lapses of memory C44-473. It is generally held that the best source of information within the family is the mother [48-533. The most consistent and carefully designed attempt in the field
492
P. J. M M~EWAN
is that made by Kosa [37] but his experience was generally most disappointing. There is great danger that inaccurate data will be collected when details of actual medical treatment and characteristics are gathered from patients. even when the characteristics are physically apparent [54]. One problem in the use of epidemiological data is the insidious characteristic of categories. It is always tempting to restrict information to categories that are clearly defined and unambiguous. But this can mask important connections. It is therefore of the utmost importance to consider most carefully the purposes of a survey before making a choice of the categories to be used. A further refinement is desirable when two or more variables are thought to have a casual relationship such that x implies y, but y need not imply x. In such cases the use of sub-categories should be employed separating x and y at the time the data is collected. What is needed when embarking upon any study of the family in relationship to disease and its prevention are the formulation of firmly based hypotheses, the selection of indicators of the health behaviour to be examined, a definition of the concepts employed and an unequivocal understanding of the logistic support available.
REFERENCES
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18. Levy D. M. Oppositional Syndromes and Oppositional Behaviour in Ps~~cl~optrtl~oloy~~ o/ Chi/dhoot/. (Edited by Hoch P. H. and Zubin J.) Grune and Stratton. N.Y. 1955. 19. Penrose L. S. T/X, Bioloy!, of .If~ml/ DL’/~~I~I.L,.s.2nd Edition. Sidgwick and Jackson. London. 1954. 20. Stein Z. and Susser M. Families of dull children I.I. Identifying family types and subcultures. J. wt?t. Sci. 106, 1296. 21. O’Gorman G. Psychosis as a cause of mental defect J. mrnt. Sci. 100, 934. 22. Bourne H. Protophrenia: A study of perverted rearing and mental dwarfism. Larwt 269, 1156. 1900. 23. Davis D. R. A disorder theory of mental retardation. J. wnr. Suhnormul. 1, 13. 24. Miller F. J. W. rt ul. Gro\ri~l~/ L;p in .I’crvcu.srlr-upo+ ryr~e. Oxford University Press. London. 1960. 25. Charles D. C. Ability and achievement of nersons earlier judged mentally deficient. J. Grnrr. Ps&~ol. Mouo~~~. 47, 3. 26. Toman,Walter Yt (II. Fmnilv Comtrllutior7. 2nd Revised Edition. Springer. N.Y.. 1969. 27. Jelliffe D. B. Social culture and nutrition. Prrrdiurrics 20. 128.
28. Keys. Ancel. The diet and the development of coronary heart disease. J. Clzrorr. Dis. 4, 364. 29. Zola. Irving. How Sick is Sick’! Working notes and reflections on the Cross Cultural Studv of Illness. WHO . Consultative document 1970. 30. Eliot T. D. Familv crises and wavs of meetine them. In Murriuyr and thcvFuwi/~~. (edited-by Becker g and Hill R.), pp. 489.-536. Heath. Boston, 1942. 31. Hill R. Grnwic Feutwcs of Ftrvlilies L~r~t/er Stwss. Social casework 39. pp. 139- 150. 32. Hill R. The American family today. In Herr/t/l nnd the Commrr~ir~. (edited bv Katz A. H. and Felton J. S.), The Free Press. N.Y.. 1962. M. F. Compururrve Furnil!, S\xterns. pp. 33. Nimkoff 346-347. Houghton Mifflin. Boston. 1965. 34. fhid. pp. 355-6. P. S. Chronic illness and socioeconomic 35. Lawrence status. Prrhl. Hlth. Rep. WU.S/I. 63, 1507. 36. Haggerty R. J. Family diagnosis: Research methods and their reliability for studies of the medical social unit. the family. ,1n1. J. p&l. H/t/z. 53. 1521. 37. Kosd John et ul. On the Reliability of Family Health Information. Sot. Sci. & Med. I, (2). pp. 165%81. 38. Kosa, John et (11.Crisis and stress m family Ilfe: A reexammatlon ot concepts. Wiac. Sociolo~qist 4, I 1. 1900. 39. Suchman E. A. et ul. An analysis of the validity of health questionnaires. Sot. Forces 36, 223. 40. Solon J. A. et al. Patterns of medical care: validity of interview information on use of hospital clinics. J. Hlth.
hum. Brhac. 3, 21.
The social approach 41. l!.S. National Health Survey. Rrpwrimq of Hospiru/isuriorr rn t/n, Hrulrl~ Inrcvric,\~ S~rrw~~ (Vital and Health Statistics. PHS Publ. 1000.Series ~-NO. 6). P.H.S. Wash. DC. 1965. 42. U.S. National Health Survey. Compuriswl ctf Hospitulistrrion Reprrirq (Vital and Health Statistics. PHS Publ. 1000. Series 2 No. X). P.H.S. Wash. DC. 1961. 1.3. Sanders H. S. How good arc hospital data from a household survey. AIII. J. pub/. Hlth. 49, 1596. 44. Commission on Chronic Illness. Chronic IIlr~rss in the L’rlitrd Srate.s. (4 vols.). Harvard University Press. Cambridge. Mass.. 1967. 45. Elinson J. and Trusscll R. E. Some factors relating to degree of correspondence for diagnostic information as obtained by household interviews and clinical evaluations. Am. J. pub/. Hlrh. 47. 31 1. 46. Krueger D. E. Measurement of prevalence of chronic disease by household interviews and clinical evaluations. 4rn. J. prrhl. H/t/?. 47, 953. -17. Trussell R. E. 1’1trl. Comparisons of various methods of estimating the prevalence of chronic disease in a community. .4ru. J. puhl. H/~/I. 46. 173.
to family health
493
studies
48. Mechanic. David and Newton M. Some problems in the analysis of morbidity data. J. Chron. Dis. 18, 569. 49. Cartwright M. Sornc Mclltodolocti~ul Pwhlrm EIICOL~IIrcwd WI u Furnil~~ Surw~. Ph.D. Thesis. London tinivcrsity. 1961. intcrvicw survey as a tech50. Feldman J. J. The household nique for the collection of morbidity data. J. Chron. Di.!. 11,535. D. The influence of mothers on their chil51. Mechanic dren’s health attitudes and behaviour. Purdiutrrc.s 33, 444.
David. Perception of parental responses to 52. Mechanic, illness. J. Hlth. hum. Brhuc. 6, 253. nursing 53. Alpert J. J. et al. Medical help and maternal care in the life of low-income families. Purdiatrics. 1968.
cir54. Lilienfeld A. and Graham S. Validity of determining cumcision status by questionnaire as related to cpidemiological studies of cancer of the cervix. J. n&n. Cancer 1nsr. 21, 713.
.