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Soci orCuIt ur aI Perspectives in Health

Santhat Sermsri, Ph.D.


Cour* Directcr of Sccic-Cultrral
Maseer Perspec{ives in

himay Hedth Care

hogram of himary Health Care Management

ASEAN Indtitute fcr Health Development Mahidcl Univerdty

leee

Concept book on Social and Cultural Dirnensions in


-Health Care
-

Repr oductiv e B eh avior

-Aging

-Urban Health
-Crowding -Family Violence
-WeII-Being

-Health Social Sciences

rsBN 971-87L29-l-5

To my rnother, son, Indhorn and daughter, Salfon

Comidn @ by Sailfrat Serasri


AI| rfghts rcerved. No pert

of 'tc

book may be neprodued,

h my frrn.rn by any msns,

qdthant

erd8dm fn xrddng fton Sanltd Serml

Ftrst edition, 500

oo1liere

Printedin October 1ee0 innargkog Tlniland


by San Clrarcn Panioh Prindry Co.,

I.trL ?AU5l-55 Iampsanit Wongr Road' Ba4Ela4 Baglot

Content

ltl

Contents

List of Tables and Chart,.,. Preface

vi

vii x

Acknowledgment

Chapter

Socio-Cultural Perspectives in Health

Significance, Definition,
1

1) Influences of IndividualAttributes, 3

2) 3) 4)

Influences of Social Structure, 5 Influences ofSocial Concerns, 7 Influences of Reference Group, 9

Future Challenge, 11

Suggested Readings, 12

Chapter 2

Health Care Services

15

Change in Health Care Philosophy, 15 Problems of Medical and Health Services, 16

ThaiHealth Seeking Behavior. 18


Utilization of Traditionaland Modern Health Care, 19 Primary Health Care Approach and NGO Efforts, 22 lmplementations, 23 Suggested Readings,25

Chapter 3

Social Determinants of Fertility

29

Biological Determinants, 30 Economic Determinants, 31 Social Determinants, 34

tv

Socio-Cultural Perspectives in Health

1.

Religion,35 Education,36
36

2.

3. Female EmPloYment,
Suggested Readings,44

lnfluence of Intermediate Variables' 38

Ghapter

Aging and

Health

- 45

Aging Phenomena,45
Definitions of Aging, 46 Demographic Cause of Aging,47 Social Cause of Derelict, 49
Risks of the Eldedy, 55 Preventive Actions, 58

Suggested Readings,62

Chapter 5

Urbanlzation lmpacts on Health

67

Trends of Urbanization, 67

Definitions,69
Causes of Urban Growth, 70
Slums and Squatters, 73

Concepts of Urbanization, 75
Urlcan Life.77

lmpacts on Health, 79 Proposed Measures, 35 Suggested Readings,86

Chapter 6

Household Crowding and Family Violence

91

Definitions,92
Housing Situations,92

Contents

Theoretical Concepts, 94
The Case of Bangkok, Thailand and Beijing, China, 97

Suggested Readings, 101

Chapter 7

Development and Health

103

Relationships Between Development and Health, 103 Concepts of Social Influences, 105
Proxy of Social Progress, 106 Framework of Education Influence, 107

Social Standing in Family System, 109 Suggested Readings,


111

Chapter

lmplications of Well-Being from Changes in Thai Society

113

Suggested Readings,'1 19

Chapter 9

Health Social Science: The State of the Art

121

Historical Review of Health Social Sciences, 121 Current Challenge to Develop Health Social Science and Progress of Teaching
Effort in the Field of Health SocialSciences, 125

Enhancement of the Development of Health Social Science, 128 Summary, 130 Suggested Readings, 1 31

Subject lndex Contributors

135 139

VI

Socio-Cultural Perspectives in Health

Tables and Chart

Table
1.1 Percentage of Households reported information on Material Possessions in their Household,

Thailand, 1990, 1994and

1996 1996

14

2.1 Percentage of Health Care Utilization in Thailand, 1970, 1979, 1985, 1991 and

27

2,2Percentage of Health Care Utilization in Thailand, classified by Urban and Rural Areas, 1991 and

1996
4.1 Percentage of the Elderly by Type of Sickness and Male-Female, Thailand,

28

1994

66

5.1 Percentage of Households on Well-Being lndex in Congested Community of Bangkok, 1994 89 5.2 Percentage of Persons reported ill or not feeling well during 2 weeks prior to the Survey, by 7 Groups of Diseases, Urban-Rural Areas, Thailand,

1996

90

6.1 Number and Percentage of Intentional Self-Harm and Assault, classified by Occupations and Male-Female, KhonKaen Province, 1998
9.1 World of Health Social Science Programme and Agencies

102 134

Chart
5.1 Urban Hierarchy in Thailand

85

Preface

vll

Preface
This book of Socio-Cultural Perspectives in Health, is a sequel of teaching and
coordinating the graduate course of Socio-Cultural Perspectives in Primary Health Care

at the ASEAN Institute for Health Development, Mahidol University. Putting together a
number of small pieces of lecture notes into a book form required revising numerous
times and consulting a number of scientific papers, published articles and official figures.

Hence, the suggested readings at the end of each chapter is quite useful for further examination into the issues concerned. To solve the dilemma of breadth of coverage against depth, the focused upon selected health issues are therefore based mainly on the author's researches and manuscripts. The book attempts an analysis of social and cultural perspectives upon selected health issues, including health care services, aging, urban health, family violence, health and development, welFbeing and a new discipline

of health social science. These selected health issues are presented in nine chapters.

Since this book was completed in a great historical year for Thais for whom 1999

is the year to celebrate lhe 72n" Birthday of His Excellency, King Bhumipol Adul-yadej,
the completion of the book is therefore designed to be part of the merit making year of all

Thais for our beloved king. Benefit and usefulness of the book should contribute to
celebrating this significant year of H.M. the King.

The book has an objective which is to acquaint the persons interested in health with the applications of social sciences to research and community work. This means

viii

Socio-Cultural Perspectives in Health

that it is necessary to examine the ways in which critical health issues have been
developed by social science viewpoints. The prime concern of the book is therefore to provide the conceptual framework of the respective health issues and also reveal the
relationshios between socio-cultural dimensions and health.

The book has nine chapters. The first chapter, entitled


Perspectives

Socio-Cultural socio-cultural

in

Health, attempts

to

identify how different levels

of

dimensions affect health and why the influences of so-called modernization operated
upon the contemporary health issues in the context of Thai society. The second chapter, Health Care Services, discusses important questions on why health care services at the

primary level in the country became grossly underutilized and how the social costs of

health care are growing. The chapter also reveals the efforts accessibility

of NGOs upon

the

of rural

health care.

A final part of the chapter deals with how the

involvement of community has helped to improve government health care and increase in

the popularity of modern health care in Thailand. The third chapter, Social Determinants

of Fertility, explores the relationship between

sociological factors and reproductive

behavior. This chapter actually formulates theoretical concepts and approaches for studying socio-cultural determinants on fertility behavior, including number of children, marriage age and sexual behavior. A well-known concept, Intermediate Variables on
Fertility, is introduced to suggest how social and cultural factors intertwine with biological

dimension. The objective of the fourth chapter, Aging and Health, is to use sociological
researches to reveal certain key processes shaping aging in contemporary society. lt is intended to provide a critical context of elderly health within which these processes can

be evaluated and remedied. The analysis, which was built on a preliminary

work

published in the Mahidol Journal (December 1998), will further seek to situate Elderly
Health within the context of health prevention policy.

Preface

ix

The fifth chapter, Urbanization lmpacts on Health, examines the central idea of

the urbanization impacts on health. As

urbanization becomes

an international

phenomena, the trend of rapid urban growth, together with the increase in a number of slums, squatters and the poor in the cities, is discussed to understand the impacts of the urban way of life on health. Since the 21" century is the century of the cities, the chapter

then formulates proposed measures and interventions for preventing a happening of


social malaise and critical health care in the cities. The sixth, Household Crowding and Family Violence, which is based on a book on the same title by John Edwards and his colleagues (1994), deals with household crowding and family violence which is now

widespread in many developing countries and cities. At the end of the chapter, it
discusses how the issues of violence against women became a public health issue. The seventh, Development and Health, is a complementary and an elaborating chapter to the
discussions in chapter one, affirming how the significance of social and cultural concepts is highly important to examine health issues and is being integrated into the development scheme as both health and development exemplify the same concept of well-being. The

eighth chapter, lmplications of Well-being from Changes in Thai Society, is designed to provide an overview to the changes in the contemporary Thai society, relating to wellbeing. lt is the chapter to document the implications of a change in the society on both physical and mental health. The final chapter, Health Social Science: A State of the Art,

suggests that the social sciences should be useful for understanding medicine and
health issues, A question arising from this chapter is how collaboration and partnership

Socio-Cultural Perspectives in Health

could be promoted among health and social scientists involved in health care systems in
coming decades.

Acknowledgement

This book is the product of, as mentioned, not only. a series of my lectures
graduate students but also

to

long collaborative effort by friends, colleagues and

students. I am therefore deeply grateful to many in helping me complete this book and

supporting me

to carry out scientific tasks. I would like first to acknowledge

the

assistance from the Household Crowding Research Team. My appreciation goes to


Professor Theodore Fuller, Professor John Edwards and Associate Professor Sairudee Vorakitphokatorn in sharing the efforts to contribute the discussions of chapter six.

I would like also to thank Dr. Patricia Rosenfield, Dr. Jose Bazelatto, Dr. Scott
Halstead, Dr. Robert Lawrence and Dr. Maureen Law for their encouragement in making

my scientific endeavor become useful and enhancing my understanding of health and social science in the final chapter of this book. Special mentors are Professor Mary-Jo Good and Professor Nick Higginbotham, who have made so many contributions to the
tasks of international health social sciences. Members of IFSSH Steering Committee are

also acknowledged. My thanks are small recompense for the amount of help I have
received.

I would like to acknowledge the assistance from the Director of the

ASEAN

Institute for Health Development, Associate Professor Som-arch Wongkumthong for his kind suggestions to make this book efficiently completed.

Preface

xl

Last but not least, completing the book was a demanding process that required many hours of labor and thought from many students and friends. I thank all graduate classes in Primary Health Care Management, Health Social Science and Urban Health.
I

wish to thank my old friend, Dr. James N, Riley, for his personal guidance to the
development of the lecture notes of chapter trrvo. Professor Arthur Kleinman, for the
preliminary work of chapter eight. Professor Paul Cohen, for the prime source of writing in

chapter five and Professor Sidney Goldstein and Mrs. Alice Goldstein for their numerous ideas during the time I was in Providence. Mr. Thomas McManamon and Miss Laura
Hollinger are also appreciated for editing the language of the book.

The timely completion of this book would not have been possible without the support and coordination from family, especially my twins, Indhorn and Saifon. lt has
been a great year in which the development and groMh of my dear twins have been
delightful and enjoyable.

Santhat Sermsri, Ph.D. 23 September 1999

Socio-Cultural Perspectives in Health

Chapter

1 Socio-Cultural Perspectives in Health


Santhat Sermsri

Significance

It has long been recognized that the origin of human suffering and ill health

is

rooted in social processes. In the late 1970s, there had been some efforts to build up inter-sectoral collaboration for health development as it was then realized that health development alone could not cope with the health problems (Alma Alta Declaration,
1g76; Sermsri, 1991; IFSSH, 1994). The prevalence of high infant deaths is, for example,

considered to result from the low socio-economic standing of patients and the lack of understanding of the cultural context of the people. In many developing countries, where

the high incidence of illness and death among the poor majority is critical, and health
care for the majority is inadequate, accessibility of health care is therefore problematic.
This id partly due to the overlooking of patient characteristics and patient constraints, and

because of the emphasis on curative rather than preventive care. Dreadful diseases like AIDS and other tropical diseases, are now recognized to be the consequence of the
imposition of modernization, inequality between rich and poor and deprivation between

groups and places. Explicitly, there are a series of AIDS epidemics that vary remarkably in different places and social classes. Non-communicable diseases now prevail in the
modern wo1d. Cancer, heart disease, and accidents are the leading causes of death and recognized as having an etiological relationship to social behavioral factors.

Definition

From above, health


interaction between

is then the outcome of a

continuing and reciprocal


other

a slowly evolving biological substance of human being and

Socio-Cultural Perspectives in Health

organisms and rapidly evolving social environments. This definition can be elaborated by information on age specific death rates,e.g., a socalled a chance of surviving or dying.

Socio-cultural perspectives in health therefore refer to the interrelationship in

which health and its parts are studied by different aspects of social and cultural
dimensions. A principle knowledge of social sciences is related to a chance of life, and

every society will develop

system/structure which will place people

at a

certain

position. Persons are placed by both their own achievements and genetic make-ups.
Therefore, one status has advantages that are not given to those of lower statuses. These advantages will lead to greater life chances. What we love and hope for or hate and fear

are experienced because of our involvement with others. Social perspective therefore
implies the involvement of others. To influence others or to be influenced by others is social interaction. Social perspective is then viewed as the influence of human activities. Social factors therefore refer to the relative standing of a person in terms of factors as

mentioned above such


ownership of property.

as

income, education, occupation, social statuses, and

Behavior is also determined by culture. Persons behave according to their


experiences, which are accumulated by their learning and socialization. Culture is that

complex whole

of perception,

beliefs, values and actions (behavior), including

knowledge, art, morals, law, custom and any other capabilities and habits acquired by

man as

member

of society. Culture distinguishes man from the lower

animals.

Individual standing then include culture. From this, it can be concluded that there are 4 levels of social-cultural influences on health: (1) Individual standings, (2) Social structure,
(3) Social concerns/awareness and (4) Reference group.

Socio-Cultural Perspectives in Health

nfl

uences of ndivid
I

ua I Attributes/Stand

ngs/Cha racteristics

Studies on social aspects and health have shown that

a person's position in the

social class will have an effect on his/her length of life. People in the lower statuses of

the society are likely to die younger than those in the higher statuses (Kitagawa and
Hauser, 1973). Individual characteristics therefore refer to the relative standing of a
person in terms of factors such as education, occupation, income or ownership of land.
We can say "people are sick because they are poor and they become poorer because

they are sick and sicker because they are poor".

These individual attributes also affect a person's thinking and actions.

high

literacy of a person for example creates political consciousness. An example of such


social consciousness can be found among people in the State of Kerala, India. Details of

this social consciousness will be discussed again below. In contrast, an increase

in

education attainment also creates generation gap between younger and older. As modern society progresses, the younger member of the farming society have then
received more formal modern education. This makes them feel that they have then no role in the agriculture based traditional society, allowing them to leave the villages and
move to cities. In addition, when younger members in traditional society are educated,

older members of the society find themselves in a society that no longer values their
knowledge and experience in the same way as before. This leads to a disorienting less of

meaning as well as a loss of respect from their younger generations and can create
lowered levels of self-confidence, self-esteem and well-being.

Therefore,

it is true that improvements in individuals'


of

social and economic

conditions are important indicators which directly affect the degree of health of an individual. People modern societies are placed by characteristics

of education,

Socio-Cultural Perspectives in Health

occupation and income, for example. In modern society, economics is a powerful force in

determining the life of individual. People then fulfill their own wills according to their
economic standings. Individuals who are able to pay, have better lives. People with low

levels of development are more likely to face life constraints and high risk of ill health

and therefore die younger. The causes for this unfortunate state are poor nutrition,
inadequate housing, poor living conditions and low knowledge about preventing illness

and death. A number of studies have elaborated the relationships between social
statuses and lack of access

to health care in both developed and less developed

countries (Cockerham, 1989; Myntii, 1992; Sermsri, 1991; Kitagawa and Hauser, 1973; United Nations, 1985; Harpham, et.al., 1988). Despite the evidence of their difficulties in

accessing health care, lower status people are still treated within the framework of welfare care,

or low quality of service, and live on a day{o-day basis. This

is

unfortunately to say that health professionals, who stand at higher levels of social classes
,

treat upper class patients with more personalized care.

The status of women is also important. The recognition of women in a society

can help improve health not only for women themselves but also for their children and family. The role of society needs to define the status of the women. When women
evaluate housekeeping as being a sort of domestic slavery, occur and society does not

object to this idea the status of women is then improved. Women's desire to be
independent of their husbands is an indication of the development of a society. Hence,

the improvements of individual status will bring about an improvement of health


general, including morbidity and mortality.

in

In addition, there are questions to be raised now that demonstrate the level of
influence of individual characteristics on health. How would social influences integrate
into biomedical perspectives? Why do some women practice breast self-examination and others do not? Why do only some women go for pap smear tests? Why do some cancer

Socio-Cultural Perspectives in Health

patients delay seeking physician consultations? What determine choice of breast feeding or comoliance with immunization recommendations?

Two empirical examples of the poor rural Thais who were suffering illness and

could cope with modern health care services in Thailand, are from Dr.
Chanawongse's experience

Krasae

Dr. Krasae reported that he had received a number of

telephone calls from his village friends when he had just begun to work in Bangkok. The village friends asked for assistance in being admitted to a Bangkok hospital. Surprisingly,
one village friend requested Dr. Krasae to help out at a hospital where the village's illness

was treated. The rural friend stated that he had brought a large amount of money to cure

his illness in the Bangkok hospital but then was charged more than the amount he had carried. The second story concerns a poor farmer who had an injury. After the hospital
personnel cleaned the wound, they asked the farmer to come back to clean the wound

within 3 days at no charge for the service. The farmer however came after a week
because the injury became infected. He was told that he did not follow the suggestion
earlier because he had no money to buy a bus fare from his village to the town hospital.

2) Influences of Social Structure

Society is theoretically

a living thing which has influence on its members. The

social development in the more developed world of Eur:ope and North America resulted in profound changes in morbidity and mortality patterns by eli.mination of epidemics and dangerous diseases. In other words, the stage of development in human well-being have
played a decisive role in the determinants of health (Sermsri, 1998).

Mortality decline (health improvements) in more developed countries before the twentieth century was a result of the three events of social development. lt Was noted that before the nineteenth century in more developed countries mortality was high, about 52

Socio-Cultural Perspectives in Health

per 1000. A decline of mortality which started right after the Green revolution, resulted in

a lower magnitude of mortality, 25-30 per 1000. A subsequent event of social change,
i.e., Industrial revolution, brought the mortality rate further downward. lt should be noted
here that the rules of laws were established by the time of the Industrial revolution. This

helped improve living conditions, especially for women and children, as well as the general population. As we moved to the nineteenth century, the changes in society
helped people become more knowledgeable about improving health and social standing.

Health technology was used then for further improvement in personal hygiene and
longevity. Life expectancy was seen to progress from 20 years to 40 and then to 60 years
in the 17tn, 19tn and20th centuries, respectively (Sermsri, 1998).

As indicated above, regarding the influence of social aspects on health, a high


level of literacy and political consciousness among the Keralites was responsible for the

equity in the distribution and consumption of public services, especially education and
health services. Although the maldistribution of public resources in Kerala, India has not

been eliminated, fertility was reduced due to a widespread understanding of individual


rights and health care services.

We can turn our attention to the impact of the fall of the socalled Asean
economic tigers in 1997-1998. This economic recession has compelled women and men

to move or migrate in search of new opportunities. Some people have entered


prostitution to earn their living, but there are also women and children who have become

victims of trafficking and have been forced into prostitution. In this climate of economic

and political instability, people live in fear and depression. Their mental health

is

adversely affected. This will affect the development of our youth who are currently
exposed to violence, drugs, pornography, and unprotected sex (Sciortino, 1998).

Socio-Cultural Perspectives in Health

3) Influence of Social Concerns/Awareness

There is

a growing globalization of youth culture, which includes violence

and

mental illness among adolescents. Young people in the cities hang out in shopping

complexes and entertainment places. This new found freedom

of socialization

is

associated with increasing levels of sexual experimentation among young people, which

has been well documented in Thailand and Indonesia. A survey in Salaya, Thailand
revealed that high school adolescents are more likely to have a lover and many of them have sex for experiment and some have aborted the fetus (Hoque, 1999). Young people

are coming into daily contact with the stimulus of sexually explicit materials through
movies, videos, magazines, books, and the internet. Premarital sexual activity is taken for

granted in many of these information sources, but the material is designed to stimulate
rather than to educate. Teenage or young women who pick up men around shopping

complexes or other meeting places may then engage in sexual relations. A study of high

school adolescent students in Salaya, Thailand, on sexual behavior (Hogue, 1999)


revealed that almost of '169 students who came from well{o-do families with financial
solvencies, admitted that they have lover. Strikingly, the parents of the students know and

are not angry for having lover. During the dating with a lover, a majority of the students

(97 percent) are walking with their partners, while more than 84 percent holds their
hands. 41 percent do kissing lips and cheek. Although a small number of the studied students (25 out of the total 169) admitted to have sexual intercourse experience. More
than 53 percent of the sexually experienced persons indicated that lover is their first sex
Danners.

Another issue relates to the dreadful diseases of STD's and HIV/AIDS.

rapid

spread of HIV/A|Ds in Asia is related to the prevalence of high risk behavior. Campaigns

to counter the serious eoidemic of AlDs have led to a substantial decline in hioh risk

Socio-Cultural Perspectives in Health

behavior. In Thailand, the AlDs prevention campaign, i.e., 100 percent condom use program in sex establishments, is an indication of social and behavioral changes. An

approach involving peer groups


adolescents are

is

necessary

if the

reproductive health needs of


to

to be met. Peer influence creates risky sexual practices. Visits

prostitutes in Thailand and other ASEAN countries, normally take place in the context of a

night out among

a group of males and are associated with

considerable alcohol

consumption (Jones, 1 998).

Discussion about premarital sex is made difficult by the lack of communication between parents and children on this taboo subject. Male culture acceptes premarital
sex and visits to prostitutes as somewhat of a rite of passage for young Thai males'

Another social issue is family violence which occurs in all economic groups, but

it is most likely to happen among the poor. One reason that explains why family violence is more likely to be found among those who are poor and unemployed, or holding low
prestige jobs, is social stress. Families that lack personal friendships are considered at greater risk of family violence. The experience of violence in childhood as well as the

witnessing of violence have been explained as factors related to violence in adult


relationships (Wahab, 1998; TIME, 1999).

Feminist approaches have argued that social structure

is both a method

to

understand family violence and can also act as a solution to the problem. The feminist
view states that men use violence to subordinate women. They perceive that men, as the domtnant class, benefit from women's fear of the violence by men.

For the elderly issues, in the later years

of life, arthritis and rheumatism, heart

problem and high blood pressure are the most prevalent chronic diseases affecting the elderly. The majority of the aged refrain from seeking medical aid from public hospitals

Socio-Cultural Perspectives in

Health

due to many impediments, besides lack of money. Out-migration also influences the
availability of care givers for elderly. Several studies also found that the number of symptoms, types of symptom and perception on the severity of the symptoms were all
significantly associated with the treatment seeking behaviors (Afrizal,1998; Raju, 1998).

Some of the health problems of the aged can be attributed to social values. Traditionally, kinship is functional as a source of support for elderly to cope with their

sickness. Eldedy have been experiencing social changes. The significance changes
which affect elderly health care are the changes of household structure and pattern of
family support. Kinship has been the most important institution providing care for elderly when they suffer from illness. Relatives are sources of support for eldedy when they are in need. The availability of kin is an important determinant for elderly health care security. Using Durkheim's concept, the members of a kinship group are integrated by a collective

consciousness, at a similarity of ideas held by the members of kinship groups. lt has


been argued that families in a society tend to form a nuclear household. This implies that elderly tend to live alone. lt seems that people today morally accept that elderly to form

an independent household, even though they have daughters living in the same village.

Hence, the elderly themselves prefer to live alone for the reason of independence
besides the fact that several daughters do not allow the elderly parents to live with them.

4) Influences of Reference Group

1960 was the decade of modernization and industrialization in Thailand brought about by an urban authority in the capital city. In the upcountry, where a majority of Thais live, farmers grew rice as a staple food to support only their family. An exchange of the

farm products was generally made for extra goods that came from cities. A farmer
learned new technologies when he visited the city. Farmers visualized new items that
never were present in the villages and purchased new fertilizer, pumping machine, and

10

Socio-Cultural Perspectives in Health

adapted their knowledge of what was called modern utilities and modern man. This
modernization eventually helped Thai farmers grow more rice and earn more cash income, As development

is defined as the improvement of farmers' living

condition, and

modernization and industrialization seem

to

adapt well

to the Thai context

encourage the new mode of cash income. This evidence reviewed here does not always

hold too long.

ln

1970, farmers, who were considered

to be innovative men, were

eventually made dependent on modern technologies, i.e., chemical fertilizer, expensive


machinery. Since the farmers lacked skill in farm marketing, they often incurred a heavy

debt. Farm lands were finally sold to urban authorities and merchants as debts became
impossible to be resolved. Farmers then left villages for cities to find jobs as unskilled workers, leaving family behind with elderly and small children surviving alone in scarce resources. Family size is apparently reduced and village resources are drained by the
locus of cities where most of the government development activities are located.

A few years ago, a daughter of a farmer would be fortunate enough to pursue


higher education after completion of the compulsory school. The young rural girl's vision

was concentrated only on building a happy family after chancing to marry a good man.
She further dreamed of the materialistic comforts of life and wanted to possess a small

house equipped with modern utilities, i,e., television, refrigerator, bicycle and radio.
However, on completion of her college education, her dream of desires and achievement

clearly changed in direction. As the effect and impact of modernization, the rural girl

anticipated

to have more modern utilities, i.e., big color TV,. micro-wave,

washing

machine and a car. Her greater desire expanded to have a two-story house. lf she gets

married she may want to postpone having a baby for some years due to her desire to

reach for success in her career outside home and village. Figures in table 1.1 are exemplified in this issue and the discussions

in Chapter 5 and 8 will be

further

elaborated. On the other hand, one often encounters incidences when a rural girl from a
poor family can not access higher education opportunities, and is expected to stay in the

Socio-Cultural Perspectives in Health

11

village to take good care of her parents. Her brother would set out for the town to earn the

cash income. Also, girls from poor families, as other girls in the village, had dreams of having beautiful clothes, good modern utilities, and saving for a house and comfortable
life. This would often instigate the poor girls to work in the city as maids and waitresses.

These girls worked hard and sent money back home to make the dreams come true.
Unfortunately in many cases, the girls were forced later infected with STD's, including HlV.

to be commercial sex workers and

Future Challenge

There have been dramatic improvements in the health profile of Thailand over the

last forty years. The provision of basic public health programs such as immunization, watei, and sanitation, and maternal and child health has reduced morbidity and mortality

from infectious disease. The extension of primary health care programs has reduced

deaths from diarrhea diseases, respiratory disease levels have declined as

consequence of sdcial and structural changes and the fertility rate has dropped as a
result of the widespreadavailability of family planning. Thailand has undergone a health transition with a shift from communicable to non-communicable, or "life-style", diseases,

such as death from cardio-vascular disease and cancers, and from occupational
diseases and road accidents. However, although the overall picture of public health in
Thailand displays a shift towards lifestyle diseases similar to wealthy countries, in many parts of Thailand diseases of poverty continue to be the primary cause of morbidity and

mortality. The poor health status of the poor is further exacerbated by inequalities in

access to health services. More recently, HIV/A|Ds and the threat of rising rates of
tuberculosis pose new challenges to public health, Moreover, the coming years will see an inflation in health costs as Thailand's population ages, privatization increases, use of modern medical technology increases and primary health care activities declines and could be changed in another form.

12

Socio-Cultural Perspectives in Health

Suggested Readings

1. Afrizal1998 "social and Demographic Changes

and Their lmpact on Elderly's Health

Care in Rural Population of Matrilineal Minangkabao," paper presented at the Fourth Asia-Pacific Socla/ Sclences and Medicine Conference (APSSAM), Yogyakarta, Indonesia, 7-1 1 December 1998.

2.

Bloom, S.W. and R.N. Wilson. 1979 "Patient-Practitioner Relationship," in H.E. Freeman, S. Levin and C.G. Reeder (Editors). Handbooks of MedicalSoclology, New York: Printice Hall Inc.

3. Caldwell, J. C. 1986 "Routes to Low Mortality in Poor Countries," Population and


Development Review,Yol12 No. 2.

4.

Cockerham, W.C. 1989 Medical Sociology. Fourth Edition, New Jersey: Prentice Hall Englewood Cliffs.

5. Harpham,

T., T. Lusty and P. Vaughan 1988 /n the Shadow of the City: Community

Health and the Urban Poor. Delhi: Oxford University Press.

6.

Hoque, A.M.M. 1999 "Sexual Behavior, Contraceptive Practice and Reproductive Health among Thai School Adolescents," Mater Thesis of Primary Health Care Management, Faculty of Graduate Studies, Mahidol University.

7.

International Forum for Social Sciences in Health (IFSSH). 1994 "Linking a Global Core

Agenda with Regional Activities for the Application of Social Sciences in Health,"
Working Document No.1, Secretariat, the lnternational Forum for SocialSciences in Health, Mahidol
U

niversity, Salaya, Thailand.

8. Jones, Gavin W. 1998 "Approach To Understanding Sexuality and Reproductive


Health," paper presented at the Fourth Asia-Pacific Socra/ Sciences and Medicine Conference (APSSAM). Yogyakarta, Indonesia, 7-1 1 December 1998.

9.

Kitagawa, E.M. and Philip M. Hauser. 1973 Differential Mortality in the United Sfafes:

A Study in Socioeconomic Epidemiology. Cambridge, Massachusetts: Harvard


University Press.

Socio-Cultural Perspectives in Health

13

10. Macintyre, Sully. 1992 "The Effects of Family Position and Status on Health," Socla/

Science and Medicine. Vol. 35, No.4.


11. Myntti, Cynthia 1992 "Social Determinants of Child Health in Yemen," paper

oresented at the Socra/ Sclence and Medicine Conference, New Delhi, 16-18 March 1992.
12. Raju, S. Siva. 1998 "Socio-Medical Approaches to the Assessment of Health Status of

Elderly," paper presented atthe Fourih Asia-Pacific Socia/ Sclences and Medicine Conference (APSSAM), Yogyakarta, Indonesia, 7-1 1 December 1998.
13. Sciortino, Rosalia '1998 "Reflections on Health Social Sciences in a Time of Crisis,"

paper presented atthe Fourth Asia-Pacific SocialSclences and Medicine Conference


(APSSAM), Yogyakarta, Indonesia, 7-11 December 1998.
14. Sermsri, Santhat 1998 Prachakornsart Thang SanKom (Social Demography). Second

Edition. Bangkok: Sam Charoen Printing Company.


15.

------- 1996 "Family Changes Against Global Health and Welfare


Strategies in Southeast Asia Countries," paper presented atthe Third Conference of
Heatth Behavior Science; Cdsis Behavior Toward Growth and Solidarity. Sophia

University, Tokyo, Japan, 27-29 September 1996.


to.

-------'1995 "lmplication of MentalWell-Being from Changes in Thai


Society," paper presented allhe World Mental Health: Problems and Priorities in Lowlncome Countries, the Rajiv Gandhi Foundation, New Delhi, India, 6-8 April 1995.

1T.

-------

199'l "Health Social Sciences in Thailand," in Santhat Sermsri

(Editor) Heatth Socla/ Sciences in Thailand. Technical Paper No.4. Faculty of Social Sciences and Humanities, Mahidol University.
18. Wahab, Sahara 1998 "Family Violence and Health Care," paper presented at the

Fourih Asia-Pacific Socia/ Sclences and Medicine Conference (APSSA M),Yogyakarta,


lndonesia, 7-1 1 December 1998.

14

Socio-Cultural Perspectives in Health

Tsble 1.1 Percentage of households reported information on material


possessions

in their household, Thailand, 1090' 1994 end 1096


1990 1004
1eo0

IIousehoH Appllance

Urban Electric fan Elechic ricecooking


e

Rurol
a7.o

Urban
e

Rural
81.2 40.2

Urban 97.2
88.6

Rural
86.?
71.8

8.?

8.6

00.o

64.9

06.o

Refrigerator
Radio

70.8 87.1

27.7

82.8 88.6 03.7

ro.0
67.2
78.8

70.o E05
01.8 17.8

64.8
76.2
87.7

?e.0
04.8 0.0 2.0

Tebvlsion

07.o
86.5

vD.o.
Telephone

43.9
41.O

80.8
16.3 19.0

7i 2i
o5
4.8 89.2 66.6

18.3

40.6
23.O

65

Alr.condidon
lYashing machine

o.0
2.8
61.5

10r
875
62.2 69.7

2i
lo.7
49.0

s0-2

Bicycb Motor-cycb Motor-car

885
87.0

105

10.7

4l.o 84J
88.z

8t.2
16.8
01.8

26.2
E7.8

83
a0.9

355

llJ
1.4

Iron
Mlcro-wave E-tan(Local farm
0mck)

9J 'oa

0.o

t.2
?.6

3J

o.3

Vacuum chaner

13.6

2.O

145
3.9

2.2 0.3

Micro-computer

Sourec: Linranorda, ctcl.,

1995. Surnmary

Rcprrt m lhe Generd Famlly Survey.

Natidul St^dsioal Of6e. 1997. Srcld Indlcarrrc 19e7.

Health Care Services

15

Chapter 2 Health Care Services


Santhat Sermsn

This chapter is based on Sermsri's writing(1989) on Utilization of Traditional and Modern Health Care Services in

Thailand and his earlier research work with James N. Riley(1974) on the Variegated Thai Medical System.

Change in Health Care PhilosoPhY

In the mist of great scientific and technological progress and vast material wealth,

the concept of health services has changed, lt is no longer the age of the one-man-show

clinician or medical specialist. Even the term hospital center has lost its luster in the age
of people involvement and community participation. On the whole, health personnel have lost influence in setting up a health policy. This is because health is, according to World

Health Organization's definition, defined as a state of complete physical, mental and


social well-being and not merely the absence of disease or infirmity. This definition takes on the three main ingredients of health, the somatic, the psychological and the sociological

aspects. This definition has been officially recognized by almost all countries in the world
today.

In the present dynamic world, many things have changed for the good of
mankind, while there are also retreats in other respects (Sermsri, 1995). The good thing is

that world health conditions have generally improved, diseases and illness have come
under control. But for a long time we have been oblivious of social factors influencing on

health. Violent deaths related to traffic accidents have increased, and homicide and suicide have soared. A new mode of life style, i.e., eating, drinking, working and having sex, causes a new class of dangerous diseases. Drug abuse has increased. Increased

cigarette smoking is causing lung cancer. Underestimated ecological factors have


produced resistant infections, such as malaria and TB, for example'

16

Socio-Cultural Perspectives in Health

As a result, health administration is faced not only with emergency


problems as before, but

health
all

it has to provide sophisticated health services, meeting

somatic, psychological and social maladjustment. Matters have become increasingly


complicated as we are now moving in the daily chemical milieu, consuming increasing

numbers

of

synthetic chemical substances, and particularly

dominance of

individualistic materialism among many population groups. Pollution of the environment is affecting somatic health, while urbanization is affecting our mental and social health. Not only in urban and industrial but also rural and agricultural progress, health hazards have

begun to outweigh advantages. This calls for holistic health care services in

a new

situation. Health personnel would include not only an orthodox clinician and specialist,

but would include selected members of social sciences, education, environment and
planners. Community participation, family support and people involvement in health care are also imperative for the 21" century of health care services. The discussions below will

reveal the changes

in health care services. Quality of services improvements are


well-informed

therefore important step for the coming years. Attentions to the quality of services,

including

a recognition of the role and responsibility of competent,

providers in influencing both the choice and continued use of the health care services, is
crucial for assuring that society and people achieve better health for all groups of people.

Problems of Medical and Health Services

Health condition

is related to people's behavior and the ecology of

health

services. lt is the interaction of the health behavior of the people with the behavior of
health workers "the user's side and the provider's side". Too often, people are blamed for

not taking advantage of treatments or making changes in their behavior. Many health personnel say people behave in a tradition, religious, and superstition, manner, which causes an increase in morbidity and mortality. Doctors provide services based on a

Health Care Services

17

belief that they are giving good treatment and therefore would like to see patients accept what they have offered.

In the view of previous health care planners, emphasis was placed on the
construction of facilities rather than on provision of services, because of their assumption that the availability of health care would automatically bring better health conditions and that accessibility and acceptability would follow. lssues of health care delivery were tied with the concepts of availability, accessibility and acceptability. The three are presumably

related and occur subsequently. These concepts were regarded as the independent
variables to the dependent variables of affordability, medical treatment, and good health.

In Thailand, the institution of traditional medicine has a long and esteemed


presence in Thai history. About a hundred years ago, western (modern) medicine came

to Thailand and then quickly become an integral part of the system of Thai medical care
system, particularly regarding the method of diagnosis and treatment. Since that time, the modern health care system has predominated, under wriften by government support
(Lyttleton, 1996; Riley and Sersmri, 1974). To understand the problems surrounding the modern health care system, it is necessary to consider the ecology of health service. This

problem, as Cohen, Farmer and Kleinman (1997) suggested, is a so-called "serviceresistant service providers". Such an idea provide an insight into the nature of health
providers and determine the direction in which interventions could effectively be directed.

Health providers tend to concentrate on characteristics of problems of the patients, e.9., language barriers, wrong beliefs, religious beliefs, poverty and lack of education, etc. In

contrast, patients focus on problems with the services, including inconvenient hours, location, lengthy waits

in unpleasant condition, attitudes of health staff, and

most

importantly, high cost of services.

18

Socio-Cultural Perspectives in Health

In Thailand, since there are many health care services where people can go to

take the services. The system is called as a

" Pluralistic Health Care Service

System".

Villagers have several choices as they seek treatments for illness. Decisions to choose depend on the severity of the ailment, but this factor is not always definite. However, it is

important

to note here that a study on health care utilization should be

analyzed

according to the type of illness symptom, including simple illness, accident, pregnancy,
acute or chronic diseases. With the simple illness, many still seek traditional practitioners,

i.e., herbalists or spirit healers. The traditional healers are respected and held in high
esteem in their villages. Most of them are old, and they are respected for the experiences

that come with age. The role of traditional medical healers and family healers

is

integrated with indigenous culture and ways of life. A consultation with a traditional healer

is preceded by a brief traditional ritual offering to the teacher-cum-healer (Guru). This


offering includes a small amount of money, and sometimes there is no need for patients
to pay any more than this initial amount (Riley and Sermsri,1974).

Thai Health Seeking Behavior

Health behavior is related to what people know, believe, think and feel about health, and how such cognitive

and affective bases are related to what they do. For example, Thais believe that the body is composed of four
elements, i.e., soil, water, wind(air) and fire. This is similar to Chinese traditional beliefs, e.9., water, wood, golden, fire and earth. Also, several foods have the quality of medicine, i.e., cold and hot.

Thai health behavior involves concentration on the symptom. Patients are more concerned with symptoms of

illness and are likely to change

a place of

consultation often---a socalled "Switching Pattern of Health Seeking

Behavior". lt could be said that Thais are not patient to complete a full course of medication. They will seek another treatment when the information available indicates a popular place is emerging (by relative, friends or family).

Twenty years elapsed, Lyttleton (1996) examined this seeking behavior of


Northeastern Thais in KhonKaen villages and revealed that many villagers went to local

or provincial hospitals. Modern medicine is the first resource for many villagers. many combtne treatment, taking herbal medicine

But,

in

conjunction with western

Health Care Services

19

pharmaceutical drugs. According

to the

research, methods

of

government

health/medical care in Thailand are always relied on for modern/western medicine (Riley

and Sermsri, 1974). Surprisingly, government primary care, which is the major health
care for the grass-root people, is grossly underutilized. People go to seek health services

from government primary care less than traditional practitioners. Official surveys around
1970 showed that a majority of Thai villagers (about 51 percent) went to drugstores to

treat themselves, and there was a preference for private clinics over government health

centers (MOPH, 1988 and lable 2.1 and 2.2). This was the situation before the
establishment of primary health care strategies. Upon implementation of such strategies,

Thais tend to switch their health care, but they found high cost of illness treatment at
government sectors.

Utilization of Traditional and Modern Health Care

When people are asked to choose the method

of medical treatment they

expressed that modern medicine is superior to traditional medicine. Based on Riley and Sermsri's (1974) research work in rural Thailand, the superiority of modern medicine relies on three inter-related explanations, including medicine, techniques of treatment, and person who performs a role of illness treatment.. According to the first explanation about " medicine

"

, Thais tend to hold the belief that modern/western medicine is far

better than the traditional one. Modern medicine

is believed to give quicker

results.

"When I have an injection I feel something running on my vein". So, many Thais when visiting modern doctors, tend to request for an injection. Also, when illness is concerned with life and dead, like a dangerous snake bite, for example, or a severe injury/wound, people are running into modern health care services, i,e., health centers or hospitals.
With respect to techniques of treatment, modern medicine has employed several fancy

means of treatment including surgery, operation, vaccination and

x-ray. In contrast,

traditional practitioners generally give herbal medicine and sometimes involve magic and

20

Socio-Cultural Perspectives in Health

superstition, as well as religious practices. When Thais judge the persons who perform

the treatment , the appearance of modern doctors is considered to be more charming,

as they are a "big doctor" or "boss," vested by the government with both the privilege
and the right to treat the patients. Modern doctors went to the highest education of the
country,. i.e., university, and spent many years with advanced medical technologies.

Government health care, including doctors and health personal, are excellent and have
higher statuses.

ln sum, a professionalization of modern medicine to perform illness treatment,


according to people's view points, is well recognized by generalThais, and the system is obviously under the auspices of government . This in turn creates a gap and barrier for

people to reach the primary care services on '1) economic costs and social costs
associated with a choice of modern and traditional treatments and 2) Professionalization of health care in Thailand. In other words, social distance within government health care is predominantly a problem. This big problem includes waiting time, discomfort, and the fact that doctors do not give enough time to the patients or some time have a negative attitude toward patients, such -as they look "scowlling" when they were asked some questions. In addition, official recognition of traditional medicine in Thailand has been on

the basis of its subordination as a non-scientific system (Cohen, 1989). Government


health care, which is also mainly modern medicine, is however unacceptable to the poor.

The government health care in all three levels of the health care system, including
primary, secondary and tertiary, is bound with redtape, making a patient pass several steps before seeing doctor for 2-3 minutes. Doctors provide services on the assumption
that they are giving good treatment and therefore would like to see patients accept what they offer. In contrast, patients come to see the doctors in order to feel better. From these

barriers, patient then come to see doctor when their illness is rather at severe stages.
Patients therefore prefer to go to health care services when they are already at a severe

stage of illness. Patients then treat their illness with their own self-care, go to lay

Health Care Services

21

professional and, most popularly visit a private drug store where there is no qualified
health oersonnel available.

As Cohen (1989) pointed out, the Thai medical system in the past failed to
develop for serving the majority because doctors were employed in the bureaucracy.
Doctors worked in private sectors in addition to serving in the government health sector. Doctors ware "two hats". More than 50 percent of heaith expenditure was therefore spent

on drugs. Why do Thais like to be government officials? The answers lie as follow.
Because the jobs offer ('1) prestige, (2) security, (3) respectability, (4) excitement and (5)

good occupation, although the salary is low.

It is then concluded that the mere existence of modern medical/health services did not ensure utilization, The bulk of resources allocated for government health services
goes to few people. Modern doctors are not likely to go to rural areas and prefer to treat urban and educated classes. The attachment of many doctors to the urban centers has

resulted in many doctors not being exposed to the health problems of the local majority
(Lyttleton, 1996). The Thai medical system failed to develop into a vehicle for serving the

health needs of the mass of the population in rural areas. As medical training

is

expensive, doctors are forced to work in the private clinic and hospitals in order to earn

an income commensurate with their high social status (Cohen, 1989). The short term
prospect of Thailand is of a dual system of health care with entrepreneurial medicine

flourishing in the large cities along with

system

of private

involvement

in

health

services. As mentioned above, the discussion on health care utilization here refers to the

simple illness, i.e., cold, fever and stomach ache, and excludes acute, chronic and
pregnancy servlces.

Socio-Cultural Perspectives in Health

Primary Health Care Approach and NGO Efforts

In 1978, member countries of WHO called for a revolutionary approach to health care. Health programs were no longer to be concerned with the absence of illness, but with the even broader principles of access to effective and decent health care services. The Thai government is committed to primary health care (PHC). This was due to the combined efforts of international pressure and lobbying movements by non-government organizations (Cohen, 1989). At the beginning of PHC movements, small pilot projects

encouraged local participation in health schemes in order to widen the scope and efficiency

of health promotion, particularly in family planning services and use

of

government health services (Lyttleton, 1996). Practices of primary health care therefore
eventually emerged in the late 1970's, suggesting that health is linked to a range of social and economic factors and not simply an issue of specific morbidity level (Rifkin and Walt,

1986). NGOs also urged the government to redistribute funds to PHC because in the
past, about 80 percent of the health budget was spent on hospital and medical schools, i.e.. on the curative side.

NGOs have argued that government health care

is

consistent with

conservative, elitist, capitalistic and urban centered approach. In contrast, NGOs are radical groups predominated by the young generation. NGOs illustrate a simple method

of self treatment which emphasizes self-reliance. NGO principles of work are rooted in
the indigenous "traditions of the country".

From 1982-1986, the period after the adoption of PHC goals, bottom-up planning

from the villages was encouraged and prevailed. This was done by several national

planning groups

in order to attack poverty more effectively. The National Rural


a process of
inter-sectoral

Development projects, for example, were constructed by

planning. Four key ministries, namely, the Interior, Education, Health and Agriculture,

-----l]]

Health Care Services

23

were collaborated in the development activities of rural populations at many levels. In recognition of the need for a clearly defined strategy, the Thai government established criteria called "the Basic Minimum Needs (BMNs)" and subsequently included them as

part of the Quality of Life program. This program was adopted to guide multi-sectoral
village level activities. lt is an integration between the health care system and other main forces of rural development. Also, the government promoted essential elements of PHC

in the villages, including health education, nutrition, mother and child health including
family planning, safe water supply and sanitation, immunization, prevention and control of

locally endemic diseases and provision of essential drugs (Boonyoen, 1987). Several
activities of primary health care were established by these four collaborative ministries.

lmplementations

As presented, it can be concluded that the strategic activities to increase the accessibility of primary health care services, were implemented as follow: Activity

1 lncreased coverage of basic services, particularly at the rural periphery

where community health workers and village health volunteers play a key role.

Activity

2
3

The initiation of training for primary health care workers, i.e., village

health communicator (VHC) and village health volunteer (VHV), were implemented.

Activity

The securing of resources to assist primary health care activities so as

to strengthen government capabilities in management and communication of health care

service. Figures in table 2.2 are exemplified in this matter. Activity

Decentralization of decision making was delegated to local/community

health care gates.

Activity

5 Promotion of community organization

and participation in every stage

of health service delivery.

24

Socio-Cultural Perspectives in Health

It should be noted here that Activity 1 is helping the shortage of decent health

care in rural areas where the majority

of

Thais live. Activity 2 is aimed at reducing the

social cost of government health services. Activity 3 could help to delegate the load of
work of local health personnel working in rural areas. Activity 4 supports the development

of a team work approach, and activity 5 also gives more support to community
participation,

A key principle of QOL including PHC and BMN, is that government services are
providing learning opportunities to villagers in the training of village health volunteers, logistical support for PHC, and the establishment of self-help funds (e.9., cooperative, insurance and self-care). As a health strategy, for example, this has to be based on effective communication between officials and villagers. But the main obstacle is found

on the government side. As Gohlert (1990) commented, the principle challenge for
government services for the majority of Thais who still live in rural poor areas, is how to

induce government officials, particularly at the provincial level, to adopt new attitudes
and acquire new skills in service roles. At issue is the bureaucratic mindset, which resists

change even if it ultimately enhances the effectiveness and the power of the government officials themselves. The provision of decent health care in particular, is thus based on the matter of government effort. The government bureaucracy, which is considered to be
a conservative force is resistant to change and monopolizes authority and resources. The

mentality of government officials is seen as that

of rulers who are firmly in charge

(Gohlert, 1990). In other words, improved, i.e., quality of care.

it is

imperative

to make the government

services

A study on family planning services in

Bangladesh

revealed that rural women's perception of a higher quality of services emerged as a

prime explanation behind the area's significantly higher contraceptive prevalence


(Koenig, et. Al., 1992). The study focused on the way family planning clients are treated by the system, not only technical aspects, but also in terms of the interpersonal process

of care giving. In poor Yunnan, China, for another example, there was no shortage of

Health Care Services

25

family planning supplies

of many

contraceptive methods and the majority

at

the the

township level still provide various contraceptives methods.

lt is so because

availability and cost of the methods do not appear to be barriers to choosing appropriate

methods (Xiaomei, 1999). In contrast, rural women with reproductive tract infection did
not seek health care nearby because they considered the quality of health services to be

bad, doctors' attitudes towards their patients are poor, and women are then reluctant to go to health facilities. This is because the women are afraid of being looked down upon (

Li Chunrui, 1995, cited from Xiaomei, 1999). With respect to the quality of care, the
provider's technical competence

is the key element in health care services.

The

competence of grassroots providers is then worrisome. As mentioned above, the health care providers at the village level had short working experience, limited training, and very

little supervision.

lt is more

important to enhance the capacity

of providers

through

training and supervising in order to provide higher quality health care services.

Suggested Readings

1.

Boonyoen, D. 1987. Thailand Case Sfudy on Health Aspecfs of Development Planning

at Village Level. Bangkok: Ministry of Public Health, Thailand.


Cohen, A., P. Farmer and A. Kleinman .1gg7. " Health Behaviour Interventions: With Whom?" Health Transition Review, Vol. 7 No. 1 (April 1997), page 81-87. Cohen, P. 1989. "The Politics of Primary Health Care in Thailand, with Special Reference to Non-Government Organization," in P. Cohen and

J.

Purcal (editors).

Ihe

Political Economy of Primary Health Care in Southeast Asia, Canberra: Australian Develooment Studies Networks.
4.

Gohlert, E. W. 1990. Power and Culture: The Struggle Against Povefty in Thailand. Bangkok: White Lotus.

5.

Koenig, M.C., et.al. 1992 "Contraceptive Use in Matlab, Bangladesh in 1990: Levels, Trends and Explanations," Sfudies in Family Planning. Vol. 23 : 6, pages 352-ffi4.

26

Socio-Cultural Perspectives in Health

6.

Lyttleton, C. 1996. "Health and Development: Knowledge Systems and Local Practice in RuralThailand," Health Transition Review Vol. 6 No. 1 (April 1996), page25-48.

7.

Ministry of Public Health (MOPH). 1988. Ihe Realization of Primary Health Care in Thailand. Bangkok: Ministry of Public Health.

8.

Rifkin, S. B. and G. Walt. '1986. "Why Health lmproves: Defining the lssues Concerning

Comprehensive Primary Health Care and Selective Primary Health Care," Socia/ Sclence and Medicine Vol. 23 No. 6 , page 559-566.

9.

Riley, J. N. and S. Sermsri. 1974. The Variegated Thai Medical Sysfem as a Context

for Birth Control Seruice. Working paper No. 6, Institute for Population and Social Research. Bangkok: Mahidol University. t0. Sermsri, S. 1995. "lmplication of MentalWell-Being from Changes in Thai Society,"

paper presented at the Conference on World Mental Health: Problems and Priorities in
Low-lncome Countries. New Delhi: Rajiv Gandhi Foundation.

1i.

....

1989. "Utilization of Traditional and Modern Health Care Services in

Thailand," in Stella R. Quah (editor). The Triumph of Practicality : Tradition and Modernity in Health Care Utilization in Se/ecfed Asian Countries. Singapore: Institute of Southeast Asian Studies, page 160-179.
12. Xiaomei, Li. 1999 "The Quality of Family Planning Services in Rural China," Graduate

Term paper submitted to fulfilments in the requirement of Graduate Course in Population Dynamics and Health, Health Social Science Program, Mahidol Universiy.

***************

Health Care Services

27

Table

2J

Percentage of Eealth Care Utilization

in Thaitand tg70,

Lg7g,1985, 1991 and 1996

Source of Health Care

t970*
2.7
t.t

t979* 4.2
8.2

l985**
0.3

l99l***
15.9

1996***
7.8

Tahe no medicine

Traditional
practitioners Self-Treatment and Drug-Stores Government health
center

2.4

2.6

2.8

5L.4

42.4

24.4

88.8

81.6

4.4

16.8

13.3

L5.7

L7.1

Government
hospitals

11.1

10.0

32.8

L2.9

2L.2

Private hospital Other lay-referral


Don't krpw Total percent
Sruroes

22.7

20.4

20.8

L2.4
L.7
o-4

18.2
1.O

0.8 100.0

100.0
of hblio

100.0

100.0

100.0

'

' Mni*y
r* Ivfirisry

flalth. ft8

and 198!. Utilization

rf Eealth M:rnpower &

Expenses

tn.uned in Medical Trcatnent 107O.

of Publio FLalth and Insinrrc for Population md Social Rc:suolu Mahidol

Univcrsity. 1987. hrblic Health Calendar 1067.

r** Nrtimd

Stati*ioal

Offie,

t993 and t995. Repcrt of the Eealth and Welfore

Survev

leeS and 10C&

28

Socio-Cultural Perspectives in Health

Table

22 Percentage of Eealth Care Utilization in Thailand,

ctassified by Urban and Rural Areas, AD, 1991 and 1996

Source

of Health Care
Urbdl

l99l
Rural 15.6 2.8 Urban

t996
Rural 7.8

Take no medicine

L7.7
2.O 87.O

7.6
L.2

Traditional practitioners Sdf-treatment and


Drug-stores Government health
center

2.5
31.7

38.5

81.2

2.8

18.1

2.4

19.8

Government hospitals Private hcspital Other lay-referral

18.2

L2.8

19.9

2L.4
15.8

24.7 2.2

to.2
1.6

33.9

r.o 2.4
100.0

o.9 o.6
100.0 17.523

Don't know
Total percent
Nurnber

o.4
100.0

o.4
100.0 16,860

5,880

5,904

Source: National Strtistioal Oftre, 1993 and 1996. Report qf the Eealth and Welfare Srurey 19C3 rud 1996-

Social Determinants of FertilitY

29

Chapter 3 Social Determinants of Fertility


Santhat Sermsri

This brief review of lecture is mainly based on two sources of writings; first, Geoffrey Hawthorn's book (1970) on The Sociology of Fertility and second, is Sermsri's book (1998) on Prachakornsat
Thang Sankom (Social Demography).

"Everyone

is

born and everyone dies, but between these two biological

processes there are vast demographic differences," said Ralph Thomlinson (1975),
American sociologist, in a book on Population Dynamics. lt is only women who give birth

and most women give birth to only one child at a time. Because conception requires two
people, and because value systems usually demand a marriage bond, family and social

institutions,i.e., ways of life, norms, attitudes, beliefs, goals , folkways and aspirations,

concerning courtship and marriage must be understood in order to determine why


women living in either the same or different social circumstances, differ in the number of

children. For example, one may want to analyze women in Thailand tend to give birth
soon after their marriage and why the number of children born to Thai women declined

very rapid from 6.12 in 1969 to 3.77 and 2.1 in 1979 and 1991, respectively. Other
relevant questions are why women in rural areas of Thailand have more children than

their counterparts in urban areas and why women with high education in urban areas

have produced smaller number of births as compared to urban women with less
educational attainments (NSO, 1 984).

Theoretically, human fertility is entirely determined by both social and biological

factors. This can be illustrated by a cautionary tale from the literature, which was a
popular research in the conventional practice of taking a number of variables and seeing

where the best correlation lies (Hawthorn, 1970). lt is for this reason that this chapter

30

Socio-Cultural Perspectives in Health

deals with the subject of social determinants of fertility. The social determinants here, as indicated in chapter 1, refer to four levels of influences on individual fertility. The four

levels include 1) individual social standing, including education, occupation, income,


employment, status of women and religion, 2) social structure, namely family, society and other social institutions which affect to behavior and activities, 3) social concerns which

refers to awareness of social norms, including belief, values, opinion and ways of life,

and 4) reference group, which influences behavior and activities, and which
role models and peer groups.

includes

Biological Determinants

It is of primary importance to understand two words, namely, fertility

and

fecundity. Fecundity refers to biological potentials, and fertility refers to performance. The
number of children a woman has, demonstrates the level of fertility of the woman. What a

man might say about how many children he can have, demonstrates fecundity, or the
ootential of the man to oroduce.

Ever since Danvin's exploration of evolution, scientists have speculated that the

differing attitudes of each sex do not depend on nationality or ethnicity. Woman seems to
differ from man in mental disposition. lt is unclear whether woman differ from man merely

because of the norms of a particular culture or because each sex is predisposed to


views and values that are embedded by generations of natural selection (Charles Darwin,
1871).

Age and sex are factors which determine the magnitude of fertility. Only women can conceive children but men have to be involved in the process of reproduction. A
study of 142 nationalities and ethnic groups around the world reported that average age of menarche is'15 years, with a range of '13-17 years. Climate and dietcan, to a certain

Social Determinants of Fertility

31

extent, have an influence on the onset of age of menarche. The cessation of fecundity is

approximately around 45 to 49 years, depending upon on environment and genetic make-up of the nationality or ethnic group. Men normally reach puberty between 11-14
years of age. Unlike women, the upper age limit of fecundity for men is not evident. The

reproductive lifetime of a man is far more than 30-35 years.

lf social obstacles were not evident, birth rates could climb extremely high. lf a
woman had one child every 10 months for 31 years, she would have 37 live births. There
is a record, revealing that woman who married at 16 and died at 64, had 39 children, with

no multiple births. Likewise, a report from Time magazine ( issued on December 1 , 1997),

revealed the famous multiple births of the McCaughey's in lowa, USA. In this case, septuplets, seven identical babies, were born to a 27 year old American woman in Des
Moines, lowa on October

22,1997.

In general, a reasonable group limit would be about

half this figure or 13 live births per woman. This means a crude birth rate of more than

100 per 1000 population per year (Thomlinson, 1975). Since this chapter will deal with

social influences on human reproduction, the discussion to follow will turn to the
illustration of the significance of social aspects of fertility.

Economic Determinants

Stycos (1962-63) and Heer (1964-65) examined fertility in Latin America and
found a positive relation between fertility and economic development. This means that couples who have higher income, tend to have a larger number of children, and those with low income tend to have a smaller number of birth. According to Stycos and Heer's

theory, marital instability come about as a result of economic hardship. This greater
marital instability led to a smaller exposure to the risk of conception. The relation between

fertility and economic level is also affected by the practice of contraceptive techniques,
abortion, and infanticide among less-economically advanced families.

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Socio-Cultural Perspectives in Health

However, the relation stated above is still doubted by many researchers. The
argument revolves around whether these social and economic factors are responsible for the so-called demographic transition in fertility over the past 200 years. Ryder (1959) has

identified three stages of fertility transition. The first is the stage of high fertility and mortality, during which time labor intensive agriculture and consanguineal families ( a
family tied by blood relation) exist. The second type of society is characterized by lower

fertility, but in which consanguineal families are replaced by a conjugal pattern (family ties based on marriage) The third type of society is like the Western form where fertility

and mortality are low, industry replaces agriculture as the dominant economic activity,
individualism predominates over familial values, and fertility is regulated by contraception within marriage.

Liebenstein (1957) proposed that there is the relationships between fertility and economic growth. Explicitly, the desire for children will remain high over the period of
rising income. On one hand, an increase in number of children ( children have utility as a

source of productive labor) will augment the family income, and provide a source of
security to offset the income drop at the end of the parents' productive

life, On the other

hand, the rise of income will promote the desire for higher quality of children, (which requires an increase in cost of training the children). Also, parents will tend to have a small number of children when the parents want to take advantage of new economic opportunities. lt is from this that the relationship between economic growth and fertility

can be either a positive or negative relation. There is a need for further investigations
since many theorists do not agree on what exactly occurs between fertility and economic growth within one society. All theorists agree though, on the idea that the growth of
population (high fertility and low mortality) in the past must have been, to a large extent, a response to economic advance.

Social Determinants of Fertilitv

Based on a reading from Time magazine, Chinese and Mexican migrants living in

the USA reported to have a large number of children after achieving success in life. The number of children among the migrants was larger than their counterparts in China and
Mexico. The question arises whether parents prefer to have more children when they are

better able to support them. lt is also appropriate to investigate the fertility patterns of rural women and poor families. Rural women and also slum residents do not practice

fertility regulations and consequently have many children. The reason for such high
fertility practices is not economics, but lies in other social determinants. For example, life

after marriage creates a set of new needs and desires. Having children is not only a
method of continuing the family line, but also gives a

good sense of family togetherness

and more confidence of human egoism.

An aggregate study carried out by researcher in more developed countries (see Heer (1966) for example) illustrated

that the direct effect of a rise in the per capita

income on fertility was positive. An increase in fertility under conditions of rising income is

also due to the prevalence of public health facilities and the level of education, both of

which have the effect of reducing infant mortality. In contrast to the previous finding,
Friedlander and Silver (1967) found

negative relationship between education and

fertility in developing countries. This negative relation exists only when that education has extended over a period of some years.

Based on the above discussions, sociologists have then assumed that there is no

direct relationship between income and fertility. The relation can be both negative or
positive depending upon the context of individuals and society. However, the direct
relationship could exist under certain circumstance such as religion, i.e,, Catholics. Also, Blake (1968) argued that once fertility control has become diffused evenly through out an

industrial society, one would expect a positive relationship between income and ideal, desired, expected or actual fertility.

34

Socio-Cultural Perspectives in Health

Easterline (1969) theorizes a strong relationship between income and fertility. He proposed that the effect of income must be seen as the effect of tastes

and preferences.

There are two possible explanations for the effect of income: first, income has the effect

of increasing fertility by giving the second generatron more resources and second,
income tends to lower fertility by increasing the relative desire for material goods.

Freedman and Coombs (1966) found an inverse relationship between fertility expectations and aspiration for children. The higher fertility is likely to accrue to those
whose income rises over time but whose tastes do not and the lowest fertilitv will accrue
to those whose tastes do rise but whose income does not.

Social Determinants

We now turn to pure social influences, rather than the supply of resource
(income), which impact on fertility. Studies show that the historical decline in birth rate

was characterized by a gradual development of an inverse relationship between fertility and social status and by a broadening of differentials. Also, the progress toward lower
fertility was more rapid in urban than rural areas. There is now something of a reverse " J

" or " U "

curve, with the lowest fertility among those of intermediate statuses and

education. There are four possible explanations for this phenomenon : first, higher status

groups can afford to have more children than other classes, second, the high social
status wives suffer because they do not participate in the work force, and so offset this
loss with a high family size, third, a high status induces relatively inefficient contraceptive

practices, and fourth, people with

a rise in status tend to get married earlier, thus

exposing themselves to a longer fecund period.

Social Determinants of Fertilitv

35

1, Religion Religious affiliation is one factor which is strongly related to a desire to have more

or less children. The greatest differences in fertility occur between Muslims and other
religious groups. Mazur (1967) reviewed 36 ethnic groups in the USSR (former Soviet
Union) and found higher fertility among Buddhists. For Moslems, Hindus and to a lesser

extent, Buddhists, there is a need for son survival under conditions of labor intensive agriculture. In several developing countries, Roman Catholics have a higher fertility than others. The Roman Catholic Church's attitude towards forms of birth control may be explain the differential use of contraception and abortion. In Brazil, fertility of Catholic

women with university education

is higher than the fertility of those women who


its

completed only secondary and primary education. lt has been theorized that, women

who are exposed more to Roman Catholic doctrine are more likely to take

prescriptions seriously, and women with more education are more likely to receive a
greater amount of instruction in Roman Catholic doctrine.

Studies on fertility in Thailand reveal an interesting phenomena of fertility behavior

among Thai Muslim and Thai Buddhist women in Bangkok and 4 Southern provinces. In Bangkok, Buddhist women had a smaller number of births when compared to Muslim

women. In contrast, Muslim women in 4 Southern provinces of the country had more
children than Buddhist women. Explanations include 1) use of contraceptive, 2) marriage

pattern (monogamy and polygamy) practiced among Buddhist and Muslim, and 3) a
sense of being minority or majority.

The relationship between fertility and religion needs further investigations. Fertility

may be higher among the Catholics, not because religion affiliation, but because they
feel like minority. Day (1968) examined the fertility of Catholic minorities in Australia, New

Zealand, Canada, UK and USA, and found that fertility of the Catholic minorities was higher than that of the Catholic majorities. Another reason for the higher fertility of the

36

Socio-Cultural Perspectives in Health

Catholic group , aside from their awareness of Roman Catholic doctrine,.is the fact that
Catholic minority couples are relatively prosperous.

2. Education
Whelpton, Campbell and Patterson (1966) indicated that there is a direct, but

weak relationship between education and fertility. ln contrast, in the UK

positive

relationship between education and contraceptive use was documented. Wane (1984) explained this relation by the fact that educated mothers are better nourished, more willing to flout harmful food taboos during pregnancy, and less subject to heavy manual

work during pregnancy than their less educated counterparts. However, the effect of
education on fertility also involves a change in social aspiration and the demand for goods. Hence, higher educated mothers tend to have a small number of births.

After examining the evidence on both sides, the fact remains that the causal
mechanrsm for the relationship between education is somewhat obscure. However, in

Thailand the education factor seems to be related to fertility. Based on the index of

number of children ever born secondary education had

to married women, Thai women with university and

smaller number

of children than women with

lower

educational attainments. This holds true in both rural and urban areas. In general though,

data on the national fertility of Thailand presented by the National Statistical Office,
showed an understanding of fertility among different groups of educational attainments
and occupations.

3. Female Employment
Blake (1965) and Davis (1967)suggested that if fertility reduction is to be the goal

of population policy, encouraging couples to limit their fertility will not be enough. The
necessary method is to demonstrate the advantages of gainful employment for mothers.
Working women in the USA, for example, who had been working for 4-5 years, expected

Social Determinants of Fertilitv

37

fewer children than they said they wanted (Whelpton, Campbell and Patterson, 1966).
However, there is a distinction within this group of working women. Among those who

worked because they liked working, fewer expected more children than they wanted. In contrast, among those who worked in order to supplement their family income, more of
the women exoected more children than thev wanted.

In ltaly, Federici (1968) documented that in the poor, agricultural south, there is

no relation between female employment and lower fertility; whereas in the north, the
expected inverse relation is clearly visible. In contrast, in Thailand (Sermsri, 1980), women working in agricultural sectors had more children (3.2 children) than their
counterpart in commercial sectors (2.6 chldren).

In all, there is a distinction between urban areas, where the association between

employment and fertility is clear, and rural areas, where it is much less so. Stycos and
Weller (1967) revealed that where female work and maternal roles are compatible, there

will be no reduction in fertility. These authors, though, cite no specification as to what


constitutes such compatible conditions. Employment may enhance the social contacts of

women. Employed women are therefore, likely to receive social support from co-workers and supervisors and, through paid employment, women may escape the monotony and

low social status of being housewives. Employment then tends to be emotionally


satisfying, providing both financial security and social resources (Verbrugge, 1983,
Waldon, 1980, and Repetti el.al., 1989). The promotion of gainful employment among
mothers in developing countries would serve to further reduce fertility once the social and

economic modernization

of those societies has already provided the necessary

conditions for reducing fertility anyvvay. Aside from reducing fertility, paid employment for

women may present further benefits to women and to society. For example, research found that women in slums of Bangkok who earned more income than their husbands

38

Socio-Cultural Perspectives in Health

were less likely to be abused, i.e., family violence, by the husbands. (see Fuller, et.al',
1

992)

With respect to the discussions presented above, the studies on

social

determinants, which are called "the correlates of fertility," concluded that, on the whole, expected associations were found between fertility and social factors (education, literacy,
urbanization, female employment) as well as between fertility and generalized factors of

modernization/development such

as infant mortality. These demand factors

explain

roughly 45-90 percent of the variance in fertility across developed and developing
countries. The wider the range of socioeconomic conditions, the greater the explanatory power of such correlates of fertility.

There arc again two simple conclusions which can

be drawn from the

discussions reviewed above. First, several social factors themselves ( including income,

education, religion and employment) can affect fertility. Secondly, these social
determinants do so by altering the balance of resources, costs, and tastes available to

and perceived by the couples. Interestingly enough, social determinants have a further
affect on what Davis and Blake have called the intermediate variables, so as to increase

or depress fertility. The next section will elaborate the impact of social factors on the
intermediate variables.

lnfluence of lntermediate Variables

Recognizing that human reproduction is an interplay between men and women, The level of reproduction can therefore be analyzed according to three phases of this
interactive behavior of the two sexes-intercourse, conception, and gestation phase. The

process of reproduction has to go through these three phases and also can be stopped

at any point of the three stages, i.e., termination of fertility. This process is called "

Social Determinants of Fertility

39

Intermediate Variables

". The important point of this concept is that these intermediate

factors are present in every society, though in any given society some factors may be more important than others in affecting the magnitude of fertility. For example, if in a society the age at entry into union is high, fertility will tend to be lower. Similarly, if
permanent celibacy is low, fertility will tend to be higher. The actual level of fertility will then depend on the importance of each factor in the intermediate variables framework as
follows.

The intermediate variables include as the followings:

Factors affecting exposure to intercourse Courtship pattern

Marriage system (e.9. single and widow)

Age at marriage
Family system (e.9. monogamy, heterogamy and polygamy)

Household circumstance (e.9. living space) Beliefs about sexual relation

Factors affecting exposure to conception


Fertility control practices

Natalcare

Factors affecting exposure to gestation Practice of Infanticide

Abortion oractice

Now some details of the factors in the intermediate variables framework are
elaborated, a primal anxiety deep within the human psyche is "sex". Sex is everywhere in

a society-as such "a quiet couple next door is having more fun in bed, on kitchen

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Socio-Cultural Perspectives in Health

tables, in limos and other venues to mention", More than 40 years after Kinsey's report on

sex, a team of researchers at the University of Chicago has released a report (Time,
October
17

, 1994). In this report, 54 % of the men say they think about sex every day or

several times a day. By contrast, 670/o of the women say they think about it only a few times a week or a few times a month. Among the key findings: Americans fall into 3 groups. One{hird have sex twice a week or more, one-third a few times a month and

one{hird a few times a year or not at all. Furthermore, about


3o/o

17o/o

of Americans men and

of women have had sex with at least 2'1 partners. The basic message of sexuality is

that men and women have found a way to come to terms with each others sexuality, and
it is called marriage. Marriage is such a powerful social institution that married people are all

alike-they are faithful to their partners as long as the marriage is intact.

According to the differing attitudes of each sex on mate preference, women of


every nationality share some nearly universal preferences in the mates they desire (Time,

May 1, 1989). Despite geographic and cultural differences, males evenTwhere value
attractiveness and youth in mates more than women do. Females are more likely than
males to seek mates who are older and are thought to be good providers.

The study on Americans also confirms much of what is accepted according to


conventional wisdom. Young adolescent Americans do have sex earlier now: by age 15,
half of all Black males have had sex, by age 17, the White adolescents have caught up to

the sexual practices of their black peers. According for religious influence,

Roman

Catholics are the most likely to be virgin s (4o/o)and Jews are more likely to have the most sex partners (34o/o have had 10 or more).

Concerning sex differences in marriage preference (mate selection), a woman

will usually look for a prosperous man oecause he is better able to support a family,
whereas a man will look for a woman whose age and appearance signal fertility. The

Social Determinants of Fertilitv

41

question of why women want to marry men who have money has been answered by a feminist. lt is because women do not have their own money as a result of the many obstacles in their lives and because cultural conditioning plays a big role in explaining
sex differences in selecting mates. Early marriage and child bearing are closely linked to

high total fertility. In Bangladesh, for example, more than two{hird of girls aged 19 and
younger have already been married.

With respect to availability of traditional and modern contraception, there

is

general agreement that the tradition of post partum abstinence is eroding with increasing

modernization. Where modern contraceptives are little used, there is also apparent
interest in traditional fertility control. The use in modern fertility control is therefore related to the availability of the modern methods. Many studies have examined correlates of the

use of modern contraceptives. Education for example is directly related to use since
education influences a woman's chances of paid employment, her earning power, and her control over childbearing. In Thailand, the success of family planning is due to the changing and high status of women. lt should be noted here that the use of traditional contraception, such as withdrawal and abstinence in some societies, i.e., Zaire serves
not only to prevent conception, but also spaces the birth intervals.

It would appear that men are not using male contraceptives more frequently
because they do not yet believe that there is a need to, that they have a responsibility to

do so, and that women have a right to expect men also to share contraceptive
responsibility. Men's reproductive responsibility is a stronger term which implies that men are obligated to carry out certain activities and can therefore be held accountable.

In a kinship system of extended families, marriage does not necessarily imply the

formation of a separate household, but in

a nuclear family system marriage does.

lt

follows that resource constraints on marriage are likely to be more severe in the nuclear

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Socio-Cultural Perspectives in Health

system result in a new household. Marriage is therefore sensitive to economic conditions,

but this sensitivity declines as the availability and efficiency of methods of birth control increase. Being single in rural areas twenty years ago was considered to be "strange". When a person reached a certain age at which social norms dictated that the person
should get married and have a family, but he/she was still single, the response would be

surprise. "ls there something wrong with him/her?" Widowhood is another example. lt was rare that a widow would enter into a second marriage. Another impact of marriage systems on fertility is that couples in certain system, such as monogamy, would have a

smaller number of children as compared to couples in


example.

polygamous society, for

Beliefs in sexuality are also considered to influence levels of fertility. In Thailand, it is believed that when a man feels uneased or ill, he should not have sex with his partner. When he breaks this prohibition he will get an illness, the symptoms of which no medicine and treatment can cure. One method to cure this illness is to apply a traditional practice.

Using boiled water and the chain of the boat. Another Thai belief dictates that, a woman

who wash her hair in the evening is not supposed to have sex with her husband.
Furthermore, it is believed that if a pregnant woman wash her hair during the period of

lactation, she will have

shorter life and when she gets old, she will suffer from

headaches. In Papua New Guinea, it is believed that performing sexual activities under big trees or in sacred places will lead to sickness. This is because, god spirits live in the
big trees.

Concerning sexuality,

man shall not sleep with his wife when she

is

menstruating, or following the time when she has given birth. ln some Asian societies,
women are treated differently during menstruation, they do not sleep with their husbands

on the same bed and are not allowed to touch any adult male family

member.

Menstruating women are also prohibited from entering the kitchen and going to places of

Social Determinants of Fertility

43

worship. In some areas of Yemen, when

pregnant women in the late stage of

pregnancy develops bleeding, which may be placenta previa, abortion placenta, she does not have to go to the hospital. lt is though that the excreted blood is bad blood and

so it is normal to bleed. More severe forms of female circumcision are practice which
have adverse consequences for physical complications and psychological health. With

respect to beliefs about diet, in India, there is a belief papaya can cause abortion if consumed early in pregnancy. In Bangladesh, delivery is considered very dirty and untouchable. Following delivery, mother and baby are kept outside the main house and they must sleep on the ground, which makes the baby and mother more susceptible to
infectious. Furthermore, a new born infant under 7 days old is not the family's child so if

the newborn falls ill, the family can ignore the illness because it is believed that the real
parent of the infant is a ghost or spirit.

It is quite clear that the

intermediate variables

of fertility are important

in

influencing a family to have a large or small number of children. However these factors

do not operate independently. As discussed earlier, social and cultural factors including

the individual attributes/characteristics, knowledge, belief, values, and norms play

an

equally significance role in determining the magnitude of the factors of the intermediate
variables, i.e., exposure to intercourse, conception and gestation. The way in which these

variables operate is through an interplay between social and cultural aspects and

biological dimensions.

In other words, biological drive arc not the only

factors

determining the levels of fertility. Fertility is also influenced by social and cultural factors, i.e., education, occupation, income and values, governing individuals to act according to cultural and societal norms.

44

Socio-Cultural Perspectives in Health

Suggested Readings

1. Bertrand, J., W.E. Bertrand and M. Malonga. 1983 "The Use of Traditional and
Modern Methods of Fertility Control in Kinshasa , Zaire," Population Sfudies. Vol. 37,

pages 129-136.

2.
oo.

Chamie, J. 1986 "Polygyny among Arabs," Population Sfudies. Vol. 40 : 1 , pages 55-

3.

Davis, K. and J. Blake. 1956 "socialStructure and Fertility:An Analytic Framework,"

Economic Development and CulturalChange, Vol. 4 :4, pages 211-235.

4.

Hawthorn, G. 1970. The Sociologyof Feftility. London: Collier-MacMillan Limited,

pages 67-111.

5.

Kammeyer, K.C.W. 1975 " Section 4: Fertility" in K.C.W. Kammeyer (editofl Population

Sfudies: Se/ecfed Essays and Research. Second Edition. Chicago: Rand McNally College Publishing Company, pages 295-299.

6.

Klausner, W.J, 1987 "Sex and Morality in a Northeastern ThaiVillage : ldealand

Practice," Reflections on Thai Culture. (Third edition). Bangkok: Amarin Printing Group,
pages 93-98, 310-312.

7.

Knodel, J., A. Chamratrithirong, N. Chayovan and N. Debavalya. 1982 Fertility in

Thailand : Trends, Differentials and Proximate Determinants. Washington, D.C. : National

Academy Press, pages 47-110.

8.

Potter, G. (Editor). 1992 The S/ence Endurance; Socra/ Conditions of Women's

Reproductive Health in Rural Egypt. Amma, Jordan : the United Nations Children's Fund.

9.

Retherford, R.D. and N.Y. Luther. 1996 "Are Fertility Differentials by Education

Converging in the United States," GENUS. Vol Lll, pages 13-17.

10. Sermsri, S. 1998. PrachakornsatThang Sankom (Social Demography). Second


edition. Bangkok : SamCharoen Panit Printing Company.

11. Thomlinson, R. 1975. Population Dynamlcs: Causes and Consequences of World


Demographic Change. New York: Random House.

Aging and Health

45

Chapter 4 Aging and Health

Santhat Sermsrl

This chapter is based mainly on three sources of wdtings. The first two are the United Nations publication (1996 a) on Added Years of Life in Asia and United Nations publication (1996 b) on
Population Ageing and Development, and the third came from Sermsri's research work (1998) on Health Preventive Behavior of the Thai Elderly.

"When I was young I wished to live a long life so as I could enjoy golden years with the

family. I am now 75 years old and a widow but feel sorry for living so long", said an elderlywoman to a reporterfrom a local Bangkok newspaper (Bangkok Post, 1997). So
began the story of this poor and ailing aged woman who lives in a senior citizen's home
in Chaingmai province. Her husband died long ago and her children were unable to bear the burden of caring for her, The problem of abandoned elderly is becoming increasingly serious with the breakdown of traditional families in Thailand (Chanswangpuwana, 1997).

Aging Phenomena

As the story above revealed, Thailand is growing grey. This story is

not

happening only in Thailand many societies have an increase in the number of elderly
people. There is

significance shift of demographic circumstances around the world,

slmilar to a contagious flu. In the past two decades, many countries had undergone much of the demographic transition from high to low levels of fertility and mortality' As a consequence, the proportion of the elderly population has increased and is expected to
increase further in the following years. In 1996, the population age 65 years and over in

the world was calculated to equal 371.1 million, or 6.5 percent of the total 5'72 billion

46

Socio-Cultural Perspectives in Health

world population. The proportion of the population aged 65 years and over equaled 13.5 percent in developed regions of the world (MDC), and 4.7 percent in the less developed countries (LDC). In 1996, the proportion of the elderly with 65 years and over exceed 10 percent in several countries in Asia and the Pacific, i.e., 14.9 percent in Australia,14.1 in Japan, 11.3 percent in New Zealand, and 10.2 percent in Hong Kong (United Nations,
1996 b). Among ASEAN countries, the estimated figures for2025 place the percents of

elderly age 60 years and over,

at

16.2, 11.6, 1 1.2, 10.3, 25.7 and 14.6 for Brunei

Darussalam, Indonesia, Malaysia, Philippines, Singapore and Thailand.

lt should be
the

noted here that the big increase in the proportion of aged 65 and over is expected in the

countries where fertility declined for many years, and that

in those countries

proportion of elderly will increase to almost 20 percent (United Nations, 1990).

This growing gray is particularly a phenomena of female elderly. Because female

life expectancy at birth exceedes that of males in nearly every country, the number of

aged females exceedes that of aged males. In addition, because most women marry
men older than themselves, and because women generally live longer than men, a much higher proportion of women than of men are widowed. Among the population age 60 and

above , the number of widows is 2 to 8 times greater than the number of male widowers.
This growing gray is a world-wide phenomena except a few countries like Pakistan, India

and Bangladesh. In Pakistan for example the proportion of elderly man is greater than
elderly women due to a long life expectancy of man. This difference in those proportions increases with age (Farooq, 1999).

Definitions of Aging

Concerning the definition of elderly, a number of countries define elderly as age

60 years and over but many use age 65 as the cut off age. In Thailand, as

in

other

ASEAN countries, for example, elderly is defined officially as persons who are 60 years

Aging and Health

47

and older. The reason for taking 60 as the cut-off age is that the retirement age in Thailand

is 60 years for both government and private

organizations. However, the

retirement age for women in China, lndonesia, Malaysia, Pakistan and Taiwan is 55
years. According to the statistics in Thailand, at present, the number of persons aged 60 years and over stands at 5 million (lPSR, 1997). The number of Thais aged 60 and over

was2.2 percent of the total population in 1960, and during 1970-1990, the period of
rapid modernization, the proportion of elderly increased from 4.8 percent to 6.7 percent
,the proportion of elderly is projected to equal 7.7 percent in 2000 and 13.1 percent in

2020.ln terms of absolute numbers, the size of Thai elderly population was l.Tmillion

in

1970, this number increased to 2.5 million in 1980 and is expected to reach 6.8 million in

the year 2010 (United Nations, 1996b). The United Nations also predicted that the growth
rate of the Thai elderly will be more than 100 percent by 2030 (Concepcion, 1996). Aging

is therefore, an unavoidable issue. The magnitude of the effect of demographic changes

has important implications for the demand for health care and the improvement in life
quality of the elderly,

Demographic Cause of Aging

A question to raise now is what the cause of this growing aging? Before the
present time,

it was generally believed that declines in both mortality and fertility had

worked together to bring about an agrng of the population. While declines in fertility
eroded the base of the age population pyramid, it was thought that declines in mortality,

which permitted people to live longer raised, the proportions in older age groups. Later works demonstrated unambiguously that the past changes in the age structure of the populations of Western countries (developed nations) and of Japan, for example, had
resulted from the declines in fertility (United Nations, 1973).

48

Socio-Cultural Perspectives in Health

To understand the above statement, a review of the population pyramid could


yield the reasons for changes in aging populations, A population pyramid is designed to
give a picture of the age-sex structure of a population in a given country, indicating either

single ages or 5 year age groups. The pyramid form consists of bars, representing age groups, in ascending order from the lowest ages to the highest. The bars for males are given on the left of a central vertical axis, and the bars for females are on the right of the

axis. Births in a given year directly determine the size of the population under one year
old at the end of that year, and because of the nature of the birth component and its
magnitude relative to the other components, it is also often the principal determinant of
the size of older age groups in the later years. In contrast, the deaths and migrations of a

given year directly affect the entire distribution in that year. Deaths are concentrated
among young children and aged persons and also there is a disproportionately large
number of young adults among migrants (Shryock et. al., 1976). In sum, when the birth rate declines, cohorts of older children may be larger than those born more recently. As

time progresses, a bulge results first at young adult ages and later at mature and more

advancedages. In1970inThailand,forexample, 18.1 percentof thepopulationwere04 years. As the fertility of Thais dropped, this proportion then fell to 16.8, 13.6 and 10.5
percent in 1975, 1980 and 1990, respectively (United Nations, 1995: 838). The aging of a

population structure is therefore part of the pattern of demographic change (Lassonde,


1

997).

Population growth in Thailand has been rapid during the past 30-40 years. The

fact of the increase just started to slow down after the 1970's. ln 1910, the

Thai

population was estimated to be about 8.2 million, and the number was increased to 17.5

million in 1947. Hence, it took Thailand 37 years to double its population in the past.

During 1947-1970, the doubling time was evidently shorter. That is,

in 1970 the

population was recorded to be about 35 million, double the 1947 population size of 17.5 million. This doubling period was only 23 years. lt is then evident that the doubling time of

Aging and Health

49

population increase will be shorter as the number of population becomes very large, with a rate of population increase which is still high.

At present, many demographic studies confirm a rapid decline in fertility and this

is due to both the availability of contraception and social values towards life. The
prevalence rate

of contraceptive use has been around 65-75 during

1993-1997.

Traditional values towards family and life are breaking down. Thai women now prefer to

pursue the career ladder rather than establishing their own family solidarity. Modern
education enhances the opportunities for women to work outside of family business.

It is useful to brief how the demographic transition occurs. The demographic transition is a
shift from high to low levels of both fertility and mortality. The transition changes the age structure of

a population from a young to an old age distribution of the population. Fertility decline reduces the
proportion of children and mortality decline raises the longevity of the old population. Thus the shape of the population pyramid changes from one with a wide base and narrow top to a steeply-sloped
pattern.

Social Cause of Derelict

In an early theoretical work on family structure, William Goode (1963) proposed

that when industrialization occurs, the family system moves to composed

nuclear family unit

of husband and wife with their

children (cited from Hohn, 1994).

lt

is

industrialization including modernization and urbanization that brings about changes in

family system. Relationships between members of the extended family alter and the
family system then changes towards nuclear family. In Asia, nuclear families are on the increase, contributing to the separation of the aged from their families. The migration of

the rural youth who seek employment opportunities in the cities in order to earn cash income, will contribute to the isolation of elderly from families. Also, the rising cost of

50

Socio-Cultural Perspectives in Health

living and increasing emphasis on individuality, which are a result of the introduction of
industrialization, put the elderly at risk of no family support (Nayar, 1996).

In Thailand, as in other Asian societies, older people are supposed to be cared for within a traditional family system. The family is the main form of social security for the eldedy

Kono, 1994). Presently, family size is reduced, and the large family seems to be

on the wane. Data from the national censuses in Thailand indicate that a reduction in
family size has occurred throughout the country, but the decline is more apparent among urban families. In 1960, the household size of Thais was 5.6, and it declined to 5.0 in
1980 (National Statistics Office, 1960 and 19S0). At present, it is speculated thatfamily

size is around 3-4 persons. Part of the decline of the extended family system, as
discussed above, can be explained by a feature of the modernization process and the
concurrent trend towards individualism. The economy is no longer family-based and now

relies on individual wage earners (Sermsri, 1995). With the breaking-up of traditional values and the introduction of modernization in the early 1960s, the extended family is gradually changing towards a nuclear family system (Pongsapich, 1992). Many young
married couples have begun to leave parents and establish their own family niche. The

effects of the rapid social structural change then result in a change in human behavior.

Explicitly,

the dislocation and disturbances of rural migrants may increase

the

occurrence

of psychiatric morbidity including behavioral disturbance, violence and

suicide. These problems will be exacerbated by the destruction of traditional family


system for buffering distress. And that, the social and family changes will undermine
social structural that have developed to ensure care for the elderly.

A study of family structure in Bangkok (Sawadyad, 1983) revealed that urban


couples are more likely to establish their own families immediately after marriage. 55.1 percent of Bangkok couples lived in a separated house from their parents in the first five years of the marriage, and the percent of nuclear families increased to 88.4 percent at

Aging and Health

51

the time of the study. As Limanonde and colleagues (1995) argued,'Thai families

in

general are of the nuclear type with two generations (parent and children), rather than

being of the extended type with three generations. The Thai family has its own
development cycle, first being nuclear, then transforming into an extended type for a
short period of time (usually about 3 or 4 years) when daughters get married and bring in

their husbands and have children. Once the married couple has their first child, they
usually move out to establish their own house, Despite the fact that Thai couples do not
live with their parents, they have regular contact with the parents. Chayovan and Knodel

(1997) contended that these regular visits have provided a continuity of social support
for the elderly.

Following is an example of a derelict person in a city of an industrialized society where circumstances are hard on people, and such a place offers cold comfort to elderly who become poor, old and sick (Ford, 1976). Miss Holmes was born in a small town and came to live in a city. After her college education, she went to work in a small bank. She remained a solitary person and retired at 65 with some US$10,000 in saving and her own

comfortable old house. Her health seemed good. Two years later it was discovered that she had glaucoma. Soon after the operation, she lost all useful vision. At this point she

had no family left, other than cousins with whom she had lost touch, and she came to depend on a friend. At age 77, now completely blind, she had

a brief episode

of

confusion, which resulted in fractures of both wrists, and at the age of 80, she broke her

lift hip. She was transferred to a rehabilitation hospital, where she experienced a period

of confusion and agitated behavior. A psychiatric consultant diagnosed chronic brain


synorome.

Her friend could no longer accept responsibility for her, so she was then admitted

to a nursing home. Miss Holmes's savings began to dwindle. She soon was unable to
walk, and by the age of 83 she had to be fed. By the time she reached the age of 85, she

52

Socio-Cultural Perspectives in Health

had only funds sufficient to burial. ln USA, approximately 9 million people over 65 like Ms. Holme, are still living alone. Most of them are living alone due to their circumstances, not

their choice, Many American elderly have no children, like the case revealed above, to
care for them and can not afford to live in a home in which they can get the proper care

and supervision by trained health personnel. Almost 2 million of those 9 million say they have no one to turn to if they are in need of help. For elderly who have children, their children can not afford the economic burden that it would cause to house their elderly parents. Many elderly then no longer have the ability to care for themselves and their
homes, and the lack of a care-giver can pose great problems. As aging growing in size,

the support systems of the elderly are withering away. Older people are out of the work

force and therefore have no income other than government services and their own
savings. As discussed earlier, traditionally these elderly have been dependent upon their

children, but recent social and family changes have made that source increasingly
unfeasible and more improbable (Just, 1999).

The same situation of the derelict persons is also prevalent in both less and more

developed societies. In Africa, for example, the extended family in Eastern African
communities to-day is not as strong as in the past (Khasiani, 1994). Changes introduced into African societies through the modernization process are creating new categories of the elderly who are not provided with care under any of the existing support system, and
are thus marginalized. In five developed Asian countries, i.e., Taiwan, Korea, HongKong,

Singapore and Japan, the family has already been small. The family unit will shrink further

because of the recent fertility declines, as well as the foreseeable future increase in
migration, Changes in the traditional value system will also occur as a result of the rise in

the level of living, the tendency towards individualization, and the purchase of privacy by
money (Kono, 1994). In Japan as in other Asian societies, it has been duty for children to

be good for parents for a long time. And that the civil law in Japan placed children
especially eldest son to support parents under an obligation. lt is saying in Japan that

Aging and Health

6?

being good for parent means children are expected to support them at least in economic terms. The eldest son has therefore responsibility to support parents. However, after the

Second World War, each child became equal in social acceptance, but tradition of the

eldest son's responsibility to stay with parents remains. Today, expanded a family is
decreasing and the trend to live with the eldest son's family is decreasing in a small number (Higuchi, 1999b). Among Japanese elderly above 65 years, who live with their children, 90 percent were living with son and his wife in 1980, but in 1994 there was 87.2 percent. For all children regardless of the gender, the proportion of the elderly living with

theirchildren was 68 percent in 1975. The numberdeclined to 55.3 percent in 1994. In a


worst situation, about 40 percent of the elderly live alone or live with only their partner (Ministry of Health and Welfare, 1996). lt was revealed in TIME newspaper that the
phenomena is widespread through out Asian society and that the elderly do not want to
live with their offspring if they can afford to do so and the younger generation who want to stay with their parents decreasing as well (TlME, 1997).

Once

rarity, the problem

of abandoned elderly, as mentioned earlier,

is

becoming increasingly serious following the breakdown of rural communities and families

and the mass migration accompanying rapid modernization, The decline in traditional
extended families, replaced by smaller nuclear ones in which the younger generations prefer to live separately, has also hurt to-day's elderly. Two groups of derelicts are 1)
rural elderly who are unable to do farm work, often because they are too old to work and have no children to help and 2) urban old people who are poor and live alone in urban

areas. lf societies want to cope with the aging issue, individuals and social institutions
must adopt within a short time. Othenruise this growing aging problem will become quite severe. lt is inevitable that family systems will change, but the contact of family members will at least help solve the isolation of the elderly in the present world. This is because the

family constitutes an important resource for the elderly. Even when the family is not
present in the same household, the family still provides social and financial supports.

54

Socio-Cultural Perspectives in Health

Yuzo Okamoto (cited from Higuchi, 1999a) discussed the situation in Japan, pointing that situations of the elderly today are very different from those of old days. ln those days,

supporting parent was only economically during short time. At present, many Japaneses

do not support parents because of the pension system. Supporting parents to day has
changed to take care of parents who are weak, disabled, dementia and bedridden, for a
long time. Statistics also showed that when Japanese elderly become bedridden, nearly half (47.3 percent) are bedridden for three years or longer, while about three out of four are bedridden for one year or more. In average, the bedridden duration before death for people above age 65 is 8.5 months (Ministry of Health and Welfare, 1996)'

In addition, Sweden is world highest aging rate of person aged 65 years and
being considered one of the best societies in the world for elderly people because of its sufficient welfare system, In '1950, aging of persons with 65 was about 10 percent and
many elderly had unfortunately forced to be admitted in poorly cared elderly homes. As a result the country established then various welfare services of the elderly care systems,
not dependent on only their families.

Migration is another social determinant of derelict persons. As governments have

aimed towards modernization, young family members are moving away from the family residence in order to seek employment outside family businesses in towns/cities. Rural

farmers can be cdlled modern farmers once they have learned

a new agricultural

technology from towns. Farmers then buy new fertilizer and new seeds as well as new
machinery. Visiting towns and cities becomes a popular mode of behavior. Later, older

family members are then being left on their own. The situation could become worse if a young child of their daughter/son is left with the parent (United Nations, 1996). In Napal,

a similar situation is documented, resulting in a lonely life of the elderly. As the young
family members of the Sherpa moved from the villages to urban centers, and so become unavailable to share the household support and take care of the elderly. Many elderly

Aging and Health

55

resisted traditional practices to divide their property lands and keep their son's share of

the family land for themselves in order to maintain their economic security (cited from,
Thanh Liem, 1999). This similardramatic social change also occurred in the Thai family system which negatively impacts in the form of non-support of emotion and funds for the elderly. In Japan as mentioned above, it is the responsibility of the eldest son to take care

of his old parents. As males and females became equal, the main caregivers were
generally female. And many families, particularly males, try to force someone to take care of the elderly. Since a care for the elderly in Japan takes a long time, the family system

may then make caregivers burnout and cause domestic breakdown (Higuchi, 1999b). This statement is exemplified by a brief story below about a young Japanese girl who became a physician and could not work due to the circumstances of being the eldest daughter of the family to take care the old parent.

Risks of the Elderly

Many writers have expressed the view that a young labor force is more efficient

than an older one, since young people excel in such qualities as physical strength,
energy, enthusiasm, adaptability and the capacity to learn new things and to innovate.

On the other hand, wisdom, experience, patience, breadth of view, stability

and

judgment are qualities more prevalent among older than among younger workers (United Nations, 1973). Economic, cultural and political progress may be retarded where the
population is composed of a relatively large proportion of aged persons. The character of

leadership becomes more conservative as the average age of the leaders rises, and

society tends to lose some of its dynamism. Furthermore, the average age has an
important effect on the spirit of the community.

56

Socio-Cultural Perspectives in Health

The changes in socio-demographic structure is of importance, since the cost of

providing for an aged population

is evidently higher than the cost of support for

population

of children. Studies in developed societies (United Nations, 1973) have

estimated the cost of support for elderly and children and found that the cost of
maintaining a child in relation to that of an older person was in the ratio of 3.5 to 6 in
Germany. In France, the costs of maintaining persons aged below 18 years and those 65 years and over, are 16,400 francs and22,500 francs, respectively. ln Great Britain it was

estimated for the financial year 1952-53 that the cost

of state social services

for

maintaining a child under 15 years of age was 34.9 British pounds, whereas the cost of

maintaining an old person was 69.6 pounds. A United Nations study reported that the needs of a child and an elderly person were roughly the sam+-70 per cent of those of

an adult. In Japan, statistics from the Ministry of Health and Welfare showed

an

increasing budget for elderly health care cost. After the Welfare Law for the elderly was enacted and revised in 1963, 1973 and 1983, the elderlyJapanese patients 70 years old

and over have to pay a small amount of health care expenses as compared to their
individual income. Today, the cost shared by each elderly patient is still increasing but

still far less expensive that the medical charges for young people. That is, maximum
charges are about US$20 per month for ambulance and about US$440 per month for inpatient care. Compared

to the average income, payment for medical cost is

not

expensive for each family. lt there is an elderly person who needs care in a family, at
least one family member has to quit his/her job and it decreases the household income.

Therefore, many Japanese families send the elderly to stay in a hospital for long{erm
care (Higuchi, 1999b).

Old age is also associated with low income (Ford, 1976), Many also believe that

the aging of the population tends to lower the rate of savings, since older persons
typically live on accumulated savings. The savings of lifetime are consumed by basic
living expenses. In addition, the community incurs large expenditures for services to the

Aging and Health

57

elderly. The aging of a population over a long period of time may have a substantial
effect on its income structure (United Nations, 1973).

Aging persons typically experience increasing isolation from family ties and
personal relationships, and often suffer the psychological effects of an abrupt retirement

at a fixed age. lsolation is aggravated by the fact that old people are likely to become
trapped in poor city areas. The aged tend to remain in the old neighborhoods and thus become socially isolated. Many low income families end up in this situation, which may be more psychologically lonely. The pinch of poverty can be acute in the big city. Costs
of living are higher, and the urban elderly are less likely to have the resource of living with

relatives. The society now, as discussed above, aggravates the aging problem and
stigmatize the aged as weak, dependent and immobile. The old person feels unwanted.

Old people often live alone or apart from their families. In addition, as

modern

educational systems are increasingly available, the gap between young and old
becomes evident, giving loneliness to the elderly. That is, when the younger members of

the society have received formal education, they feel that they have no role in the
traditional agriculture based society. This encourages them to migrate to cities, while the

elderly are still uneducated and find themselves in a society that no longer values their
knowledge and experience in the same way as before. This leads to a disorienting loss of meaning as well as a loss of respect from their younger family members. This then leads

to lowered levels of self-confidence, self-esteem and well-being (Thanh Liem, 1999).

The social isolation of old people in urban areas is then aggregated by


inadequate and deteriorating public transportation.

In other words, transportation

difficulties are a major problem, since not only food, but health and medical care, church

attendance, cultural activities, recreation, and social contacts depend upon adequate

transportation facilities.

A study in American communities in

1970 showed that

transportation difficulties were a major problem. Some engineering solutions need to be

58

Socio-Cultural Perspectives in Health

implemented. Safe and cheap urban transportation should improve the lives of the
elderly. Our urban transportation system, as everyone knows, with its heavy dependence on the automobile, is out of the reach of the elderly.

Preventive Actions

Chayovan and Knodel (1997) revealed that the health status of the Thai elderly is still poor. Common types of illness include back pain, arthritis, high blood pressure, ulcer

and heart disease. Statistics from a national survey in Thailand (National Statistical Office,
1997) also exemplified the poor health status of the Thai elderly, including arthritis, dizzy,

eye-sickness, sleepness, faint, memory and blood pressure (table 4.1). The elderly are at

a high risk of ill health and have lesser access to available health car. A self-reported
assessment of perceived health situation among Thai elderly was conducted (Thamarak, 1996), revealing that elderly females reported themselves to be in poor health twice as

often as males. Chronic illness was reported to be higher amongst the institutionalized
elderly than the non-institutionalized, 66 percent in comparison with 54 percent. The most

common illnesses are those of the circulatory system and masculo-skeleton. From these studies, it is clear that the health of the elderly is in need of attention and care. In a study
in Shanghai, China, the rate of dementia is higher among the elderly with little education.

llliterates were five times higher in dementia morbidity than those who had attended college. Some believe that a lack of education slows brain development in the early years

so that the loss of brain cells in late life has more serious conseouences for mental
functions (cited from Thanh Liem, 1999). With respect to psychiatric disorders, a study in
Fiji, Malaysia, the Philippines and the Republic of Korea reported the presence of mental

disorders is prevailing among the elderly. The mental disorders includes (1) sleep
difficulties, (2) worry and anxiety, (3) loss of interest, (4) tiredness and (5) forgetfulness. This demonstrated that the level of all health problems remained static and increased

Aging and Health

59

with age. In Fiji, for example, older persons announced loss of interest and forgetfulness
more often than did younger persons.

According to the experiences of developed countries, which were revealed


above, many governments

in developing societies have established social

security

schemes and the liberalization of old-age benefits. Foremost among these needs are
adequate housing and accommodation, health and medicalcare, including hospital care,

social services, and leisure time facilities. An increase in longevity presents

heavy

public financial burden because of the requirement of long periods of medical care. For

women, life expectancy has been increased, so that there is

a higher

proportion of

widowed, divorced and lonely elderly women. Also, it was noted above that in Sweden
where there is a large number of elderly, people are now complaining about the fact that
one working individual must support more than five or six elderly as compared to the past

when one working individual would support only one elderly individual. In Japan, people also anticipate a big burden for the young husband and wife, who will have to take care
of the eldedy for many more years since life expectancy has increased.

A story of young eldest girl in Japan who had been forced by circumstance to
take care her parents, is revealed as

follow. Michiko is a young graduated

physician

and dreams to be a good surgeon for a community hospital in Japan. Her father is a high school teacher and is 66 years old. After the retirement of her father from a public school, he

is working in a private school. Michiko's mother

is a housewife and 62 years old. Her

mother has never worked outside. lt is expected that when her father

stops working

he

will be able to get pensions and probably live comfortablly in a small community in rural
Japan.

Michiko has one younger sister and two younger brothers and so she is the
eldest daughter in the family and still single. Her sister is living in the same prefecture but

60

Socio-Cultural Perspectives in Health

it takes about one hour by car for her sister to go to her parent's home. Her sister lives

with her husband, 2 children and mother-in-law in a house that her father-in-law built. Her
mother-in-law is widowed. Her husband has to pay back for the house for many years. lt

is common for average salaried workers to have a loan for a house. lt is clear that it will

be impossible for her sister to take care of the parents in the future. One of Michiko's brother is living in another prefecture. He left hometown at the age

of 19 to

enter

university and stayed there. A few years ago, her brother got married to a local woman

and works in the prefecture. He has a plan to build a house next to his parents-in-law's house. His wife is working outside and his brother's plan is good for their children. His
wife will be able to ask her parents to take care of the children while working. Of course, he and his wife will not be able to take care of Michiko' parents in the future, although he
is "the eldest son". Another younger brother is handicapped.

In a traditional family system in Japan, Michiko's mother insists on the eldest son

taking care of his parents. She was then against the eldest son's plan to build a house
next to his parents-in-law's house. When Michiko came to Thailand for further advanced training she left her luggage in her parent's house. Her mother refused at first her request

because she probably knew what was going to be. Michiko had left home just after the graduation from high school and has lived in a dormitory since. Old single daughters are
often disliked by the son's family. Michiko's parents, as stated above, will be able to get

enough pension to live. But who will take care of them if they would fall down? lt is often questioned in Japan as young modern Japanese working in hospital or any business company often wonder why children refuse to take care of their parents. As the story
reveals, now many know that it is beyond an individual ability. How about the elderly with no children or with small pensions? Even if the elderly have many children like Michigo's family, it is still not enough for longterm-care.

Aging and Health

61

Aside from the obvious socio-economic pitfalls of an aging populqtion, there are
also many constraints on the health care system, Older people need different health care than the rest of the population. The eldedy are in need of different diagnostic equipment, treatment and rehabilitation. They also need more long-term hospitalization and care. Not

only is this different standard of care more expensive, but it is also difficult to find the
appropriate and adequate technologies and numbers of trained personnel to care for the increasing needs of a growing eldedy population. Since there are few geriatric hospital facilities in Thailand and those that do exist are located only in big urban areas, the majority of the elderly have less access to the available health care services.

lt

is

therefore a need to strengthen the existing health infrastructure and to set a mechanism

for creating awareness of health care. Preventive actions

are simultaneously needed

to

reduce the risks of disease to the elderly (Sermsri, 1997). Preventive and curative
facilities, and appropriate health education programs, can contribute to the avoidance of

accidents and reduce the incidence of disability. Proper public and private initiatives at
the state and local levels are needed to cover the financial burden without misuse.

A primary screening service, such as an exercise program, should be provided.


In Bangkok, a health promotion program was established a few years ago. The elderly who had more family support were those who became the members of this program and those who visited the facilities (Meesook, 1997). From the discussion stated earlier, the
elderly are at a great risk of ill health but have less access to health care services, Both

awareness and preventive care need

to be implemented. The strengthening

of

awareness about elderly health through the existing network of health care is desirable (Sermsri, 1998). Preventive health care is also useful to reduce the risk of diseases to the elderly.

It is useful to involve exercise in health prevention and in programs for creating


awareness of elderly health because exercise builds muscles and burns fat, makes the

oz

Socio-Cultural Perspectives in Health

heart and lungs work more efficiently, lowers the concentration of sugars circulating in the blood that can gum up the body's systems, increases the flow of thought-provoking blood to the brain, and makes bones stronger and more dense (National Geographic,
1997). This situation means that the country welfare system must become an important role of support for an increasing number of the elderly. As revealed above, the question

is what should be the role of the government versus the family in caring for the eldedy, Due to the increasing economic cost of health care and economic crisis prevailing in
many families, especially poor social strata groups, the family and the government will have to shoulder a share of the responsibilities for the provision of economic and social security for the elderly.

Suggested Readings

1. Chanswangpuwana, Matchima. 1997. "Greying Society," Bangkok Posf. Wednesday


October 1 , 1997.

2. Chayovan,

N. and J. Knodel. 1997

Report on the Survey of the Wetfare of the

Elderly in Thailand IPS Publicalion 248197. Bangkok: Institute of Population Studies.

3.

Farooq, Ghulam. 1999. "HowAging Becomes a Serious Problem in Future in Pakistan,

and What can be done about

it? Paper submitted

in fulfillment of the requirements for the

graduate course in Socio-Cultural Perspectives in Primary Health Care, ASEAN Institute for Health Development and Graduate School, Mahidol University.

4.

Ford, Amas B. 1976. "Derelict People," Urban Health in America. New York: Oxford

University Press.

5.

Higuchi, Michiyo (a). 1999 "Quality of Life and Life Satisfaction of Elderly People in

Salaya, Thailand," Master Thesis of Primary Health Care Management, ASEAN Institute

for Health Development, Mahidol University.

Aging and Health

63

6. -----------

(b). 1999 "Elderly lssues in Japan," Paper submitted in fulfillment of

the requirements for the graduate course in Socio-Cultural Perspectives in Primary Health Care, ASEAN Institute for Health Development and Graduate School, Mahidol University.

7.

Hohn, C. 1994. "Ageing and the Family in the Context of Western Type Developed

countries," in United Nations. Ageing and the Family. New York: Department for
Economic and Social Information and Policy Analysis.

8.

Institute for Population and Social Research (IPSR). 1997. Mahidol Population Gazette,

Volume 6 Number 1 (July).

9. Just, Laura.

1999 " The Growth of theAging Population and lts Effects on the United

States Health Care System," Paper submitted in fulfillment of the requirements for the graduate course in Socio-Cultural Perspectives in Primary Health Care, ASEAN Institute for Health Development and Graduate School, Mahidol University.

10. Khasiani, Shanyisa. 1994. "The Changing Role of the Family in Meeting the Needs of
Ageing Population in the Developing Countries, with Particular Focus on Eastern Africa,"
in United Nations. Ageing and the Family. New York: Department for Economic and Social Information and Policy Analysis.

11, Knodel, J., N. Chayovan and S. Siriboon. 1992. The lmpacts of Fertility Decline on
the FamilialSysfem of Support for the Elderly: An lllustration from Thailand. New York:

Pooulation Council Research Division.

12. Kono, S. 1994. "Ageing and the Family in the Developed Countries and Areas of Asia
Continuities and Transitions," in United Nations. Ageing and the Family. New York: Department for Economic and Social Information and Policy Analysis.

13. Lassonde, Louise.


Publication Inc.

1997 . Coping with Population Challenges. London: Earthsean

14. Limanonda, B., K. Wongboonsin,

S, Vibulsresth, and V. Prachuabmoh Ruffolo. 1995.

Summary Repoft on The General Family Suruey,lPS Publication No. 228195. Bangkok: lnstitute of Population Studies.

64

Socio-Cultural Perspectives in Health

15. Meesook, Sivalee. 1997. "Factors Affecting Attendance of Government Health

Promotion Program for Elderly: A Survey in Hoamark Area, Bangkok, Thailand," Master of Arts Thesis, Faculty of Graduate Studies, Mahidol University.

16. National Statistical Office. 1997. Soclal lndicators 1997. Bangkok: Office of the Prime
Minister, National Statistical Office.

17. Nayar, U. 1996. "The Situation of Ageing: The Chip and the Old Black," in United
Nations, Added Years of Life in Asia: Current Situation and Future Challenges. Asian Population Studies No. 141. Bangkok: Economic and Social Commission for Asia and the Pacific (ESCAP).

18. Pongsapich, Amara . 1992. "Changing Family Pattern in Thailand," in UNESCO. The
Changing Family in Asia. Bangkok: UNESCO Principal Regional Office for Asia and the
Pacific.

19. Sermsri, Santhat. 1997. "Health Preventive Behaviors of the Thai Elderly," paper
presented at the Second Asia-Pacific Conference of Sociology. Kuala Lumpur, Malaysia,
18-20 September 1997.

20.

. 1995. "lmplication of MentalWell-Being from Changes in Thai

Society," paper presented atlhe lntemational Conference on World Mental Health: Problems and Piorities in Low lncome Countries,6-8 April 1997, New Delhi: the Rajiv Gandhi Foundation.

21, Shryock, H.S., J.S. Siegel and Associates. 1976. The Methods and Materials of
Demography. In E.G. Stockwell (editor). Condensed edition. New York: Academic Press.

22. Sawadyad, Prasit. 1983. Family and Knship in Bangkok Bangkok: Chulalongkorn
University.

23. famarak, Sasithorn, 1996 "Alternative Types of Care and Their lmapcts on the
Quality of Life of the Thai Elderly," Doctoral Dissertation of Population and Development, The National Institute of Development Administration (NIDA).

24. Thanh Liem, Le. 1999 "Mental Health in the Elderly People," Paper submitted

in

fulfillment of the requirements for the graduate course in Socio-Cultural Perspectives in

Aging and Health

Primary Health Care, ASEAN Institute for Health Development and Graduate School, Mahidol University,

25. United Nations. t996 (a). Added Years of life in Asia: Cunent Situation and Future
Challenges. Asian Population Studies No. 141. Bangkok: Economic and Social Commission for Asia and the Pacific (ESCAP). 26.
. 1996(b). Population Ageing and Development: Report of the

Regional Seminar on Population Ageing and Developmenf. Asian Population Studies No.

140. Bangkok: Economic and Social Commission for Asia and the Pacific (ESCAP).

27.

----------

1995. World Population Prospecfs; The 1994 Revision.

ST/ESA/SERA/145. New York: Department for Economic and Social Information and
Policy Analysis, Population Division.

28.

---------

1994. Ageing and the Family. New York: Department for Economic

and Social Information and Policy Analysis. 29.

.1973. The Determinants and Consequences of Population Trends.

Volume 1. Population Studies No. Affairs,

50. New York: Department of Economic and Social

**************

66

Socio-Cultural Perspectives in Health

Table

4.1

Percentage of the Elderly by Type of Sickness and Male-Female,

Thailand, 1994

Symptom of Sickness Arthritis Dizzy

Total 72.4
49.2

Male 67.3 38.9


39.1

Female 76.5
57.6
46.1

Eye Sickness
Cannot Sleep Faint Often Lost memory Blood Pressure
Constipate

43.0
44.7 28.2

36.5
19.0 23.8
22.1

51.4 35.7 30.0

27.2
25.0

27.3
24.1

22.5
20.5

20.5
21.7

Peptic Ulcer

19.6

Source : NationalStatisticalOffice, 1997 Social Indicators 1997

Urbanization lmoacts on Health

67

Chapter 5 Urbanization lmpacts on Health

Santhat Sermsri

This lecture review is based on two writings of Sermsri (1996 and 1998) on Health and the Urban Poor in Bangkok and Prachakornsat Thang Sankom (Social Demography) respectively.

Trends of Urbanization

The year 2000 marks a turning point in the history of urbanization in developing
countries of the Asia-Pacific region. That is, the level of urbanization in these countries of

the region will reach nearly 40-50 percent. Many people are now living in urban places and move will be added in years to come. The urban growth rate in many developing countries has been in a range of 3-4 per cent per annum during 1990-1995, compared

with only 0.7 per cent in the more developed regions (United Nations,
Urbanization in the Asia-Pacific region becomes

1997).

a fact of life, being a part of the


populations

international phenomena. lt is expected that by the year 2020 a majority of the population

in the countries of the region will be living in urban areas while rural

decrease. lt is also predicted that the rate of urban population growth will increase much

faster. As such, urbanization will play an important role in shaping the well-being of the
population in the region.

It has been revealed that a country possesses a high level of urbanism when
urbanization becomes the prevailing condition. Urbanism is a dynamic process meaning

that at the same time numbers of people move into cities, people change from
agricultural work to industrial work and importantly change their behavtor and ways of
life. Urbanism is then pertinent in extending its influence outward. People can no longer

escape urban ways of life even{hough they are living in a rural village. Urbanism enters

68

Socio-Cultural Perspectives in Health

through industry, medicine, ornamentation, clothing and shoes, style in dress and
manners, jokes, songs and music and forms of entertainment coming over the radio or on

the printed page. The rural village, within the influential sphere of a city can neither keep

all of its people in nor the unwanted influences out. lf such a village cannot find
employment for all who must work, some or several will feel compelled to migrate. Urban

living calls for different relations to time, space and people. New comers to towns and

cities must enter into new types of social systems and organizations. Like other social
problems in a world of change, those of urbanism are never completely solved.

The long-old problems of urban concentration result in slums and crowded


residential areas. Slums and squatters have begun to appear at urban centers. In many

developing countries, there are the twin challenges of over-urbanization and underindustrialization. Pathological urban conditions, such as over-urbanization in any country, means the existence in any country of a problem of rural development.

Urbanization in the region is also a large city phenomena. Very large cities in the

region, especially a capital city, have strongly dominated the urban scene. The United
Nations (1997) predicted that this region will have 14 out of the 30 largest cities in the

world. Each city will have a population of at least 10 million. But with this extremely rapid inorease, half of the populations of Asian cities in the year 2000 will live in slums and
squatter settlements. Such an increase in the size and dominance of big cities calls for a

massive mobilization of resources to cope with the development of social well-being, including health care, housing, sanitation, transportation, environmental quality as well as
welfare and security,

Urbanization lmpacts on Health

69

Definition

Urbanization

is a

process

of

population concentration

in urban areas and

proceeds in two ways 1)the multiplication of points of concentration and 2) the increase in population size in urban areas. Urbanization is, therefore, influenced by demographic characteristics and boundaries.

lt

includes the interaction of area phenomena and

demographic phenomena. Population concentration is necessary for an emergence of


center activities and also reflects technological development. Urban is then defined as an outcome of population gathering together and developing a way of life characterized by formal contacts with others.

Criteria used in defining places as urban areas include 1)


inhabitants,

number of
population

2) central places for focal points -' activities of the urban

including administration, health, education, welfare, transportation, security, religions and commercial activities. Since there is

a lack of one single official definition of what

constitutes an urban area, the local administrative unit of a country is used to connote urban place. For example, in Thailand, the practice is to use the Ministry of Interior's administrative unit of

"

municipal area" as equivalent to urban place (see Chart 5.1:

Urban Hierarchy in Thailand). Under the Municipal Act there are three classes of
municipalities, namely, Nakorn (city), Muang (town) and Tambon (small town). Nakorn
refers to an area with at least 50,000 inhabitants, and

a population density of not less

than 3,000 persons per square kilometre. Muang denotes the same population density as

the Nakorn but requires at least 10,000 inhabitants. A Tambon has no specific numerical criteria but can be established wherever considered to be appropriate. Places outside
municipalities were therefore classified as rural places which include the sanitary districts

and villages. In April 1999, all 981 sanitary districts have been designated as urban
places. As such, the level of urbanization based on the proportion of population residing

in "municipal areas" is thererore higher than the criteria used before 1999 that was

70

Socio-Cultural Perspectives in Health

somewhat underestimated since Sanitary districts were designated as part of rural areas'
It is estimated that the level of urbanization in Thailand, as it included all sanitary districts

being considered urban areas, is about 49 percent in 1999, increased 'from

27

.1 percent to

in 1990. From this, it is possible to identify five concepts which have been used
distinguish urban-rural places. 1) Administrative area,2) Population size,

3)

Local

government office, 4) Urban characteristics and 5) Predominant economic activities.

With respect to the definition of slums and squatters, the term "slum" is used to indicate housing which falls below a certain level which is necessary to contribute to human development. The term "squatter settlements" is used to indicate housing that is
either the result of illegal occupation or has been developed in an unauthorized fashion (World Bank, 1992; cited from Aldrich and Sandhu, 1995). However, slums and squatter

settlements are often difficult to separate. ln practice, slums generally refer to housing which has fallen into such disrepair. A squatter area could be a slum. Slums may occupy

public lands, river banks, both sides of

a railroad and other land plots of both

government and private lands. In Thailand, slum dwellers and squatters generally have low-incomes, low social status and hold no regular employment as well as occupy
housing of temporary migrants.

Causes of urban growth

Causes of urban growth involve an increase in the number of births by urban residents and a large stream of migration. Explicitly, migration from rural areas where the majority of the country's population live, is a major reservoir of urban growth. When only a small number of rural migrants rush to urban areas it can create social malaise.
Furthermore,

a penetration of capitalism from centralized bureaucracy in urban to

rural

and deterioration of traditional relationships of rural people creates an exodus of rural migration

to the cities. This idea will be further elaborated in the discussions

on

Urbanization lmoacts on Health

71

"Dependency Theory" of urbanization. Lastly, an improved technology is essential to

cause more and frequent moves of both rural and urban population. In developing
countries, urban growth is mainly a situation for the capital city of a nation. The capital

city of Bangkok, for example, is so centralized in many aspects. The sheer size of
Bangkok's population, which in 1997was estimated to have a "night-time population" of

eight million and a day-time population of ten million. The growth of the capital city,
therefore, dominates the growth of the country urban population and is based mainly on

the migration of rural population. However, the capital city has a huge number of poor
residents living in slums and squatter areas. Urbanization in Thailand is then categorized

as over-urbanization. The term "over-urbanization" is coined to describe societies where there are more urban workers than urban and industrial jobs. A clear consequence of over-urbanization is related to the situation where economic stagnation and slowed
development exists in the city.

In order to better understand the development of Thailand capital's city, Bangkok,

brief details of the history of the city should be known. Bangkok was developed from a fishing village on the east bank of the Chao Phraya River at the beginning of the Chakri
dynasty in1782. The citywas firstconstructed in orderto be a fortified island city. Klongs

(canals) were dug to serve the city transportation. Opened to the West in 1818 after nearly a century and a half of isolation, Bangkok gradually began to absorb western
influence. During the 1850's, under King Rama lV, Bangkok developed into an important

commercial center. In year 1782, Bangkok became the capital of Thailand, with a population

of about 400,000. lts beginning population


1

increased slowly, reaching

890,000 in '1937 and almost

.4 million in 1950. The population had grown to 3.8 million in

1975 and reached almost 5 million in 1980. By 1995 the population grew to 6.6 million with a rate of growth, roughly3.T percent. Recently, in 1996, the growth rate has declined slightly to about 2.2 percent.

72

Socio-Cultural Perspectives in Health

Bangkok has long been Thailand's primate city and there is no other city in the country which has even one million population. Nearly twothirds of the country's urban
population were residents of Bangkok. ln 1990, Bangkok was the home of 58 percent of

urban

Thais.

The predominant consumer goods industries and import dependent

industries are located in and around Bangkok. Bangkok then becomes the center of the national economy network and the largest consumer market. Export industries are also

concentrated

in Bangkok due to its access to port facilities, communications and

financial services.

Bangkok, an administrative area of 1560 sq.km. (around 605 sq.miles), is the

capital city of Thailand. As stated above, Bangkok is a primate city and has a rapid
growth which is accompanied by a rapid increase in slums and squatter areas. There were 448 slums in the 1980's compared to 1520 slums in the mid 1990's. The slums and squatters vary in size from a small settlement with 35 households to a site with 20,000 residents. A majority of slum dwellers are poor and reside in low quality housing. The number of low income residents in slums and squatter areas is estimated to be around
1.'12 million or in 255,000 households. The National Statistical Office (1994) reported that

a majority of the households in slums and squatter areas of Bangkok were below the level

of well-being (table 5.1), Although it was revealed (Suganya Hutaserani and Pornchai
Tapwong, 1990; Mathee Krongkaew, 1993) that poverty in Bangkok has declined since
1980, a large number of poor persons living in slums are still evident. Poverty incidence

in Bangkok in 1975176 was 7.8 percent and declined to 3.5, 3.5 and 3.4 in 1980/81,
1985/86, and 1988/89, respectively. The presence of slums and squattersettlements is a

clear indicator of the failure of a society and government to provide adequate habitat for
human development.

Urbanizatron lmpacts on Health

73

Slums and Squatters

Lands of urban slums and squatters in Bangkok have different status, including

public lands, government, semi-government organizations and private properties. The


ooor moved into the lands without permission, are described in the case study below.
Many lands are both land locked and stretch along the canals, Most slum dwellers and

squatter residents build shacks out

of poor materials (Archam,

1997). Slums and

squatter areas consist of many houses constructed, as stated , on plots of vacant lands. Many slums and squatters are located close to the workplaces of these poor residents. Recently slums and squatter areas have been emerging under bridges of streets and highways. Many houses resemble shacks although better wooden houses with two floors also exist. Many houses lie on wet soils and swamps. The space in the house is small,

consisting of an average of 1 2

to

100

sq. meters. Toilet facilities are inside the houses.

Electricity and water supply have been provided by the local government. The average household size is 5 persons and more (Edwards et.al, 1994). In the highest categories of household size, there are 10 or more persons. One example of a poor slum in Bangkok is the oldest slum nearby a shipping pier where rural migrants moved in forty years ago. A slum was erected by the gasoline company which rented the land from the government

and built shelters for their workers around the pier. A few years later, the company
abrogated the contract to the government and returned the land to save the budget. The
workers and families decided to stay on illegally in the area, without the permission from the authority concerned (Limsuphan, 1997)'

Since 1980, the infrastructure of many slums and squatter areas has been
improved through the efforts of government and non-government organizations.

lt

has

been observed that the situation for slum dwellers and squatter residents in Bangkok is

far better than in the past. An example of a special provision to these low-income
residents in Bangkok is clearly demonstrated by the policy relating to the development of

74

Socio-Cultural Perspectives in Health

slums and squatter settlements. In past years there were a number of projects on urban

community development that helped improve living conditions of slum dwellers and

squatter residents. The projects were mainly concerned with upgrading the living
conditions of the slum and squatter residents. Urban and city services were provided to
these poor areas. The following are the outputs from these project activities.

1 Walkways

at low cost built by funds from outside and labor from people in the

communities themselves.

2
3 4

Water supply, built by loans provided by banks and houses connected to the

city water supply. Drainage built and connected to the city main system.

Garbage collected from houses and each house paid a smallfee per month. constructed and repaired by Housing Authority.

5 Housing

Income generating activities, the target is to increase a monthly income. Revolving funds given to communities. Every family became a shareholder of

the cooperative. The contributions range from 30-500 Baht..

8 Community center created and used for formal meetings, day-care, education
and recreation facilities.
9 Social changes promoted self-reliance and self-help within the communities.

It should be noted here that the extensive survey conducted for the National Urban Development Policy Framework reported that much higher proportion of
construction site workers living in Bangkok city, do not have pure drinking water and do not use toilet (Ueda, 1997),

Urbanization lmpacts on Health

75

Concepts of Urbanization

Since the end of World War ll, together with the establishment of relationships with the developed countries in the West, the population increased in many developing countries resulting in an increase in the growth of cities. Large numbers of rural people relocated to the largest cities which had been the seat of center activities and the administration by the elite groups. Many of these cities were primate or first in size.
Unlike the sparsely populated rural hinterlands of most of the developed nations where

the early urbanization and development took place, many developing countries are
characterized by dense population, i.e., the situation

of a rapid increase in

rural

population and a decline in farm lands. Furthermore, the sociocultural conditions were different in the developed world than they are in the developing ones. The pull of cities

has much to do with the lack of alternative jobs in the local villages. In countries
dominated by western culture and colonial administrative centers, the force of the market place has not created a hierarchy of cities which support the growth of local economy. lf
rural people want to go where the action is they have to move to the large city or capital

city. ln other words, rural people leave the densely populated farm areas for the
opportunities of large and administrative market centers.

The Dependency theory holds

that the existence of such phenomena is due to

the exploitation of the developed world to the developing countries. The argument lies

that raw material and financial assets needed by the developed world are actually
supplied by countries in the third world (cited from Aldrich and Sanhu, 1995). Local elites

and multinational corporations, the arguments goes, create a common cause to exploit
the resources of people and the land in the interests of making a profit. Populations in the

third world are then entirely dependent upon the global economy. Nothing is left for
development because the local elites export all their share of the profits to more lucrative
investments in the developed countries or industrialized nations. lt is presently clear that

76

Socio-Cultural Perspectives in Health

trade interactions between Third World or developing countries and the industrialized
nations are the key factors in predicting the absorption of labor into the labor market..

And that, the concentration of populations in cities is a result of not only geography and
historical reasons but also market sources, elite decisions and the culture of civilization.

With respect to
population is

positive impact of urbanization,

high concentration of

a condition of the improvements of basic

infrastructure and this in turn

allows the development of new ideas and technologies. When humankind are free from

diseases and starving they then will have time to bring an innovation to their community
and family. As innovation emerges, a process of development follows. lt is an innovation

that brings about changes in production and a rise in living conditions. Work status,
especially for women, is for example changed. Women in the past were confined to
house chores and supposed to breed and rear children. As changes in women's roles

occur, women are now working outside family management and looking for more
education. As education increases, social mobility will come and this in turn leads to a rise in level of living. lt is in this manner that urbanization will bring about development. Urbanization is then seen as a necessary condition for continued development and the

rising quality of life. The growth of industry can contribute to rising urbanization by
shifting people from low to high production employment, Urbanization then requires the greater specialization of jobs and employment. The diffusion of social and economic

progress promotes social

welfare, increases food production, reduces income

disparities and provides educational and health services to the various segments of the

population. Urbanization, therefore, tends to be associated with the development of


modern employment, an increase in literacy, a rise in industrial productivity and virtually

all the improvement in health conditions and standard of living. Many may believe then that urbanization is an important aspect of socioeconomic development. In other words, cities have generally been associated with human development.

Urbanization lmpacts on Health

77

Regarding rural migration as the contribution to city growth, the urban labor pool
is formed by the large number of rural migrants who actively contribute to the economic

growth of

a city and may be regarded as the basis for such city development.

ln

contrast, some city residents tend to use these cheap laborers but do not bother to provide housing and social welfare schemes. ln the past, many governments tried to control the movement of rural migrants based on the belief that such movements create housing problems in cities. However, when the countries shifted to free markets due to
globalization forces, and more open systems, the governments loosened control over the

development process, then the numbers of rural migrants increased rapidly. Since
housing was not defined as service, housing in cities became problematic. Cities then

were extremely crowded.

A policy for slum and

squatter clearance emerged and

authorities then relocated residents of these poor areas to new places. This approach

had limited success in Thailand, for example, because the relocation sites were
inadequate in terms of the infrastructure and services. Slum dwellers and squatter
residents were very distant from their employment and work and they had to commute on

weekends. lt can be concluded that these types of policies tended to create social unrest
leading to injury, social instability and political demonstrations.

Urban Life

The urban scene presents a picture of wealth, class, comfort and modern living.
Rising in the morning at the flick of a switch turning off an alarm clock and the push of a button for the light, shower, tooth-brush and then the coffee pot. The electric toaster pops bread and then ready its time to leave for a long traffic jam in the big city. The school bus arrives, the children are heading to school and several who do not have school buses,

run to grab crowded public buses. The head of the family drives off in air-conditioned
care to his office. lf there is no big problems in the family economy, the wife stays home,

giving supervision to the daily cleaning of the house and then heads for the shopping

t6

Socio-Cultural Perspectives in Health

center around noon. For wives with a burden in the family economy, they leave home for their offices with the husbands for another heavy day in the office. At night, the older children take off for the disco with the latest high tech sound system and laser lights
while the younger ones join parents to watch TV on wide-screens or play with their own comouters.

Urban life may seems exciting and fulfilling. However, when looking at it more

closely, urban men appear lost among the masses

of

machinery, technologies,

telecommunications and wealthy desires, to achieve a decent way of life. Life is too fast-

paced and too like a rat-race, So much waste and poverty for those unfortunate enough
not to have been born rich or for whom golden opportunities never come. A breakdown

of social relation ties in the family and at work apparently becomes a daily subject of
debates and a search for definite solutions. The city seems to drain the life out of man with its passionate drive for material production possession and its ambition for wealth

and more comfort. Man is weighted down by city life and he becomes its slave. lt is
hoped that education may assure an adequate background in this highly complex world

of urbanization, for maintaining good-old morals and traditional practices. Man should
have values to be counted as a human being.

Of the 25 million children living in extreme poverty in Brazil, eight million are said

to live on the streets. The children will spend their days scavenging through garbage and
are tempted to eat food which they find amongst the garbage. Many of them have been violently sick and some had died from what they believe was related to food they found

and could not resist. Occasionally, fights break out between rival groups in the wealthier parts of town where garbage is "good", as it brings them more cash when it is resold.
The dream of most of the children is to find an "honest job", i.e., to be a bus driver, a factory worker, a plumber, a teacher, a nurse or a social worker (Baruffati, 1997).

Urbanization lmpacts on Health

79

In contrast, in rural areas, the countryside, which is the oasis in the desert of a frustrating world of urban growth, beckons to the weary traveler. The air is fresh and
clean, unpolluted by smoke and fumes from exhaust pipes of factories and vehicles. For
many, the lungs do not have to work overtime to perform the function of air purification. In

this countryside, one can know the meaning of blessed quiet, away from the cacophany of sounds in the city, of honking horns in which many describe the frustration as too loud

for comfort. Rural areas have an abundance of space where one can see the clear sky
overhead unblocked by huge and high concrete. One can stretch out his hands and not

bump into somebody, some buildings and some vehicles. Man lives with nature and
neighbors, looking for a deep/bound feeling of contentment. Of course, the houses will
not have the convenience of modern day living, but they will make better homes than the

empty ivory tower of the city. Home provides and promotes better shelter. The school is also a place where the children can learn lessons from books and dedicated teachers although the best rooms and facilities may not be enough or even present. Health centers and hospitals will provide friendly and quality care to rural folks and keep
promising decent health care.

lmpacts on Health

As mentioned earlier, in less developed and developing countries (LDC), many

cities have experienced rising levels of urbanization but they suffer from economic
stagnation. Problems

of

urban poverty, inadequate housing and lack

of

urban

infrastructure as well as unemployment are easily seen. The socioeconomic progress


tends to be confined to a few large urban places, particularly the capital city in the case
of Thai urbanization. People now see a divorce of urbanization from development. Unlike

the experience in more developed nations (MDC), rising urbanization in less developed
and developing societies has not been associated with an increase in development and quality of life in particular. Rather, problems of urban poverty, inadequate housing, rise

80

Socio-Cultural Perspectives in Health

in urban slums and squatter settlements, poor infrastructure and unemployment, are
ubiquitous.

The attractiveness of a primate city, together with the failure in rural development

programs encourage rural workers to flood into the capital city. This is because the
situation in the rural areas and small towns is also underdeveloped. Since migration is a selective process, rural migrants to cities are also a special population group by virtue of their characteristics and attributes and their willingness to change. Persons who migrate

may change many of the conditions of their life which in turn affects health. A question

that has long been of interest is whether migrants arc a superior group in relation to
health. For example, a study in England revealed that migrants are stronger in terms of

physical health. However, Hull (1974) found that migrants have higher mental
hospitalization and also heart disease incidence.

lt is difficult to conclude

the

relationships between migration and health and it needs a consideration of a particular


context of the relation. ln other words, the risk of illness depends upon the similarity of the

destination and home places. As Wessen (1971) concluded that health result of the
migration experience may be a function not of geographic or social change itself, but of the characteristics of the miorant and the environment at his or her destination.

As revealed above, a high centralization of the country is confined in the capital


city. A serious problem is the mushrooming of shanty towns, squatter areas and slums. The economies of a primate city are export oriented. Economic advantage, therefore,
results from the concentration of industry and this has attracted labor forces from rural areas, peripheral locations and urban residents to stay and work in this big primate city. Negative effects of big urban centers and primate cities are parasitic. The focuses of the

primate city also rob the countryside of valuable manpower, consume all investment funds, prevent the level of other city development, dominate the cultural pattern and lead to the breakdown of social and cultural traditions. The primate city also has a high rate of

Urbanization lmpacts on Health

81

consumption as opposed to production, creates the concentration of multiple sources of


pollution and demands for utilities which leads to an accumulation of waste products in

the water, air and ground, There is an obvious increase in accidents, VD, violence,
addictions and crimes.

A big problem of health of urban residents is associated

with

both dangerous diseases and old health problems like infectious and non-communicable diseases.

report on the Poverty

of Cities in the

Developing World

Popline

Newsletter,1997) revealed that cities in dqveloping countries are no longer the islands of

relative privilege they were in the decades after World War

ll. For example,

infant

mortality levels in Latin America and sub-Saharan Africa in the 1990s are as high in the large cities as in the smallest towns, Martin Brockerhoff and Ellen Brennan of the United

Nations population Division found that based on infant survival and other indicators of

children's well-being, the advantage diminished since the 1970s,

of city dwellers in the developing world has and cities that grow faster experience a more severe

decline. The authors note that the urban transformation of the developing world bears some resemblance to the 19'h century urbanization of now developed nations, but today far more people are crowding into bigger cities. Cities of tropical Africa with 50,000 to
1

million people have actually experienced an increase in infant mortality from 73 to 90 deaths per '1,000 births. Cities that have grown annually by more than 5 percent have
higher infant mortality rates than cities that have grown by less than 3 percent'

As mortality is not the only single indicator of health, several health measures should be brought into the investigation.

measurement

of health status of the

population refers to a wide range of mortality and morbidity rates, including illness, physician consultation, restricted activity day, hospitalized day, health manpower ratio'
infant mortality, child death, maternal mortality and life expectancy.

82

Socio-Cultural Perspectives in Health

Good descriptions of the health problems of the urban poor in the developing countries can be elaborated in three groups of factors which are detrimental to health (Harpham, Lusty and Vaughan, 1988). The first includes direct problems

of

poverty

including low income, limited education and insufficient diet. The second relates to man-

made conditions

of the urban

environment, namely, overcrowding, poor housing,

industrialization, pollution and a general exposure to infectious diseases. The third is the result of social and psychological instability and insecurity.

The excessive vulnerability of the urban poor and their exposure to pathogenic agents means that infectious diseases and malnutrition are severe health problems in

cities, particularly, slums and squatter areas. An imported reservoir of infection

is

replenished by rural-urban migration, which in turn reinforces local transmission. Urban

malaria is an example. The breeding site of the carrier mosquitoes (Anopheles) is


created by water collecting in small plastic boxes and other containers. Epidemics of
similar vector-borne diseases, especially dengue haemorrhagic fever, have occurred in poor urban areas. Tuberculosis is highly prevalent in the slums and squatter areas where

infection is frequent. The scarcity and contamination of water supplies and the lack of
sanitation and appropriate sewage disposal make diarrhoeal diseases one of the most

important health problems in poor urban areas in many developing countries. Other illnesses and diseases are also influenced by factors of overcrowding, poor housing

conditions, density
contamination

of

insects, lack

of

rubbish disposal, poor personal hygiene,

of food, low literacy and inappropriate weaning and other feeding

practices. The National Statistical Office (1996) reported pattern of the diseases in urban areas in Thailand is related to crowding, pollution and mental well-being (table 5.2). n high incidence of preventable infections in children, such as measles, whooping cough
and polio, are more and predominantly prevalent.

Urbanization lmpacts on Health

83

Social and psychological problems of the poor urban and slum areas lead to

another group of problems, like child abuse, family violence and divorce. UNICEF
estimates that there are about 40 million abandoned children in Latin American countries (Tacon, 1981 ; cited from Harpham et.al., 1988). Also, migrants from rural villages who are unable to adjust to urban ways of life and living condition, face mental illness and many stresses. Alcoholism and depression are often found to be the most severe mental health symptoms in poor urban areas (WHO, '1984; cited from Harpham et.al', 1988).

In many cities of the developing world, around 20-50 percent of the population
live in intense deprivation. Calorie deficit among the urban poor, which is the first clear
situation of poor health in cities, is seen to be larger than that of the rural poor (Austin,
1gB0). Urban slum Thai children are, for example, well below the 50'n percentile in weight

for age in the first six months of infant life (Kanjanithiti and Wray, 1972).

Urban

malnutrition is a severe contributor and consequence of urban poverty and also is a


reflection of the shift to the cities of the rural malnourished.

The Bangkok Metropolitan Administration (BMA) has reported a low birth weight incidence in slum communities of 5-6 percent, but a higher incidence of 9 percent was

found in the slum communities (Ueda, 1997). Mild and moderate protein energy
malnutrition (PEM) among children under five living in Bangkok slums in 1988 were about
'16

and 1.5 percent, respectively. Hence, the benefits of child feeding, i.e., breastfeeding

and caring practices, are not fully understood by mothers in these urban poor
communities. lt is even more severe that these urban mothers were highly exposed to the advertisement and aggressive marketing of infant food formula.

Another important issue is health in poor housing conditions. A 1991 study on


housing types and health (Sermsri, et.al., 1991) revealed a higher level of illness among

residents in slum and public flats in Bangkok. lt was concluded that slum dwellers

84

Socio-C0ltural Perspectives in Health

showed higher illness and hospitalization than their counterparts living in better housing conditions, like detached houses. Surprisingly, mental illness among slum dwellers was also higher, as much as those in higher economic housing. Ueda (1997) examined child

feeding practice among mothers in Bangkok congested communities and reconfirmed


that crowding factors has negative impact on every aspects of child feeding and care.

Another important health problem is health care utilization. lt is revealed that the

presence of large hospitals and out-patient departments has almost had a depressing

effect upon the development of a more coherent health care service infrastructure in cities and urban areas. Many people go to drug stores for illnesses and only visit
hospitals when there is an emergency. The National Economic and Social Development

Board (1992) collected the data on where the slum dwellers seeking the health care

services. While people

in construction sites lack adequate access to health

care

services, other slum dwellers have access to some types of health services. The pattern

of health utilization is found to be similar to the utilization of poor rural people (Sermsri,
1995 and 1989). That is, a small proportion of Bangkok urban poor residents including

slum dweller and construction sites workers resort to the public health centers. Many of

the urban poor consulted and obtained medicine from drug stores and private clinics
(Ueda, 1997).

It can be concluded that when the groMh of a city is confined into a few urban

places, urbanization tends to be associated with urban problems. Regarding health,


medical expenditures of people is increasing. The burden of medical cost also increases

due to

common practice

of using

sophisticated medical equipment, laboratory

examinations, and high standard medication. With respect

to the social malaize, a lack of


social that

problems of morals, ethics and values are actually spread. Mental health problems become apparent cohesion

, the elderly are

excluded and isolated, due to

in family and social institutions. lt could be mistaken to conclude

Urbanization lmpacts on Health

85

urbanization which is associated with economic growth, would bring health development

to the urban residents. In fact, an emerging development paradigm has redefined the relationship between economic development and human development. Economrc
development is not a prerequisite for human development but an investing in num.an development is perceived as key intervention for economic development. An adoption of strategies for effective health improvements and intervention for urban poor residents

requires better understanding of the causality pertaining to the socio-economic and


cultural status and health care services. A clear picture of mothers giving care to their

children in the urban poor residents should exemplify the statement. That is, an
increased financial control

of

mothers helps them allocate the limited household

resources to the most vulnerable family. However, coupled with the rapidly progressive modernization and urbanization, increased income available to women do not necessary

help them to make decision for the beneficial behavior. From this, it is then cleared that other social influences play equal roles in making a better health for the urban poor.
Mothers of severely malnourished children are, as Ueda (1997)

found, often those with

low self-esteem, low confidence and less education. A woman may form an intention to perform a behavior depending upon the overall pressure from those around her. Whether

or not the person's own judgment can overcome the influence of those around her will depend on the individual's strength of will and susceptibility to pressure. That is, the
human development is clearly important for the development of life including individual, community and nation.

Proposed Measures

Proposed measures aimed at improving the health status of the population and

bringing

closer association between development and urbanization can

be

summarized here as follows:

Socio-Cultural Perspectives in Health

t. Establish standard criteria for basic minimum


2.

needs for urban residents,

especially those in low social strata and in congested crowded areas; Promote community participation approaches in health, social and economic activities;

3.

Encourage the collaboration among private health agencies, semi-government organizations and government sectors in community development programs;

4.

Foster a system of reciprocal relationships between officials as providers and

the public consumers in public services; and

5.

Establish a more efficient distribution of national development benefits to both rural areas and smalltowns.

Suggested Readings

1. Aldrich, Brian C. and Ranvinder S. Sandhu. 1995 Housing the Urban Poor: Policy and
Practice in Developing Countries. London: Zed Books.

2.

Baruffati, Veronica. 1997 "street Life in Alagados, Salvador da Bahia," Speaking

aboutRlghfs: Canadian Human Rlghfs Foundation Newsletter. VolXll, No. 2/1997:10.

3.

Edwards, J.N., T.D. Fuller, S. Vorakitphokatorn and S. Sermsri. 1994 Household

Crowding and lts Consequences. Boulder, Colorado: The Westview Press.

4.

Harpham T., T. Lusty and P. Vaughan.

1988 ln the Shadow of the City: Community

Health and the lJrban Poor. Oxford: Oxford University Press.

5. Maethee

Krongkaew 1993 Sixth Annual Meeting of Thailand Economic Association.

21 January 1993.

6.

National Statistical Office. 1994. The 1994 Demographic Suruey of Population in

Congested Community of Bangkok Metropolis. Bangkok: Office of the Prime Minister,

National Statistical Office.

7.

-----------

1996. Repoft of the Health and Welfare Suruey 1996.

Bangkok: Office of the Prime Minister, National Statistical Office'

Urbanization lmpacts on Health

87

8. OrathaiArcham. 1997

Community Based Urban Environmental Management in

Bangkok, Publication of Institute for Population and Social Research, Mahidol University.

9.

Popline: World Population Neuvs Services. Volume 19, November-December 1997.

10. Santht Sermsri 1995 "Health and the Urban Poor in Bangkok," in Paul Cohen and
John Purcal (editors) Health and Development in Soufh Easf Asia. Canberra: Australian Development Studies Network.
11.

1998 Prachakornsat Thang Sankom (Social Demography). Second

Edition. Bangkok: Sam Charoen Publishing Company. tz. Types and Health Status in Bangkok," Paper presented atthe 30h InternationalCongress
of the lnternational lnstitute of Sociology, Kobe, Japan, 5-9 August 1991.

13. Suganya Hutaserani and PornchaiTapwong 1990 Urban Poor: Upgrading.


Publication of Thailand Development Research Institute.

14. Suwan Limsumphan 1997 "Cultural Dimensions of Controland Protection of Sexual


Life: the Case of Female Adolescents in Urban Poor Community of Bangkok," M.A.

Thesis, Graduate Studies, Mahidol University.


1

5.

Ueda, Misaki Akasaka 1997 "Child Feeding and Caring Behavior of Mothers with 1-3

Year Old Children Of Urban Poor Communities in Bangkok: A Socio-Behavioral Perspective," Master Thesis of Primary Health Care Management, Graduate Studies, Mahidol University.

16. United Nations

'1997 "World Urbanization Prospects: The 1996 Revision," Population

Newsletter. Number 63 (June). New York: Population Division, Department of Economic

and SocialAffairs.

***************

88

Socio-Cultural Percpectives in Health

Chart S.L Urban Hierarchy in Thailand

1. Metropolis
Bangkok has been designated as a rnetopolis since 1972 . TWo new
ale

@laces with population of at least 50,fiX) ard ppulation density of at least

. Muang Muricipality
@laces with populalion of at least l0,q)0 ard population densily of at least

District
(Sds with population more than 5,000)

5.2 Rural Sanitary District


wilh

6. Village

Note: Urban ard Rural Sds are terms used by the National Statistical Oflice

in tlrc 1980 C-ersus Reporl

Urbanization lmpacts on Health

89

Tabb

6J

Percentage of EousehoHs on Vt/ett-Being Index

in Congested Community of

Banglok,1994

Index of \trdt-being

Bangkok

l{hole

West

Easf & Nor0t


7.0

South

Egh
Ilfiedium

?n.l
1e.0

2e.4
2?.7
47.9

L7.2

lG4
76.7

l8.e
8&0
100.o

Low

60.0 100.o
National Statisrioal OfEe, 1994. The

T.tal

100.0

loo.o

Sourei

lee4 Demrgfaplrlo Survey of Populdion in Congeed

Connrmtty of Bangkrk Metopolis

90

Socio-Cultural Perspectives in Health

2 weeks prior Tabb 6.2 Percentage of Persons reported ill or not fteling well drring Thailan4 1006' to the suvey, by ? Granps of Dirseq urban-Rural Areasr
Rurd
6{"16
18.Ee

Group of

Ilieae

Urban 70.80
11.67

G.l Dieaes of the ReryirdrrY

sYstem

G.2 Itieases of the Digedive system G.8

Itiea*s

of urinarY system

L4e
10.8E

%7a

G.4 Cardiovascular dieases


G.5 Inftc{ious dieaes

eJ0
&2e

t.?fi

GB Ihea*s of dein
G.7 Allergic condidons

t4;r
&o4
100.o
IroE31600.
e

t.78

Lel
roo.o
5r3g7r7oO.

Totd Perent
Total Number of Caes

survey le souroe : National statistioal offioe, 1996. Repoft of the Eealth and \ilelfare

&

Household Crowding and Family Violence

91

Chapter 6 Household Crowding and Family Violence


Santhat Sermsri, Sai rudee Vorakitphokatorn,

Theodore D. Fuller and John N. Edwards

The discussion of this chapter is based mainly on Edwards, et.el. (1994) writting on

Household Crowding and lts Consequences;

As revealed in the preceding chapter, housing types in Bangkok are related to health conditions. Slum dwellers are more likely

to have higher illness,

more

hospitalization than their counterparts living in others and better housing types, including

concrete commercial shop-houses and detached houses in many housing development projects in suburban Bangkok (Sermsri, et.al., 1991). Slum dwellers are poorwho build their shack with poor materials, although better wooden houses with two floors can be

found in these congested communities.

lt

was also documented by the

National

Statistical Office (1994) that a majority of the households in Bangkok slum and squatter areas are characterized as very low level of living standard.

Echoes of the concern about city living have long been heard. Cities are full of

congested and crowded residents. History has revealed that residential crowding is a crucial source of city decay and a contributory factor to increased social disorganization. Desmond Morris (1969),

a critic of city life, maintains that each kind of animal has

evolved to exist in a certain amount of living space. For the human population, a concern

of the discussion bears on household crowding and its consequences such as health.
The term household crowding refers to a primary environment that an individual spends time, related to others on a personal basis and engages in a wide range of personally
important activities.

92

Socio-Cultural Perspectives in Health

Definitions

Density has been used to identify the magnitude of crowding and its meaning denotes the number of dwelling structures in a given unit of land area, the number of rooms per dwelling unit, and the number of persons per room. Density is therefore an index of crowding, telling about the objective level of crowding. Knowing the number of persons per room has the advantage of dealing with the micro-environment in which a

person resides and indicates the potential for primary interaction between household
members. From this, it is obvious that there is a subjective side to crowding. People in objectively defined congested circumstances will perceive the situation and differently
have different feelings. Some people may feel crowded more intensely than others, even

when there is the same level of objective crowding. Two approaches in identifying
subjective crowding are 1) an experience in which one's demand for space exceeds the supply and 2) the experience of crowding results when a person is unable to achieve his

or her desired level of privacy. That is, when an individual is exposed to more contact

with others than he/she desires. Two terms that reflect these two concepts are
perceived crowding and 2) lack of privacy. (see Edwards, et.el, (1994).

'1)

Housing Situations

Apparently, the situation of household crowding is likely to be associated with squatter residents and slum dwellings. A slum generally consists of many houses on plots of both government and private vacant lands. The residents of the slums construct

their houses somewhat over night as many resemble shacks. Many slums are located
next to the work places and places to do their earning activities, i.e, the factory, market,

shipping pier or local business and commercial activities. For example, recent slums in
Bangkok have been emerging under the bridges of streets and highways. Many houses,

therefore, lie on wet soils and swamps and the residents are self-employed and general

Household Crowding and Family Violence

93

manual laborers, including construction workers and street vendors as well as those with daily labor and the unemployed. The space in a house is generally small, consisting of an

average of 12 Io 100 sq. meters. The average household size is 5 persons (Edwards
et.al., 1994). Several households however, have 10 or more members.

As discussed in Chapter 5, the infrastructure of many slums in Bangkok has been

improved since 1980 through the efforts

of both government and

non-government

agencies. Public utilities have been arranged as projects designed to improve health conditions. This also has attracted more rural and poor migrants to search for jobs and
betterment. The government has built many public apartments and smallflats (averaging
20 sq. meters), to replace slum dweller traditional houses. In a short time, many residents

in these oublic flats have vacated their new modern flats for the reason that life in these

public flats was not culturally fitting to their earning a living. Social interaction among
neighbors was felt to be lacking in the government flats. Housewives needed to operate

their own vendor shops and grocery stores. When the economy of the city in the
beginning of '1990's was good, several low-cost housing development projects were constructed and offered to the poor slum dwellers, However, the prices of the housing units are still too high for low income families and these new housing places are very
distant from their working places. As a result, slum dwellers are unable to improve their housing and are forced to continue to live in the congested/crowded households.

ln the ooor northeastern Brazilian state of Bahia, homes are built on stilts in the polluted waters. This extremely poor settlement is populated predominantly by blacks and migrants from other parts of the city who can no longer afford rents elsewhere. Most
women who work are maids or washerwomen to wealthier families, leaving an older child

in charge of several younger siblings. Many men go out in search of piece work each
morning. The street is generally a public space but not so in this community where it is

an extension of the "home". Children sell peanuts roasted on the street by an older

94

Socio-Cultural Perspectives in Health

sibling. In such an environment where the line between private and public space is so
thin, the street becomes a familiar environment in which they must survive at all costs:

forming alliances with others in a similar situation, employing violence and theft, and
covering up for each other, Children grow up in a family environment where poverty
forces the eldest children to prematurely leave the family home in order to free up scarce resources for their younger brothers and sisters. Psychological abuse becomes the only

way for parents to maintain an illusion of control over their lives (Baruffati, 1997; Leman,
1997).

Theoretical Concepts

Building on prior research (Gove and Hughes, 1983), overcrowding is viewed as leading to disturbed social relations and social pathologies. The more households are crowded, the more stressful the situation. The greater the stress experienced, the more
likely disturbances in family relations and decrements in well-being are to occur. In other words, stress is hypothesized to be a crucial intervening variable between crowding both as objectively and subjectively measured and a set of dependent variables having to do

with family relations and the well-being of individuals as the diagram demonstrates
below.

Objective* Subjective*StreSS

Crowding Crowding

--f

Family Relation and Well-being

Since the family forms the core of the household, behavioral disturbances
created by overcrowding would be exhibited in family member interactions. Some of its

severe and adverse consequences could bear on the husband-wife relationship,


particularly family violence and divorce.

Household Crowding and Family Violence

95

Tylor and Knowldore (1964) who began a research work on crowding, proposed

the epidemiological concepts of crowding and disease, that crowded communities tend

to provide more fertile ground for the spread of infection than scattered communities. A
body of research has documented the detrimental effects of housing conditions such as
sanitation, space, air quality, food storage facilities, lighting, noise and especially damp,

cold and moldy conditions---on a variety of illnesses, including tuberculosis, digestive


disease, anemia, gastro-enteritis and other contagious diseases (Smith, 1990; Cassel,
1979: Standard, '1976). The view, however, that poor housing conditions and household

crowding are inevitably linked to poor health is challenged by several researchers, who question the role played by both crowding and housing quality. Cassel (1979:129) for example, contends that the past century has witnessed

a change from a

complete

conviction that there is a simple and direct relationship between the quality of the house

and health statuses, to one of considerable uncertainty and confusion. A review of the
literature since 1920 reveals some studies showing a relationship between housing and

various indicators of poor health, others showing inverse relationships. Two questions

arise, under what certain circumstances

is

crowding linked

to the

incidence of

communicable diseases, and what circumstances have no such relationship?

With respect to Simmel's contention, dense circumstances lead to an overloading primary unit of analysis, of an individual's nervous system. This takes the individual as the
in demonstrating crowded households influence individual behavior and deviant behavior

particular. selye (1952) described a common pattern of response among animals when
involves they are subjected to stress, which density could bring about. The syndrome

of exhaustion' three Stages: an alarm reaction, a stage of resistance, and finally a stage the animal The animal suffers lowered resistance due to the stress. Disease occurs and dies. In other words, high density is more stressful as stress increases'

96

Socio-Cultural Perspectives in Health

Deviant and aberrant behavior are frequent.observations among animals in high

density populations. Freedman (1975) described that the size of an animal population
plays an important role. In roaming populations, increases in size are likely to put a strain

on food supplies. Lloyd (1975) said also that aberrant responses are due to stress
induced by social pressure. Does this mean that the animal studies have no relevance to human crowding? Experts on both sides of this issue have relevant points. Although
human culture is a unique and highly complex adaptation to our environment, it does not

remove us entirely from being subject to biological and psychological processes. The

issue is not whether humans are different than other animals but it is

a problem

of

assessing if there is any commonality across species. We must proceed with caution and avoid overly simplistic extrapolation.

A substantial literature from the medical, public health and social

scientific

communities has documented the link between stress and illness (see Edwards, et.el,,
1994). The list of diseases related to stress include many symptoms and in particular, psycho-stress symptoms. Various infectious and communicable diseases may be linked

to stress (Booth and Cowell, 1976). There are several findings showing this type of
relations as follows
:

After introducing several controlvariables, crowding has detrimentaleffects on health (Gove and Hughes, 1983).
Men appeared to be affected by crowding to a somewhat greater extent than

women (Booth, 1976). Focusing more on specific aspects of housing quality (Strachan, 1988), dampness and mould have detrimental effects on respiratory illnesses (i.e, wheezing, coughs and colds). Some studies demonstrated ill effects of poor housing for children.

Household Crowding and Family Violence

97

The Case of Bangkok, Thailand and Beijing, China

In fact, a stressful life style is seen in many groups of residents in Bangkok as the

city is moving to modernization and materialism. Invasion of modern development and


industrialization have resulted in a consequence of worry and increased risk of illness.
Although a majority of city people may have better incomes and living conditions, several

groups of the city residents, especially the poor and slum dwellers, have been faced with several difficulties in life, a breakdown of the traditional family and the decline in moral
and ethicaljudgments.

Employing

measure

of stress, family violence is

introduced

as

one

consequence of crowding and poor housing conditions. We are proposing the theoretical

framework of the relationship between crowding and stress, well-being and family
instability. The main hypothesis is that poor housing and high levels

of

household

crowding are detrimental to physical and psychological health including illness and stress. Since we are interested in family instability, violence is used to indicate the
stability of family.

As mentioned above, crowding may be defined as a state of psychological stress

that sometimes accompanies high population density. Individuals may feel crowded
more intensely than others, even given the same level of crowding. lt is anticipated that

those with higher levels of crowding are likely to risk stressful life-styles. And this in turn
leads to conflicts and quarrels with the spouse, i.e., marital instability and family violence.

We hypothesized that psychological distress is a function of household crowding and


has a detrimental impact on family instability. The quality of housing and the extent of household crowding both have objective and subjective aspects. The experience of

crowding results when one is unable to achieve desired levels of well-being. That is'

98

Socio-Cultural Perspectives in Health

when one is exposed to more contact with other people than one desires, stress
becomes easily apparent and leads to risk of marital instability.

Following the global initiative of Health for All, the concept of family support has

become an utmost need for improving the health of people. Authorities in health are advised to adopt the strategies of family support in health care services. At the same

time, and surprisingly, family systems in many societies are threatened by series of
invasions, i.e., modernization, industrialization, free market economy and lately, satellite

technologies. The impact of these invasions has generated a new mode of life in the
society, terminating in changes in traditional values and family relations. This also creates stressful behavior and the decline of family support. Young children of a farmer would not hesitate to leave the family seeking work in the cities to fulfill their materialistic desires.
Many youngsters from the urban environment are lured to alcohol and drug addiction.

The shift from a traditional way of life to materialistic and modern mode of living has a profound impact on family life. Both the function of the family and the roles of the family members are transformed. ln a market economy, the capacity of the family to care

for itself as a unit is under threat, and this void contributes to the children's instability
(Taneeya Runcharoen, 1997). Especially, women are affected by these changes as they must balance the demands of household tasks with a need to acquire the achievements

of the career ladder. Women are given more opportunities to work outside the home.
High numbers of rural women have migrated to get employment in urban areas. Under
this condition women often face difficulties in dealing with different roles in conflict which ultimately lead to stress or other mental well-being problems. As a result, it stimulates the

high prevalence of marital instability, including conflicts, quarrels, violence, divorce and suicide. The most recent case in point comes from a study in China. Michael Phillips, a
psychiatrist at Beijing Hui Long Guan Hospital, is leading a team of researchers and has revealed the outcomes of the study. A 29-year old Chinese woman who lived in a village

Household Crowding and Family Violence

99

with her husband and young son committed suicide. lt was found that there is a common occurrence of conflict and argument in Chinese families. A story was then revealed, the young woman returned home after work, washed some dishes, cooked a meal for her son and then drank a pint of insecticide. She died after being rushed to a hospital. Dr.
Phillips commented that China is the only country in the world where more young women commit suicide than men. The rate is 40 percent higher and it accounts for 55.8 percent

of female suicides. In China, suicides are estimated to be 30 per 100,000

people

compared with an average rate of 10.7 per 100,000 in the rest of the world. The suicide
rate among women in China is 33.5 per 100,000 versus 7.1 per 100,000 in the rest of the world.

Many people believe that suicide is evidence for mental illness. But the case in China is related to the family and friends. Phillips said a significant proportion of the

cases show little evidence of psychiatric disorders. I then concluded that the female
suicides in China appear to be the spontaneous response to family and domestic conflict (Ford Foundation Report, 1999). In India, the National Crime Record Book 1990 shows

that the cause of suicide is also related to social and institutional factors including unemployment, domestic violence, social

and political protest and

sense of

meaninglessness in life (cited from Arenth, 1999). lt should be noted here that Durkheim

(1951)was the first sociologist documenting the causes of suicide in 3 types of social
effects and integration. First, egoistic suicide is a result from a failure to integrate into society. Secondly, altruistic suicide is due to hyper-integration that leaves people without

the capacity to resist burdensome demands of society and the third type is called
"Anomic surcide". Anomy is a situation where a person falls in between social change and moral instability, and commits suicide due to changes in society that lead to moral instability resulting in the loss of family norms. In India as mentioned above, family
tensions contribute to social dynamics that lead to suicide. Quarrels with a spouse or inlaws account for 13.2 percent of the suicides in the 1990 statistics of the Indian Ministry

100

Socio-Cultural Perspectives in Health

of Home Affairs. Professor Banaje, who studied in West Bengal and Uttar Pradesh also

found that quarrels with

a spouse and in-laws, 45.7 percent and 38.3 percent,

respectively, were the main factors for female suicide (cited from Arenth, 1999).

As available statistics revealed, the divorce rate is increasing year by

year.

Family violence becomes prevalent and the broken family is often put in front headlines

of local newspapers. As revealed, conflicts, quarrels and violence within a family

is

predominantly on the rise. lf this trend continues, ways and means to achieve better
health for all of the people through family support is questionabte.

The following excerpts clearly exemplify the level of deteriorating family relations

in Bangkok, Thailand.

One wife says " I want a divorce. I want him to go".

"l am not interested in seeing his face".


"l was folding my clothes when he started to scold me. I scolded him back. So.
he walked over and kicked me in the mouth",

"My husband and I do not hit very often, but when we do we must see blood". A wife from cambodia reported that in a month there are 30 days but my husband hit me 60 times.

The signs of family change and stressful life are seen in many developing
societies of Asia, particularly perpetuated in the capital cities. Bangkok is also no exception, ascending rapidly

in its economic wealth, but

unfortunately; faced with

explosive social problems. An increase in the number of slums and squatter areas in Bangkok is accompanied by

a rapid increase in crowding in the city. A decline

in

traditional family systems creates a more stressful life for city residents. The family has obviously become smaller, and the family ties weakening or break. Violence within a

Household Crowding and Family Violence

101

family is predominantly on the rise. lf this trend continues, better health through family

support or community involvement

is

unlikely. With the scarce

of family

violence

information, the figures in table 6.1 represent a useful understanding about the trend of

social violence and stressful life. A report on trauma registry from KhonKaen provincial hospital, Thailand indicates that there were 1287 cases

of intentional self-harm

and

assault in 1998. The incidence of these injuries were predominantly among the poor, including laborers and farm workers. Place of the incidence was largely urban settings.
Interestingly, this kind of violence appeared to prevail among housewives (tabte 6.1). lt is

then concluded that violence to women needs be recognized as


problems (Arrows for Change, 1998).

a public health

Suggested Readings

'1

Arenth, Jutta. 1999 "Suicide and Social Determinants," a paper submitted in fulfillment

of the Graduate Course on Socio-Cultural Perspectives in Primary Health Care, ASEAN Institute for Health Development and Graduate School, Mahidol Unii4esity.

2. Asian-Pacific Resource & Research Centre for Women (ARROW). 1998 "Addressing
Rape: The Urgency for Action," ARROWS for Change: Women's and Gender Perspectives in Health Policies and Programmes. Vol. 4. No. 2 (September).

3. Baruffati, Veronica "Street Life in Alagados, Salvador da Bahia, 1997 " Speaking about
Rights: Canadian Human Righfs Foundation Newsletter. Vol.Xll No.2/'1997:5, 10.

4.

Edwards, J., T. Fuller, S. Vorakitphokatorn and S. Sermsri. 1994. Crowding and lts

Consequences. Boulder, Colorado: The Westview Press.

5.

Leman, Maria-Claire. 1997. "Casa Alianza Takes on the Legacy War: The Street

Children of Guatemala," Speaking about Rrghfs; Canadian Human Righfs Foundation


Newsletter, Vol. Xll, No. 2/1997:6.

6.

National Statistical Office. 1994. The 1994 Demographic Suruey of Population in

Congested Community of Bangkok Metropolis. Bangkok: Office of the Prime Minister.

102

Socio-Cultural Perspectives in Health

7. Sermsri,

Santhat. 1996 "Family Changes against Global Health and Welfare

Strategies in Southeast Asia Countries." Paper presented at the Third Conference

of

Heafth Behavioralscience; Cnsis Behaviortowards Grovvth and Solidarity. Sophia


U

niversity, Tokyo, September

27

-29.

8.

Sriwiwat, S.;W.Chadbunchachai; S. Homjoo; S. Kulleab;and P. Teekayauphun. 1999.

Trauma Registry 1998 KhonKaen HospitaL KhonKaen Province: Integrated Regional Trauma Service KhonKaen.

9. Taneeya

Runcharoen. 1997 "Working Children of Asia," Speaking about Rights:

Canadian Human Righfs Foundation Newsletter, Vol.Xll, No. 2/1997:12.

****************

Table 6.1 Number and Percentage of Intentional Self-Harm and Assault, classified by Occupations and Male-Female, KhonKaen Province, 1998

Occupation Number Housewoves/House-work Officials


Self-e mployed/Merchant

Male

Female Percent 4.3 2.3 4.2


16.3 17.7 51.1
4.1

Number

Percent
16.8
1.4

Students

Farm workers Laborers Others Total

40 21 39 152 165 476 38 931

100.0

60 5 42 63 37 124 25 356

11.8 17.7 10.4

34.8 7.0 100.0

Source: Sriwiwat, S., et.al. 1999 Trauma Registry 1998 KhonKaen Hospital.

Development and Health

103

Chapter 7 Development and Health

Santhat Sermsri

As presented in the preceding chapters, the relationship between development

and health has been recognized and the direction of the relation has widely been examined

in

many socio-cultural settings

to better understand the benefits of

development on health improvements and vice versa. In this chapter, the relationships between development and health will now be summarized in two perspectives, i.e., the
improvements of health through the changes in a society and the improvement of health status via the development of individual characteristics. Since the eadier chapters have

discussed the influences of social changes on mortality and morbidity, this chapter will conclude the determinants of social factors on health. When people are upgraded by the
improvement of their well-being, it is then postulated

that people should be better off in

accessing health care and taking an active role having a better awareness of health
concerns.

Relationships Between Development and Health

Development is defined as a systematic improvement of

a person in aspects of

living conditions. There is now more recognition of the fact that development cannot be

measured in economic terms but it should give its due to social progress. That is, the
ultimate goal of the development process is to improve the quality of life. However, the

development in Thailand in the early years of modernization era was confined to modern economic goals and that was the mistaken outcome of Thai development approaches, particularly to those living in rural areas. Development should be taken with caution due to the negative impact of development in later years. When rural people were asked to change their farming system, i.e., a change in subsistent economy to market and cash

104

Socio-Cultural Perspectives in Health

production, the consequences

of

development were then related

to

stress and a

strained life. Farmers were then losing their lands and heavily in debted. Many daughters

of farmers were accidentally caught up with HIV/STD and AIDS. The

relationships

between development and the quality of life should then be examined very cautiously.

Health on the other hand, is regarded as a determinant of development. With

respect to a causal relation, health is believed to lead development. That is, 1) the

beneficial consequences

of

epidemic eradication, e.g., malaria, tryponosmiosis,

scshistosomiasis and yellow fever, on agricultural and economic development were

documented, 2) the number of working days of the labor force forfeited to disease would

be reduced. lt was also shown that lowering malaria and yaws prevalence

has

decreased absenteeism substantially, and 3) a healthy person is likely to have a better working performance than a sick person. Development is also influencing health and the causal relation for improving life quality is elaborated below.

The definition of health, according to WHO, is a state of complete physical,


mental and social well-being, and not merely the absence of disease or infirmity. Health
is therefore the outcomes of a continuing and reciprocal interaction between the evolving

biological substance of human beings and social environments, including behavior, individuals, society and social institutions. Health

is therefore a

component of

development. lt is a dynamic of the relationships between health institutions and society, Health is often used to express the condition of development, referring to the situation of

the whole social system which combines the improvement of physiological (health) aspects, social and environmental factors. Health
improvement is also a social development process.

is a

development aim. Health

Development and Health

105

Concepts of Social Influences

Principle knowledge of sociology is relative to life chance. The person's status in

a society will develop some kind of structure into which a person is placed and is often determined by his/her characteristics and achievements. One's status has therefore advantages, privileges, rights and power that are not given to those of lower status.
These advantages will lead to greater life chance and greater chance to live. Since the

basis and significance of all human behavior is social interaction, people need people. This is the fact of human experience. Human beings are social beings. What we love,
fear, hate and hope are experienced and shaped because of our involvement with others

(Hobbs and Blank, 1982). Society is made up of people who influence one another.
Individuals make choices and decisions. But the kinds of choices and decisions they
make are limited by their experience and involvement in society.

In our society, because of the influence of modernization and materialism, the


means of subsistence refers

to money. With a free-market economy, money is

the

powerful medium for which all goods are exchanged. Money can buy everything that a

person needs as well as many other things he does not need. As materials and
production are unequally distributed, the poor, therefore, own less, produce less and

subsist on

precarious level.

privilege of life can be then described as social

procession. This life chance includes economic power and importantly

relationship

to the sources of social

and the

a participation in making decisions that affect

community, an ability to realize one's own decisions and plans and the possession of
knowledge. These all include access to pleasurable things and to the services of others.

As economic measures are being used as an indicator of development, poverty

is the crucial element for high mortality as it operates via factors such as poor diet,
inadequate medical assistance, low education, apathy and poor housing conditions,

106

Socio-Cultural Perspectives in Health

including the lack of elementary sanitation facilities. As stated in Chapter 1, the study of

social class differentials in mortality has traditionally relied on taking either occupation

and income as well as education as indicators of social class. With a new mode of
modernization, class differentials substantially widened because it was the upper classes

who could most readily draw upon the possibilities provided

by

medical and

technological progress. Social development, therefore, implies the creation

of

the

conditions necessary for an effective treatment of ill health. With industrialization, many of

the traditional health hazards tend to recede or to cede their place to new hazards
accompanying the transformation of the economy. The cross-tabulation of the male
expectation of life at birth with per capita gross national products was for example found

to be informative. Both variables are used to connote a complex web of factors, namely,
health and development.

Proxy of Social Progress

As suggested above, the development should not be confined only to economic

measures but should provide the best possible satisfaction

of human needs and

aspirations. Hence, development is supposed to give its benefit to the social progress of human and education is one possible means to enable persons to reach a better level in
life.

Studies on the social aspects and health in chapter

'1

have shown that a person's

position in the social class will have an effect on his/her length of life. ln other words, people in the lower statuses of the social structure of a society are likely to die younger
than those in the higher statuses. As discussed in the beginning of this book, individual

characteristics, therefore, refer to the relative standing of a person in terms of factors like education and occupation. These individual attributes have also affected their thinking and behavior. For example, the high literacy of persons creates political consciousness

Development and Health

107

among the Keralites of lndia and was then responsible for the equity of public services,

especially education and health services. Although the maldistribution


resources

of

public

in Kerala has not been

eliminated, the imbalance

of health resources

fortunately was reduced due to a widespread understanding of individual rights and


health care serviees. Another good example of public awareness, which has helped to

reduce the prevalence of smoking in Thailand through a "Non-smoking campaign" is

being led by a group of rural doctors and a leading medical specialist acting as a
crusader to fight against the bad habits of a society. Also, an awareness of the social
movement

for "Democratic government" emerged during political unrest in May

1980.

Framework of Education Influences

The discussion now turns specifically to an important aspect of social progress, i.e., education, particularly relating to a mother's education on child care (Jain, 199a). In

trying to identify the mechanisms through which

mother's education affects child

mortality, the care variable is first divided into preventive and curative care. Preventive

care can be further subdivided into medical and non-medical elements.

time

dimension can be added to both the preventive and curative care in order to relate it to

the age-dependent outcome variables such as neonatal, post-neonatal, infant, or


childhood mortality. For example, preventive care during the antenatal period and during the delivery of the child would influence the level of neonatal mortality. The influence of
these factors will diminish in progression from neonatal to post-neonatal mortality and to mortality beyond infancY.

From the above, it is hypothesized that the mother's education influences the degree of preventive care which in turn determines the extent and severity of sickness suffered by a child. A mother's education in conjunction with the severity of an illness episode determines the need and use of curative medical care which in turn determines

108

Socio-Cultural Perspectives in Health

the outcome of a particular episode of sickness. The availability of medical services can
modify the relationship between a mother's education and the care received by a child. lt

is, therefore, hypothesized that since all mothers can be assumed to be equally
interested in saving the life of their children, they, irrespective of their education, will seek

curative care within their means and depending upon the severity of illness. For this
reason, the association between a mother's education and curative care is likely to be weak. On the other hand, educated mothers are more likely to use preventive care than

mothers with little or no education, because education may lead them to modify their
behavior to reduce risks.

Kanfmann and Cleland (1994) revealed the outcomes of their studies on this
issue (mother's education and child care) that the risk of mortality of the under-five-year-

old children decreased by 2-5 per cent with each year of maternal schooling. Caldwell
(1974) also observed that education increased the likelihood of independent decisionmaking. The reasons are based on the premise that women who are educated and gain

esteem and self-worth, are likely to be better service-users than less-educated women.

Being educated often enhances the ability of women to express themselves and
communicate effectively with health care providers. Also, higher educated mothers are
likely to receive better treatment by health care providers. In sum, education makes more

confidence, more ability to confront resistance and more articulation when seeking an

answer. The complexity

of health care services can be daunting and require

combination of expertise and confidence to cope with bureaucracy. Education is a social "empowering" process involved in instructing, acquiring and transforming knowledge. lt is a process of individual social identity being transformed.

During 30 years

of

reproductive evolution

in Thailand, research evidence


extensive

indicated that fertility decline is not only due to the accessibility of contraceptive methods

but also the improvement of education, especially for women. There is

Develooment and Health

109

evidence showing that fertility and education are inversely related. Women with higher

educational attainments tend

to get

married

at later ages, and

thereby reduce

childbearing span (Knodel et.al., 1982). Furthermore, married women with high
educatronal levels often decided to delay the experience of motherhood since they did not desire to trade off their career success for that of rearing a child. Using the concept

of the intermediate variables of fertility behavior discussed in chapter 2, a

multiple

regression of household crowding data showed that among biological and social factors,

educational attainment for married women played a significant impact on reducing the
number of children (Sermsri, et.al., '1989).

Morbidity and mortality patterns among Thais are generally associated with
education. More illness and hospitalization predominantly prevails among low and less educated families. A study on mortality and morbidity differentials in Thailand revealed that education still plays an important role in determining the differences in illness and
deaths (lPSR, 1985). lt should be noted here that education attainment is generally based

on the completion of the formal schooling system. Non-formal education, including


occupational training, religious practices and the exposure to educational media, as well as community involvement in public works, were incorporated. From this, the influences

of formal education should not be considered in isolation from non-formal trainings,


workshops and skill practices.

Social Standing in FamilY SYstem

The status of women is also important.. In the case of the rapid increase in birth rate, women in Thailand who have high social status, tend to know how to manage the number of children desired. A desire for greater participation in educational opportunity and careers, extend to a desire for increasing the betterment of their children and family.

The empowerment of women through education, derived from formal and non-formal

110

Socio-Cultural Perspectives in Health

education systems, is regarded as

a decisive force to make women's life better and

stimulate more involvement of women in decision making, both for the family and communi$ and towards development in general. Education is also positively related to
occupation and income. That is, the development of a better life chance exists for not
only women but also family and nation.

Interestingly, decision making by

the women in the family in particular, is not


the the

solely dependent on education alone. woman in

lt is dependent on the social standing of

a family. As social status is derived by social norms, the power of

daughter-in-law depends, therefore, on the authority of the mother-in-law. The effect of


domination by the mother-in-law has been revealed, affects the choice of better feeding

and health practices of the daughter-in-law related to child health (Myntti, 1992).

Excerpts below exemplify the influences of social standing in a family on health and life quality. lt is empirical evidence gathered from Thai residents in urban places of Bangkok, revealing the uncomfortable feeling of the young son-in-law in living with a

family. "We must consider about things and understand that we cannot do as we please.
I

do not dare bring friends to come to the house to have a drink. Sometimes my wife told

me to go drink outside. I once told my father-in-law that I wanted just one time to drink

with my friends. He did not say yes, he only nodded. I felt somewhat reluctant to pursue
my request. lt is hard to say. lt is his house."

"l do not have that kind of freedom. I cannot even raise my voice when arguing
with my wife. I must consider her father."

"ln the house where I live, when my father-in-law is drunk he will shoot his mouth
off about anything. I dare not mingle and must go away in this case."

Development and Health

111

It is possible that the subject of in-laws brings a special attention to health issues.

The effect of a dominating mother-in-law could impact the daughter-in-law's choice of


feeding and rearing her children. As pointed above, Myntti (1992) examined childbearing

in different social statuses of women in a small village, revealing that the authority of
women in the family and her social relationships with her husband and family is of crucial

importance in determining child nutritional status. From the discussion above,

it

is

concluded that health, education and women must be integrated into the development
process. The development of health can be achieved through other general development activities.

Suggested Readings

1. Cleland, J.G. and J.K. van Ginneken. 1989. "Maternal Education and Child Survival
Developing Countries: The Search for Pathways of Influence," in J.C. Caldwell and G.

in

Santow (Editors). Se/ecfed Readings in the Cultural, Social and Behavioral Determinants of Heatth : Health Transition Series No. 1 . Canbera, Australia: Health Transition Reviw.

2.

Edwards, J.N., T.D. Fuller, S. Vorakitphokatorn and S, Sermsri. 1994. Household

Crowidng and lts Consequences. Boulder: Westview Press.

3, Jain, A. 1994. "Maternal Education and Childcate," Health Transition Review.Vol.4:2.

4.

Knodel, J., A. Chamratrithirong, N. Chayovan and N. Debavalya. 1982. Feftili$ in

Thaitand: Trends, Differentials and Proximate Determinants. Report no. 13 Committee on Population and Demography. Washington D.C: NationalAcademy Press.

5.

Macintyre, Sally.1992 "fhe Effects of Family Position and Status on Health," Socia/

Sciences and Medicine, Volume 35, No.

4' 1992 453-464.

6.

Myntti, Cynthia, 1992. "social Determinants of Child Health in Yemen," paper

presented at the Confe rence of Socialsclence & Medicine, New Delhi, 16-18 March 1992.

112

Socio-Cultural Perspectives in Health

7. Sermsri, S., S. Vorakitphokatorn, T.D.

Fuller and J.N. Edwards. 1989. Social Factors

and Reproductive Behavior," paper presented atthe Annual National Conference of


Thailand Population Assoclation, Bangkok: 9-10 November 1989.

8. Weinstein, M. 1980 "Behavioral and Psychological Factors in Urban Areas,"'Heatth in


the City. New York: Pergamon Press.

****************

Well-Beings in Thai Society

113

:r

Chapter 8 lmplications of Well-Beings from Changes in Thai Society


Santhat Sermsri

A mode of life in Thai society has shown signs of worries, stressful behavior and
vulnerable risks of illness and deaths since the turn of the 21 st century. Invasion of modernization and materialism in the early modern development era in Thailand has resulted in a mixed consequence, a decline of mortality, ethical judgments, violation of
human rights, a wider gap between rich and poor and the exploitation of under-privileged

classes.

A burden in balancing the modern development through the technological

invasions and decent traditional ways of life becomes difficult for the people and families

in rural poor strata, where a majority of the nation population live, An exodus of rural
migrants to urban areas has accelerated chronic malaise of social values and activities, in particular among the poor. Thais are now facing with a stage of uncertainty in life and dislocation of decent social environments.

As Thai society moves on to modernization and industrialization in the early


1g60's brought by an urban authority in the capital city, traditional values and norms of

the people are on the stake. People are told Io change their mode of living. The adoption

of new technology and methods of farming from subsistence to market economy is considered to be of innovative manner. People are urged to learn new modern and
advanced technologies from cities. Peasants then become acquainted with city life in

hope of enriching their agricultural productions. They return taking

modern

methodologies of farming such as use of fertilizer, insecticides and water pumping


machines all which provide to enhance and aid towards achieving a productive outcome.

' Discussion

in this chapter was presented at the Conference on World Mental Health : Problems

and priorities in Low-lncome Countries, organized bythe Rajiv Gandhi Foundation, New Delhi, India'
6-8 April 1995.

114

Socio-Cultural Perspectives in Health

The efforts of such practices enable the children of farmers to further their education

ladder.

lt is indeed a remarkable change. Attitudes and norms among the rural

population are now focusing their directions to marry those who own property equipped

with facilities of modern utilities and being individualistic. A daughter of a farmer for example would continue

to further on for higher education after completing the

compulsory education. A young girl expectations would rise especially after completion
of the secondary education. Expectations could be in the order of deriving more luxurious

living status through owning color TV, big stereo equipment, refrigerator, microwave, washing machine and a

car.

Furthermore the young daughter would not hesitate to

reveal her desire to plan for building the family accordingly, mainly in fulfillment of the

materialistic desire, Such prevailing ideas

of

modern development has spread

contagiously around the villages. As discussed in the previous chapter, most young girls from the lower economic ladder strives to working hard as a maid or waitress in order for

their materialistic dream come true. Often times the girls migrate to cities where she hopes to find

a better paid job in order to serve the wishes of the family

dreams.

However, during the search for more productive income they are unfortunately snared knowingly or unknowingly into the commercial sex business. The ignorance results in a

bitter ending of the dream since she discovers to be infected with HIV/AIDS. The
unboundless ambitious dream has fractured the families dream and shift negatively to

resort the life of the underprivileged people. Such stressful unfortunate confrontations
seem insuperable consequences derived due to the evolution of modern development.

Although the impact of advanced medical technology has beneficial outcomes and effectively serve to save a lot of lives, could also result in a hazardous draw-back

for the lower working classes. Among the various episodes encountered among the
underprivileged poor, a few examples will be highlighted to endow the vision of untoward consequences derived out of advanced medical technology. Organ transplantation may
lure and tempt the poor to sell their organ to those in higher economic strata, while they

Well-Beings in Thai Society

115

remain as disable person in this modern materialistic society. The tube baby technology

which demands a surrogate mother appears to oppose the laws of karma and

is

unacceptable to the Thais. Furthermore, practice of modern medicine often omits and neglects to consider the beneficial effects of traditional values and practices. This often
provokes a feeling of uncertainty and a sense of something being amiss from the web of Thai traditional society. The poor are further eliminated from receiving better health care

derived due to modern technology as the cost of advanced medical treatments are
expensive with skyrocketing costs. Rise in medical budget is well stand that it is due to

the introduction of advanced technologies and high consumption of medicine. lt is often


noticed that private medical care advertises for being equipped with medical equipment

with advanced electronic devices for diagnosis. When patients consult for treatment
unnecessary tests are carried out without the mutual consideration of the patient family.

In other words, the accessibility of medical technologies is solely dependent upon the ability to be affordable to the cost. People who can afford and eliminate the monetary barrier are those who are in better health situations. Technical progress has therefore resulted to depress towards achieving good health care measures among the lower socioeconomic strata thereby creating a rise in mental well-being and ethical judgments
as well as the violation of human right.

A wider gap between rich and poor classes is accelerated on by an era

of

information revolution. Thai society is relatively illiterate, although statistics indicated a large proportion of the Thais completed a compulsory education. The quality of reading and writing is still questionable, as majority of Thais (80 percent) are living in rural farm
areas. A method of national education particularly in upcountry and rural areas, is mainly

based on the teachers skill with "black board and white chalk". Schools in upcountry are
hardly equipped with the basic technology of electronic computers. A price of a personal

computer is higher than the national average income for

a person. The information

revolution is then only rewarding the urban high economic classes. Strain and stress as a

116

Socio-Cultural Perspectives in Health

result of education inequality are prevailing among students and families especially when

faced with competition national examination for college education which is annual event
is well understood to produce a lot of stress for a majority of students since only a small

number of applications, i.e., about three in ten are accepted. Moreover, the chances of

recruitment are mainly from the urban family with

background where electronic

information system is easily accessible and acquainted. The information revolution has

been available only in the urban setting and penalized the rural and underprivileged
economic classes. This has resulted towards creation of resentment among the rural and urban poor, who have been conveniently ignored and stripped of the right to gain acess
to electronic information on oar with the urban rich.

The signs of rapid social change and stressful life style are actually seen

in

Bangkok, a socalled primate city. Bangkok has a rapid increase in its population and faced with explosive social problems. The size of Bangkok population was 1.8 million in
1960 and then 4.7 million by 1980. In 1997 the Bangkok population is estimated to be

around 8-10 million. With the present rapid growth, Bangkok population should double every 15-20 years. Bangkok's primacy is illustrated by the fact that its population size is
more than 50 times as larger as Thailand's second largest city (Sternstein, 1984). Over

60 percent of Thais who live in urban areas of the whole nation, resides in the Bangkok
capital city.

Bangkok dominates the entire economic fabric of the country and obviously dominates in all every sphere of Thai culture and life style, including political, religious, educational, health and daily ways of livings. The dominance locus of Bangkok is quite

strong as governments have frequently encouraged

a concentration of population

through economic pricing. Living consumption, including public bus fare, oil price, food

price and several social basic educational and health infrastructure are subsidized for
Bangkok consumers, while rural people who are economically poorer and heavily taxed.

Well-Beings in Thai Society

117

Although economic success of Thailand is well recognized, the concentration of the

prosperity

is confined to only a capital city. There is still a wide gap

between

development of the city and in up-countries. This superior modernization of the capital city is then accompanied by a rapid increase of slums. This pull force, together with rural
constraint discussed above, motivates an exodus of rural poor migrants and makes out

the rural exodus migration less selective in terms of skill, education and economic
standings. In addition, land price in the city has been extremely high and the occupancy

of housing is more difficult and impossible for the poor migrants as well as the poor for
the city born. As a result, rural migrants and urban poor are now falling into slums and poor housing conditions. In '1994, a recent projection of the number of slums in Bangkok
is about 1,200. This is quite rapid and high as the number in 1980 was only 448 slums in

the city. ln other words, one in four of Bangkok residents is living in slum areas.

Bangkok has long been experiencing housing problems and now faced with a significant pressing problem with crowding, marital instability, violence in a family, poor physical health and rising of stressful life and well-being. Housing analysts of a major leading local newspaper in Bangkok "Thai Rath" put a headline "The prospect for the occupancy of a house in the city is 99.9 percent impossible." Due to the skyrocketing of land price and a rise of construction commodities, Bangkokians who want to buy their own house, have to spend 80 percent of monthly income for the housing expenses. For the urban poor the only alternative to have their own niche, is poor housing conditions in
slums or 12 square meters in a public flat. Thailand's capital city is now identified as one

of the crowded cities in the world. Bangkok's level of crowding is comparable to that of Hong Kong. The population density of Hong Kong is 13,097 persons per square mile (in
1980), compared to 9,280 in Bangkok

in 1987. Despite high levels of crowding,

Thais

also express a sense of crowding in their living residence. Edwards and his colleagues

(1994) have revealed that the experience of household crowding is a chronic stressor,

and that has a strong detrimental effect on psychological well-being. Thais who feel

118

Socio-Cultural Perspectives in Health

of crowded are more likely to report marital instability, more family arguments, the feeling

greater tension between the parent child relationship, and need

to discipline their

children more often. A focus group interview is helpful in elaborating these stressful life style. lt reflects the cultural relevance of Thai experience. In talking about the relationship
"l between wife and husband, the following examples are exemplified. One wife indicated

was folding my clothes when he started to scold me. I scolded him back, so he walked over and kicked my mouth," Another wife stated, "l tell you with no shame that we hit
each other often," A third wife responded, "My husband and I do not hit every often, but

when we do, we must see blood," Furthermore, husbands were not hesitant to mention
that violence had occurred in the family. When asked what actions they would take if they had problems with their wives, one male focus group member stated, "l might hit her".

As presented, people living in the city today have suffered a great deal from
stressful events. Mental well-being of residents in the city is also observed to be high. particularly, poor residents are exposing themselves to more pathogenic agents and stressful life style. Urban malaria is still a serious problem and dengue haemorrhagic
fever has significantly occurred in the poor urban slums. Tuberculosis is also easily found

in slums. This relationship between disease incidence and poor housing has been
revealed in many countries. In Manila, Philippines, the amount of severe malnutrition and infant deaths was three times higher in the slums than in the rest of the city (Harphan, et.al., 1g88). ln slums of Bombay, lndia, the prevalence rate for leprosy was about 22 per

1,000, compared to a city average of 6.9 per 1,000. Incidence of hookworm among Singapore squatters was 74 percent higher than among the residents in flats. ln the West, rates for both communicable disease and accidents were as much as one-third
higher in slum than in well-designed housings.

It is then concluded that the invasion of modernization, materialism and freee


market economy system has been painful for Thais particularly those in underprivileged

Well-Beings in Thai Society

119

classes of upcountry and the poor in the city. A rise in many Mega department-stores in

the cities in the country is clearly an example of the consumerist society. People find
these departmentstores as a concert park and church of the city residents. A whole family of the city creates its own niche in the mega-shopping malls. A free competition
has allowed a new group of entrepreneurs to exploit peripheral groups of consumers and

created more desire and greed to people. Prices of goods and services are extraordinary high and go unchecked by authorities concerned. A commercial advertisement become a major tool to destroy people social values, leading to the collapse of honest, sincere and a sense of social belonging. Both men and women, adults and children, all
this sort of social malaise is the sign of social and psychological illnesses, vulnerable to a

decay of human values and dignity. This is more happening in the capital city where the
urbanization and development divorced from the experience in developed countries. The extremely rapid groMh of Bangkok is then seen as a parasitic factor to creating stressful

life style. This is a result of the unplanned introduction of modernization, technological advancements and information era. Thailand has become a modern society for more than 100 years. At the beginning the pace seemed to be helpful to bring people off from
hard living conditions by the adoption of newly introduced methods of farming. Education

was also open, and more opportunities to many children of farmers were derived. World
views were enhanced. Unfortunately, the recent development and the growth of the city

showed sign of uncertainty, and destroy the dignity, social values and tradition of the people today. Stress and strain are part of daily life, leading to a social malaise in the
Thai society.

Suggested Readings

1. Edwards, J.N., T.D. Fuller,

S. Vorakitphokatorn and S. Sermsri.

1994 Household

Crowding and its Consequences. Boulder: Westview Press.

Socio-Cultural Perspecdves In Heallh

2. Harpham,

T., T. Lusty and P. Vaughan. 1988

ln the Shadow of the Cify. Oxford : the

Oxford University Press,

3. Sermsri, S. 1995 "Health

of the Urlcan Poor in Bangkok," in P' Cohen and J. Purcal

(editors). Heatth and Devetopment in SoutheastAsia. Canbena : Australian Development


Studies Network.

4. Stemstein,

L. 1984 "The Growth of the Population of the World's Preeminent Primate

City," Joumal of SouffreastAsian Studies. Vol. 15.

5. United Nations. 1991World


Nations.

Urbanlzatbn Prospects 1990. NewYork: the United

Health Social Science: A State of the Art

12'l

Chapter

9 Health Social Science:

The State of the Art

Santhat Sermsri

Health Social Science is a term meaning the contributions of social science toward the improvement of human health. This scientific discipline is based on a strong belief that social methodologies and concepts are of value to contribute to the better understanding of
individual and community health. The twenty-year old discipline has been flourishing in many

schools of health and medicine, particularly in developing countries. The discipline evolved out of an interest from health and medical scientists who were considering the incidence of illness and deaths of the human population as

a result of the

consequences of social

malaise. Infant and child mortality, as a prominent pediatrician described, is not a health
problem. They are social problems resulting in health consequences. An epidemic of deadly

diseases, like AIDS,

is another example of the consequences of

modernization,

individualistic pursuits, inequality, deprivation and balance of power between men and
women.

Historical Review of Health Social Science

Health Social Science, as stated above, refers to the involvement of social science in the study of the health care system, The term was established on the assumption that social

science perspectives, including concepts and methodologies when they are well related to

'

Discussion in this chapter was presented at the plenary session one of the Fourth Asia-Pacific Social

Science and Medicine Conference (APSSAM): Health Social Science Action and Partnership: Retrospective and Prospective Discourse, Yogyakarta, Indonesia, 7-l I December 1998.

122

Socio-Cultural Persoectives in Health

health care, could make health care services, for example, more relevant to the people they serve. At an individual level, health status can not be understood without examining issues of

social and cultural aspects of the people. lt holds that social scientists are in a position to provide significant contributions to the development of health care systems (Higginbotham,
1992). This new scientific term has been used in academic arenas with a belief that health is

not an isolated element of the biological organism. Health is considered to be a social


process which includes socio-psycho, cultural, economic and political contexts of individual, family and community relating to well-being. Professor Prabha Ramalingaswami (1990) also

commented that medicine was once viewed as a social science. And medicine would be
meaningful when it is for the majority. With an experience in working in developing countries, Rosenfield (1982) viewed that the development of appropriate control strategies for tropical diseases in the developing areas should be based on the integration of social, economic and

epidemiological information.

lt is simply said that to better understand

individual and

community health requires a sufficient input from social science methods and concepts as
health and medicine aim to reach people and communities. Since the1970s the perspectives

in social science for health have been steadily increasing in many developing countries in the Asia and the Pacific region where the demand of health care is high, health resources
are low and a greater understanding of people and community is urgently needed. lt should

be noted here that the first graduate training program in health social science

was

established in 1976 at Mahidol University, which has two outstanding medical schools in
Thailand (Sermsri, 1991
).

As mentioned earlier. the health social sciences first evolved out of the interest from
health and medical scientists who were working on health issues in the third world countries

around 1960. The high incidence of illness and death among the poor majority was critical and health care for the poor was inadequate, resulting from the consequences of the social

Health Social Science: A State of the Art

123

and conditions and mismanagement of the health care system. The occurrence of epidemics

to be infections in the early days of modernization in developing countries was considered


associated with

a lack of health skills among the population and a lack of community mindfulness among health care providers. High infant mortality was identified by a
(Wray, pediatrician who was working with a university hospital in Bangkok around the 1970s

patients and 1g78), as social problems, resulting from the low socio-economic standing of
the lack of understanding of the cultural context of the population. Accessibility to health care

was also problematic due to overlooking patient limitations and because of the emphasis on curative rather than preventive care among health authorities. Dreadful diseases like AIDS

and tropical diseases, are now recognized to be the consequence of the imposition of
modernization, inequality, deprivation and the imbalance in power between men and women

and between poor and rich. Non-communicable diseases now prevail in modern societies,
i.e., cancer, heart disease, accidents and mental illness which are now the leading causes of

deaths and illness and are recognized as having an etiologically relationship to social
behavior factors.

Efforts in the field of health social science to understand health and medicine have and been shaped by three types of collaboration; namely multi-disciplinary, inter-disciplinary of trans-disciplinary approaches (Albrecht, Freeman and Higginbotham, 1995). These types

insure the collaborations hold that the multi-disciplinary work is a crucial component to work of outcomes of the researches are utilized effectively. As Good (1992) described the
be two internationat health scholars, G. Plato and P. Rosenfield, collaborative efforts can

also involve developed which not only integrate health and social science perspectives but
has long disciplines that cross departmental boundaries, The product of these collaborations

has not yet been considered in Asia and Pacific countries, but the active collaboration
documented developed. studies in health social science in India, for example, have been

124

Socio-Cultural Perspectives in Health

since 1950 but there is no currently existing integrated program of health and social science (Ramlingaswami, 1990). In contrast, Rosenfield (1992) referred

to the first

non-medical

practitioner, William Petty, who analyzed the interaction of health and social conditions in
1600. And many schools of health and medical science have adopted social science into

their health activities. A world-wide compendium of health social science activities can be

overviewed by the list

of

international programmes and agencies

in table 9.1. These

organizations include, for example, the Applied Diarrhea Disease Research Project (ADDR),

the Carnegie Health and Human Behavior Programme, the Field Epidemiology Training
Program, the Ford Foundation Health and Population Program, the International Health policy Program, the International Development Research Centre Health Science, the International

Clinical Epidemiological Network (INCLEN), the John Hopkins Health Science Schoot, the Takami Fellowship Program, the Taft University of Health Science and the World Health Organization Tropical Disease Research in Social and Economic Research Programme
(rFSSH, 1994),

The contribution of social science methods and concepts have been widely applied

in many health research projects in the countries of the region since the establishment of
global and International programs and organizations in health, e.g., the International Forum
for Social Sciences in Health (IFSSH); Social Science & Medicine; and the Council on Health Research for Development (COHRED). Explicitly, in August 1991, with clear support from the Carnegie Corporation, the Ford Foundation, the International Development Research Centre (IDRC) and the Rockefeller Foundation, a planning meeting was convened in New York. The

founding group of social science members established guidelines for the "Forum" functions and its organizational structure. A shared image of the Forum as a global collegium emerged

with the goal of building a scientific community to create an identity. A milestone of the
Forum happened in Bali, Indonesia, January 1992, when that the birth of the Forum was

Health Social Science: A State of the Art

125

officially announced (IFSSH, 1994). That is, a team approach between health and social scientists has become imperative for health research and policy application for health care
systems as many international organizations in both the health and social sciences also gear

their work towards the support of the application of social science in health fields. Biomedical researchers have adjusted their roles to be of team members. Social scientists are

urged to perform

leading role in health care research. Many international research

institutes and funding agencies also play an important role in supporting this development and advocate support for health social science partnerships in health care decisions (lFSSH,
1994; Higginbotham, 1994; Good, 1994; Rosenfield, 1992).

Since the establishment of the global IFSSH, initiatives in networking among local health and social scientists in several countries in the Asia-Pacific region have emerged, allowing the development of many movements of professional associations of health social

science in Australia, The Philippines, China, Indonesia and Thailand (APNET, 1996). This
development is occurring at a crucial time when the collaboration is moving from a multi-

disciplinary to a trans-disciplinary work (Rosenfield, 1992; Higginbotham, 1994). Health issues are then analyzed through

a common conceptual framework shared by

several

disciplines in a research team. Researches in health social science conducted under the auspices of international funding agencies have resulted in an input for policy formulation in

health care programs, for example, networking among health social scientists, health
workers and community people.

Current Challenge to Develop Health Social Science and the Progress of Teaching Efforts in the Field of Health Social Science

126

Socio-Cultural Pefspectives in Health

The activities of health social science research have mainly focused on the inclusion

of social science disciplines in health and ignored the specific requirements of what the
subject of social science essentially prioritized for the particular improvement of health. This collaboration

of the inter-disciplinary work allows a type of patchiness between

social

sciences and health, meaning a misperception of the application of social science discipline

to health activities, A course of social science for medical students in Thailand was, for
example, arranged in a way that each individual subject of social sciences was taught in
sequence separately and independently. There was little effort to integrate the social science

subjects for the purpose of medical needs.

A problem in combining the social science

subjects involved is related to an imbalance of the demand from each subject and time
constraints of a course provided. A coordinator is more likely to face with difficulty in finding

a point where the threshold of the subject requirement is in consensus. An inter-disciplinary teaching course, on the other hand, is also involved around an introduction of each social

science subject in the component. The subject was then found to be overlapping and
redundant. On several occasions, social scientists were accidentally embarrassed by the attendance of a few medical students in a class of 100 persons, The subject was also considered to be a low priority and there was a lack of enthusiasm among the medical students. lt appeared that the social science subject for health and medical students were arranged without considering what social science issues would be essential for the target
students who would be working in the community and outside the hospitals. Particularly, with

a clientele of the grass-roots people, medical and health personnel are hardly involved with the poor and the farming majority. lt was concluded that social scientists had been invited to

teach as part of the development requirement of relevant medical curriculum instead of


preparing students to work with the community,

Health Social Science: A State of the Art

127

Health research also includes a social science component due to the requirements

of international funding agencies. Social science research is believed to be an

integral

domain of health development as health activities have to reach communities and people.
The subject of health social science is also considered to support decision-making bodies of

health authorities. As mentioned earlier, research in health social science tends to take place

within

a traditional

system, meaning each social science discipline had developed

separately. Hence, each social science subject adopts a different base of assumptions, concepts and methodologies. Each profession has its own "truth" to pursue and there is
pressure to retain a singular perspective within the discipline. Despite this drawback, a more

career minded perspective may allow health social scientists to be professionally rewarded
for their experience in specialized fields in specific aspects of health social sciences.

By the end of the 20'n century, the collaboration of health social science was
transformed into

a team approach not identified as either

inter-disciplinary

or

trans-

disciplinary. lt is a team that consists of various disciplines and does not necessarily include

a single social science subject. The team is formed in a manner that is convenient and
dependent upon resources available under the health umbrella. And, the collaboration is

actually managed by health and bio-medical staff.

research group, led by

health

scientist, incorporated a health system approach in order to study hospital relevance to the
patients. The team members were drawn from a number of different units in one hospital and

from disciplines covering a broad range of health system research perspectives, without
explicit links to the health social science institutes (Supachutikul, 1998).

A second type of collaborative team working on the development of methods of participatory action research conducted field activities in building a "civil society" in a
provincial town outside of Bangkok (Phuengsamlee, et.el., 1998). The collaboration consisted

128

Socio-Cultural Perspectives in Health

of environmentalists, educators and community workers who utilized some social science
methods, i.e., small group discussions and participant observation techniques that were embedded in a process of mobilizing community participation. However, the social method

was classified as being drawn from

new methodology. Members

of the team

acknowledged having gained knowledge by working with team members and people in the
community, as well as having learned what they termed a new research paradigm. The team

was unaware that the so-called new methods were actually traditional social science
techniques. This occurrence in the research team is inherited by increasing numbers of

grouplr each with their own interests. lt was speculated that this change arose due to the
misperception of social science contributions among bio-medical researchers and health
authorities. And, the movement of health social science in the above situation has also been

launched outside the umbrella of the health and medical professions which isolates the
partnership of health social science.

Enhancement of the Development of Health Social Science

A lack of integration between social science and health has led to the use of the term

"team" replacing the term "inter-disciplinary". This occurrence can be explained by the
recent developments in the professions of social science, particularly anthropology and sociology and a so-called convergence of social science in the late 20'n century. Sociology

has borrowed research techniques from anthropological methods and demographic


techniques. Economic analyses are now using the techniques of focus group interviews. Anthropologists have been using statistical testing methods. Sociology and anthropology are
almost identical in their theoretical components of social and behavioral perspectives.

Health Social Science: A State of the Art

129

The social science collaboration in health in the beginning of the 21" century appears

to be losing its momentum a'nong health care institutions. Two international conferences in
Bangkok exemplify this statement.

lt is because of the lack of enthusiasm from health

authorities that social sciences seemed to be excluded from these two events, i.e', (1) the conference on Collaborative Health in the Next Century and (2) the meeting of Public Health

perspectives

on Future Challenges. Due to the emerging trends of social

science

convergence among several disciplines, research in health social science is increasingly


being seen as a common sense approach for many people. This is relevant to Good's views

on the inter-disciplinary and trans-disciplinary approaches. That is, the multi-disciplinary


approach tends to be accompanied by simplified methodology with no distinction among

disciplines (Good, 1992).

lt is hoped that health social science researchers

should be

determined to take a proactive role in clarifying the uniqueness of health social science in the

health decision-making process and promote the essential soundness of the disciplines within the health care communities. lt is time to put more effort into collaborating in health and medical activities and in building partnerships to move towards the goal of health social

science.

lt is time to strengthen the dialogue among

health social scientists and health

"We must scientists as well as local community workers. As Higginbotham (1994) described,

create institutional arrangements that can circumvent the dominant forces which divide disciplines and inhibit the exchange
researchers."

of knowledge among groups of

inter-disciplinary

lf the discipline of health social science is to be developed, it must receive support from medical and health care institutes. The success of the applied field of social science to

health can be established through the interests

of both health and social science

professions. Each health social science training program should be paired with a medical

school or health institute. In Asia and the Pacific, experience with technical assistance

130

Socio-Cultural Perspectives in Health

provided by medical schools has met with mixed results. At one extreme, there is the success of medical schools which have played a significant role in strengthening health
social science, including Yogyakarta, Indonesia; Newcastle, Australia; Rajmanhu, India and Khonkean, Thailand.

At the other extreme, medical schools have been less active

in

supporting collaboration with health social science because of irreconcilable differences as

to respective roles and functions over limited resources. This includes Mahidol University,
Thailand; De La Salle, The Philippines; Chandigarh, New Delhi, India and some outside the Asia-Pacific region, i.e., Nairobi, Kenya and Daoula, Cameroon. From this, it is observed that

these groups

of health social

scientists tend

to work independently and outside the

partnership of medical schools and health institutes. A compromise of these two extreme dichotomies is the movement of health social science in new establishments in Hanoi,
Vietnam; Kumine, China and Nihon, Japan.

Summary

The chapter reviews the movements of health social science in the Asia-Pacific
region, with the suggestion that the success of health social science depends upon building

partnerships between health and social scientists. lt was noted that the establishment of the
International Forum for Social Sciences in Health, through the regional networking bodies in

each region, i.e., Asia-Pacific Social Science and Medicine (APSSAM), would

offer

possibilities and solutions to how health and social scientists can best collaborate in their common interest in improving, as well as in encouraging the social science community to
further its contributions to health. Only the latter has been partly realized. There are presently

several local movements in networking among health social scientists in the region. At the
national level, social scientists have begun to be part of decision-making in health.

Health Social Science: A State of the Art

131

It appears that social science at the turn of the 21't century is entering a new phase

where it has become broad, thus affecting the specific contributions that can be made by a sound scientific knowledge of social science. This in turn has created an emerging mode of

work in the health area that is based on a team approach and one which does not
necessarily include the social science component. A team member who is not a social scientist, can act as one. The reason for this is that the definition and perception of social science has not been clearly understood by health authorities and institutes. The exclusion of

social science from recent health activities was therefore explained by the lack of strong
collaboration among health and social scientists,

lt is difficult to strengthen health

social

science independent

of

health and medical institutes when the perceptions and

understanding of its endeavors and objectives are very crude'

The future success of health social science lies in its ability to collaborate with the health sciences. As progressive health authorities have commented, there is

a need for

social and health science

to

interact. For social scientists, the means for building

collaborative partnerships must begin with dialogues with health scientists. Both training and research issues must be considered. With respect to the long term benefits and creating a socially institutionalized health social science, the integration of social science into the core
work of health and medical schools is considered essential.

Suggested Readings

1. Asia-Pacific Network (APNET). 1996 lhe APNET Steering Commiftee Meeting. Femental,
Australia, 10-1 1 and 16 February 1996.

132

Socio-Cultural Perspectives in Health

2. Albrecht, G., S. Freeman and N. Higginbotham. 1995 Complexity and Human Health: the
Case for Transdisciplinary Paradigm. Newcastle, Australia: Centre for Clinical Epidemiology

and Biostatistics, University of Newcastle.

3. Higginbotham, Nick. 1994 "Capacity

Building for Health Socialscience: the International

Clinical Epidemiology Network (INCLEN) Social Science Program and the International
Forum for Social Sciences in Health (IFSSH)," Acta Tropica, Vol. 57.
4.

*---, 1992 "Developing Partnership

for Health and Social Science

Research:the International Clinical Epidemiology Network (INCLEN)Socialscience Component," Socla/ Sclence & Medicine. Vol. 35, No. 11.

5.

International Forum for Social Sciences in Health (IFSSH). 1994 Linking a Gtobat Core

Agenda with Regional Activities for the Application of Sociatsciences in Heatth. Working Document No.1
Health.

. Bangkok:

Secretariat of the International Forum for Social Sciences in

6. Good, Mary-Jo. 1992 "Local Knowledge: Research Capacity Building in International


Health," Socra/ Sclence & Medicine. Vol. 35, No. 11.

7.

Phungsamlee, Anuchat and associates. 1998 Ruom Sang VisaiThas Kanjanaburi

(Visions of the Civil Society in Kanjanaburi Province), Paper presented at the Conference of Mahidol Social Science Research Network, December 1 , 1998.

8.

Ramalingaswami, Prabha. 1990 "social Sciences in the Health Field in India," The tndian
1.

Journal of SocialSclence. Vol. 3. No.

9.

Rosenfield, Patricia. 1992 "The Potential of Transdisciplinary Research for Sustaining and

Extending Linkage between Health and Social Sciences," Socra/ Science & Medicine.YoL 35, No.11.
10.

-----------

1982 The Need for Socra/ and Economic Research in Tropical

Disease Sfudies," Proceeding of SEAMEO-TROPMED Regional Seminar and National

Health Social Science: A State of the Art

133

Workshop on Socia/ and Economic Research in TropicalDisease. Bangkok: Thai Watana Panich Press Co., Ltd.

11. Sermsri, Santhat. 1991 "Health Social Sciences in Thailand," in S. Sermsri (Editor).
Heafth Socra/ Sciences in Thailand. Salaya, Thailand: Faculty of Social Sciences and

Humanities, Mahidol University.

12. Supachutikul, Anuwat. 1998. "Neaw Thang Vithee Karn Sang Team Nei Rabob (Team
Approach in Health System)", ThaiHealth Sysfem Newslefter. Vol. 4. No.4 (October).

13. Wray, J. D. 1978. "Prevalence of Malnutrition among Rural and Urban Children by Age
and Severity in Thailand," in T. Harpham, T. Lusty and P. Vaughan. (Editors). ln the Shadow

of the City: Community Health and the Urban Poor. Oxford: the Oxford University Press.

134

Socio-Cultural Perspectives in Health

Table 9.1 World of Health Social Science Programmes and Agencies

Programmey'Agency

Applied Diarrhoeal Research Project (USAID)


Network of Community Oriented Educational Institutions for the Health Sciences (WHO) Data for Decision Making Project (USAID)

Field Epidemiology Training Program (CDC,WHO,USAID)


Federation for International Cooperation of Health Services and Systems Research Centres

Special Programme for Research, Development and Research Training in Human Reproduction (UNDP, World Bank, WHO,
UNPF) Health Systems Research and Development (WHO, DGIS, SAREC)

International Forum for Social Sciences in Health (Carnegie Corporation, Ford Foundation, IDRC, Rockefeller Foundation) International Health Policy Program (Few Charitable Trust, Camegie Corporation, World Bank) International Clinical Epidemiology Network (Rockefeller Foundation) National Epidemiology Boards (Rockefeller Foundation) NeMork for Health Reform (WHO, UNDP, World Bank) Puebla Group Special Programme for Research and Training in Tropical Diseases (UNDP, World Bank, WHO) Takemi Programme in International Health (Harvard School of Public Health) University Partnership Programme (IDRC)

CDC United States Centers for Disease Control and Prevention


DGIS Netherland Ministry for Development Cooperation IDRC International Develooment Research Centre of Canada
SAREC Swedish Agency for Research Cooperation with Developing Countries
UNDP United Nations Development Programme

UNPF United Nations Population Fund


UNICEF United Nations Children's Fund

USAID United States Agency for International Development WHO World Health Organization
Source: Nugens, Yvo. Science

br

Health: Essential National Health Research and lts lmplementing Agency. Geneva,

Switzerland: the Council on Health Research for Develooment.

Subpotln&x

135

Subject lndex
A

Contraceptive practica, 31,32,3/t-S, 39, 41 Consciousness health,

3,6, 1G107

Allls,

1, 7+.,',t1, 104',',t21, 123

Courtship, 29, 39 Crorvding,

Assault, Statistics, 1()2 Adolescent sexualiV,

U, 9142, 9+97,

10J., 1 17

4O

Culture, 2, 2l}'3f]., 41, 43,65, 80, 96, 116


D

Aging definition,464T Aging, Causes ot, 46,

4Vfi,63,67 6669,6

Death, /|8 Demograptry, Social,29

Aging health, 8, 46, 62-dt,


Aspiration,

tbmographic transition, 32,46, 49


Density, 92,96,'117

Attitudes,30,40
Availability health, 1 7 Awareness, Social, 7,
B

Ibpendency, T6

S,

107

Derelict, 46, 49,613, 6F66, 69


Development, 6,

8ffi,

109104

Bangkok cN, 6, 71-7J, 97, 1q),'l'161'17 Basic minimum needs, 2&24 Beharior, Social, 2, 8, 18, 60,94, 106, 123 Belief in sexuality, 3fr,4243 Biologicaf determinant,

Danelopment definition, 10, 1(B

Dariant beharior,96

[bbrminants, Social, il), 34-38

Dseae grouping,90
122 Doctor, 16'17,2O21
E

n,43,

Births,31,34-36,
Breastfeeding, fXl Bureaucracy,
21

, n

Education influence. 3,6, 31, frt,

S,

41,43,67,

,24,

E,

'1G110, 11+116, 119

c
Capital city,

Economic cost, 20, 66, 116

7],117

Economic impacts, 4,6, 31-33

Children, Number of, 29-fr1,

ffi7,4243,62,U,

ElderV,

8,

46, 49. 62-63, 65, 84

78.85
City,6S. 91 City life,

ElderV definition, ElderV health, 113, 11&

&47
46, 613, 6669, 61,

e9.

11,4,7Vn,91,934,97,
't19

Elderty number, 4647,62 Eldest child, 62-63,

66,62 69d)

City population

,71,76, 116

Employment,

G37

Collaboration, l-lealth, 1, 86., 12 124,

1271il,

144

bcbnded famity, 63

Community dwelopment, 74, 86., 18-127 Conception, 2$33, 39, 43

15

Scoio-Grlnrral Ferqrotilrcs in

l:bdtt

F 1(I) Family planning,2+26,33,39,41 Family size, 10, &,62,73 Family structure, fl161 Famity sysbm, 33, 39, 41, rt+60, 56, 60, 1(D Family support, 9, 4$60, 56,61,98 Family violence, 8, 88, 94, 97 ,9&1@, 'l 7-1 18 Fecundity definition, 3031 Female elderly, z16
Family change,

Herbal medicine, 18

6(}$,

66,

O, 78,98,

HIV/AIB, 7.,'l'1,'1o4.,114,123
Holistic health, 16
Housing,

7,

83, 9X3, 96, 97, 106, 117

Household croarding,9't'Q2,97 Household structure,9, 93


|

lllness, 4243, 90 Income influence, 4, 3134, 43, 1(E


Individual'tty,

&,

121

Fertility, 29,3237,3$40, 43, 47, 45,62,

1G

Individual standings,

24, lGJ.10&16

turtility definition, 30,


Fertility regulations,

1(F1@ 33, g, 4142

Industrialization,6, 49, 76
Infant mortality, '1, 43,81, 123 Infectious diseases, 812,96, 123

G
Ciestation, 39,

43 1*22,24 ,77

Institution, 129 Inbgration, 12t123, 128


Intercourse, 3839, ,13 Interdiscipline , 122-123, 126129 Inter-mediab variables, 38, 43, 1(D Inter-sectoral collaboration, 1, 22
K

Gorernment health care,

Gorernment officials,21
Grassroots, 26,

126

H
Health belief,

18 Health definition,l-2,1M Health care service definition, 15 Health care sevice,6, 11, 1S18, 21-22.26,61, U,116,122 Flealth cost, 11 Flealth impacts, T9 Health problems, 16, 20,824 Health social sciences, 121 ,12+126, 12$131 Flealth status, 11, 16, 81, 8ffi, 91, 116, 122 l-fealth technology, 6, 11+115 Flealth transition, 11, 104 l-fealth utilization, 1&21,2728, U

Kinship
L

tie,9,

41

Litu sVle, 16, 97, 113, 116


Longw'rty, 69
Lovuer status,

4,57,62,

'1(E, 114, 1'19

M Male culture, 8, 41 Marital instability. 31, 979, 118 Maniage, 29,31, 34, 3J.4o, 42

Mabrialistic society, 10, 16, 106, 119'116, 11&


119

Subpot

In&x

L37

Medical care,17,19, 21, 1(B


Medical technologry,

Perspectives, SocieCultural, 2 Plauralistic health, 18, 21 Premarital ss<, 8 Preventive health, 68'62, 1O7 Primary health care, 11,15,22-23

U.

11

+116

Medical treatment,19, Menarche age, frXl1

U,'122

Mental health,6, 68,834,9699, 104, 113, 1'18 Migrant, 33, 4&49,

U,

67,

n,

80

Primab ci$1,72,76,6
Poor, 8, 62. 73,
813,

Migration impacts,9, 11,49, 64, @, ro, 76,T1, 80, 8r3, 113,117 Modernization, $10, 14, 3738, 60, 1CKr, 10S16,

93, 1 191 1 6

Population pyramid,43

Pwerty, 72,

n, A,
1

106, 1 14

113.117119,121
Modern life, 16, 11*114 Modern health care, 6, 19,21
Modern man, 10,64 Modern medicine, 17, 1*21, 1'16

Process, Social, Prostitute,

I S

Prwiders, Flealth,

o
OualiV of children, 32 Ouafity of lite,24,11O

MorbidiV,'11,8'1, 1@
Mortality decline,

ffi,

11,47, 1061G, 1@, 123

OualiV of sevice, 16,2+25


R

Mother education, 107-1G' Municipality, @ Multkliscipline , 122-123. 1 29130


N

Refurence group, 2, 9 Religion,

fr,,36,40

Reproduction,33
Revolution, 11S1 16
1

lbtworking,l26
Norrcommunicable diseases,
23

Rural litu, 79, 116

Nongwernment organization, 22, 93

s
Seeking beharior, 18 Self-harm, Statistics, 1(2

Norms,30,42

o
Occupation impacts, 4. 1o2,

16

Se<uality,

7.M,42
3$41, 114 913, 1@, 117

Over-urbanization, 68, 71, 75,


P

So< factor, 30,

Slum, 68,

n, 72-74, 7-7a, 8,83,


,7,
1O7, 1'lg

Patchiness, Patients, 20

l26

Social change,65, 114, 1'16, 119 Social concern

Participation, 16, 23 Partnership, '1fl)

Social costs, 20, 66 Social factors, 2, lGJ, 111, 123

138

SocieCultural Ferqrotives in l:bal0l

67, 86,1q,,1061(E,110,'116,121 Sociaf science , 2, 121 , 2ts'l31 Social science knoruledge, 2, 12b123 Social support, 6CBt, 69 Society,b SocioCultural perspectives, 2 Socio{conomic standing, 1 Squatter, n,72,7-7a,g0 Statusofwomen, 4,6,26,$,G07,41,86,9& 9!1, 107-110, 114
Social influence , 2, 16, 2S, 31 , 34, 3&@, ,13,
1

Under-urbanization,

68

tltitization,Heatth,1921,2V2e,U
V
Value sysbm, 2g-O, 43, W,62,113, 119 Molence, 8, 16, 94,

97,1M18

W WelFbeing,67,89, g4,g7,1(Xt, 117118


Woman status, 4,6,26,30, 99,107-110
Y Youth cutture, T

GOZ 4'1,re,86,9&

Status, Social, 24,

34,10F16, 1G110 1,2,

Status, Socioeconomic,

122

rt**it**r***r******

Stress,8,967.

lm,

104, 113, 116, 118

Structure, Social, 2, 6, 8, 60,68

Suicide,99 Swithching patbrn, 1&19


T Traditional medicine, 17, 19,20, 42. 116 Traditional practitioner, 18 Transition, Damographic, 33, 46, 4&49

Transdiscipline, 123, 129


Transportation, 67
U

Urban area,

689, 116

Urban groarth,

7!71

Urban health, 804, 91, 1 18


Urban life,

47,77-A

Urban hierarclry,88

Urbanism,6T,En
Urbanization defi nition, 69,

E
76.fr,

Urbanization trends, 49, 67,

n,

84, 1 19

Contributors

139

Contributors
Santhat Sermsri is a Professor of Population and Health and the former Dean of the
Faculty of Social Sciences and Humanities, Mahidol University, Bangkok, Thailand. Professor Sermsri received Master and Ph.D. degrees from Brown University with

concentrations in population and medical sociology. His research interests include health care services, social impacts of urbanization on health. He is the author of numerous articles, chapters and technical reports.

Sairudee Vorakitphokatorn Associate Professor of Psychology at the Institute of


Population and Social Research, Mahidol University, Bangkok, Thailand. Dr. Vorakitphokatorn received her Master's and Ph.D. degrees from the University of lllinois.
She has conducted several research projects on AIDS and Child Care. She is the author

of numerous papers and rePorts.

Theodore D. Fuller is a Professor of Sociology at Virginia Polytechnic Institute and


State University, Virginia, U.S.A. Professor Fuller received Master and Ph.D. degrees from

the University of Michigan. Since 1974, Pro'fessor Fuller has worked extensively in Thailand, primarily in the area of migration and urban crowding. He has published book, several chapter and numerous articles based on his research in Thailand.

John N. Edwards Professor of Sociology

at Virginia Polytechnic Institute and State

University, Virginia, U.S.A. Professor Edwards received Master and Ph.D. degrees from the University of Nebraska. His primary research interests concern issues related to marriage and the family. Professor Edwards with the above contributors, has recently completed the research project on Household Crowding in Bangkok . He has written several books and numerous journal and articles.

PBINTINE

BY: sFM O{FBOEN PFM0{

IBRNEKOIO CD.,

Lm.

Brief Biography of Santhat Sermsri


Education: Ph.D. in sociology-Demography, Brown University, Providence, U.s.A.
A.M. in Sociology-Demography, Brown University, Providence, U.S.A.
M.A. in Sociology, Chulalongkorn University, Bangkok, Thailand B.Sc. in Sociology and Anthropology, Chiangmai University, Chaingmai, Thailand

Awards and Honors:


Secretary-General of the International Forum for Social Sciences in Health, Caracas,

Vanezuela, 1992-1996 Sponsor

of Health Social Sciences, the International Clinical Epidemiolgy

Network

(INCLEN), Philadelphia, U.S.A., 1989-1992 Ph.D. Fellowship of the Rockefeller Foundation, 1976-1980 Graduate Study Scholarship of the Institute for Social Research, Chulalongkorn UniversitY, 1972'1974

Academic Appointments:
Professor

of

Population and Health, Social Science Department, Faculty

of

Social

Sciences & Humanities, Mahidol University, 1998-present


Short Term Consultant (STC), World Health Organization, Rangoon, Myanmar, MarchMaY, 1998

Member

of Executive Board, the ASEAN Institute for Health Development,

Mahidol

University, 1 994-Present Dean, the Faculty of Social Science and Humanities, Mahidol University, 1988-1992
Harvard Visiting Scholar, Social Medicine Department, Harvard Medical School, 1993

Member

of Steering Board,

Research Committee

of the Sociology of Health,

the

International Sociological Association, Madrid, Spain, 1984-2000


Member of Executive Committee, Asia-Pacific Sociological Association, Tokyo, Japan,
1

997-present

Member of Sub-Committee in Social Science and Humanities, Scientific Corportion between Japan and Thailand, National Research Council of Thailand (NRCT),
1

989-present

Chairman, Expert Group

of Social Behavior and Style of Life,

Medical Science

Department, Ministry of Public Health, 198S-present