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Changing families and its effect on the health of family members in Kerala: A qualitative exploration

Open AccessPublished:June 23, 2022DOI:https://doi.org/10.1016/j.cegh.2022.101094

      Abstract

      Problem considered

      The study of changing families and the effect on changes in the health of family members is important for planning health policy and programs. Kerala is in fast epidemiological transition and the ‘Kerala model of development’ is famous. The state had the matrilineal family system and now has a social milieu maintaining a high burden of non-communicable diseases for which lifestyle modification through family-level interventions is a suggested solution.
      The specific objectives were to explore the changes in families, understand the health effects of changing families on family members, and describe stakeholder's perspectives on access and utilization of health services.

      Methods

      92 in-depth interviews and 17 focus group discussions were conducted in three representative districts in Kerala. Participants from different age groups from urban and rural settings were separately studied.

      Results

      The reported changes were, related to nuclearization, role functions of women, elderly care, food habits, parenting styles, type of marriage, household-level decision making, and health service utilization. The linkages of these changes to the perceived health status were also explored.

      Conclusions

      The reports of stakeholders threw light on poor social penetration of health programs, explanations for new parenting styles, elderly care, and changing behavior of adolescents. The study revealed intergenerational conflicts and gives recommendations for better health care in the community.

      Keywords

      1. Introduction

      Family is the basic sociological unit in society and the concept of changing family is well known.
      • Barnard J.A.
      Family. Encyclopedia Britannica.
      , The intergenerational change in structural and functional attributes of the family is termed changing families.
      • Hantrais L.
      • Brannen J.
      • Bennett F.
      Family change, intergenerational relations, and policy implications.
      Changes are expected to happen for structural attributes like type of family, age composition, functions like care of the children, gender relations, and for factors influencing these changes like market influences, availability of health services, etc. These changes are expected to influence the health status of the family members and are especially relevant in Kerala due to the social changes resulting in mortality reduction and fast epidemiologic transition. The Kerala model of health care is popular and the Government has recently transformed primary health centers into family health centers.
      The concept of changing families has been elaborated and the intra-familial micro-process was described by Julien O Teitler.
      • Teitler Julien O.
      The Changing Family.
      Perceptions of changes in the family, health status, and the linkages between these are expected to influence health service utilization.
      • Mosadeghrad A.M.
      Factors influencing healthcare service quality.
      Theoretical framework for the study: This was developed based on structural and functional changes on one side and elements of changing families and changes in the health of the family members as the outcome. These changes and the effects of these changes were considered as the major themes for the framework of the study (Fig. 1).
      The objectives of the study were to explore the changes that occurred in contemporary families, to understand the health effects on family members, through the words of stakeholders, and to describe their perspectives on the utilization of health services.

      2. Methods

      Study design: Change that happened at the family level as explained by various stakeholders was the focus of inquiry. In order to understand the meaning of the changes in stakeholder's perspectives, a qualitative approach was used. Being a qualitative study using a general inductive approach, the study tried to explore the perceptions of different stakeholder groups through In-depth interviews (IDI) and Focus group discussions (FGD).
      Ethical considerations: The study obtained ethical clearance from the Kerala University of Health Sciences EthicsCommittee.

      University Ethics Committee Certificate (UEC). Kerala University of Health Sciences, Thrissur: UEC 1/2016.

      Informed consent and consent to publish were obtained from all participants before data collection.
      The study sites and population: Kerala, the south-most state of India is unique in having the highest developmental index according to NITI Aayog ranking, and Universal literacy. The state has a 47.7% urban population.

      Kerala population Census 2011 – 2022; Available from https://www.census2011.co.in/census/state/kerala.

      Out of 14 revenue districts, three were selected representing the southern, central, and northern regions of the state (See Fig. 2, for the study sites). The stakeholder categories studied were family members from different age groups from rural and urban settings, health care providers, community leaders, and policymakers.

      2.1 Sampling and sample size

      A purposive sampling technique with a maximum variance approach was used. Historically the state has three distinctive regions namely Travancore, Valluvanad, and Malabar, and in order to get the representativeness of these regions, the fourteen districts were divided into 3 regions and one from each region was purposively selected.
      In order to account for the variations in living conditions and cultural complexities, different stakeholder groups were considered within these regions based on age and occupation.
      Regional locations like urban or rural were also considered as a criterion for sample selection. The point of data saturation in terms of richness and volume of information decided the number of FGDs and IDIs.
      The study was conducted from 20 January 2019 to 30 January 2020.
      Data collection: The data was collected by trained investigators in the natural settings using IDI, and FGD guides. A total of 92 IDIs and 17 FGDs were conducted. The distribution of IDI and FGDs were, 11 (IDI) and 4 (FGD) among Young Adults (15–24 years), 5 (IDI), and 3 (FGD) among married Men& Women, 33(IDI) and 3 (FGD) among 30–59 years, 5 (IDI) and 2 (FGD) among 60–80 years, 2 (IDI) and 2 (FGD) among >80years, 17(IDI) and 3 (FGD) among health service providers. Each interview took 45 min–75 min and the FGD sessions took 120 min–150 min. The interviews and FGDs were recorded after getting informed consent from the participants. The proformas for the in-depth interviews and FGD guides were developed and piloted in the same study areas. The FGDs were conducted by the Investigators of the study coordinating center and the in-depth interviews were done by the trained site investigators.
      Data analysis: Qualitative data analysis progressed along with the data collection. The transcription and translation was done by the trained research team who were the study site investigators. Preliminary steps for checking the quality of data were followed by reading and re-reading the transcript, free listing, and pile sorting of the text. The domains were checked and categorized, coding was done and sub themes were identified. Thematic analysis using hybrid coding was used (Inductive and deductive). There were a total of 5 major themes and each theme had 6-8 sub-themes. Few of the subthemes were joined together and categories were made. Additional field notes were also examined especially on communications and verbal languages. Tables was made based on the qualifiers and the frequency of responses or same or different replies categorized as most/sometimes/rare/none etc. In case of doubts about slang and rhetoric, local linguistic experts were consulted. Quotable quotes were identified and reviewed based on the local context and study framework. Analysis was done manually using MS Office and EXCEL software tools.
      Quality, rigor, and reflexivity were maintained at each level of the study (at the design level by preparing the interview guide and other tools in consultation with concerned experts and stakeholder representatives, at the conduct level by uniform training and adherence to rigorous time discipline and keeping a log of activities and using checklists and at analysis level by developing an analysis plan in advance, analysis by the direct involvement of researchers and various triangulation strategies). All study tools were finalized after piloting in the same study sites and separate training workshops were organized again after piloting. The dynamics of focus group discussion was assessed using sociograms and if noted as of poor quality was repeated. The study coordination center arranged periodic site visits for ensuring the quality of data collection. Triangulation at various levels like methods, investigator and data levels was used to ensure the validity of conclusions.
      The importance of researcher's reflexivity was discussed during the training of investigators. Reflexivity was assessed using the discussion logs describing multiple layers of reflection considering the interpretations of the researcher and the context of the data collection.

      3. Results

      Qualitative descriptive approach built on the paradigm of policy advocacy resulted in a large volume of textual data which was analyzed to get a wide range of conclusive informations. The themes evolved such as nuclearization of the family, changing age of marriage, and single child-families were mentioned by more than 80% of the respondents as notable structural changes.
      Changing decision-making roles, gender equations, type of marriage and dowry system, changes in lifestyle like food habits and physical activity, changed parenting practices and changed practices of caring for sick, disabled and the elderly were the significant functional changes reported.
      Neo-locality or moving away from parent's house was reported as a new phenomenon and was pointed out as the reason for joint family disintegration. In the traditional setting of the joint family, decision-making was collective one by all family members. In nuclear families, the decision-making role was reported to be shifted to the breadwinner of the family. Referring to freedom at the husband's house after marriage, an elderly woman participant said “in olden days, marriage was like slavery, a lot of insecurity at the married house. Ladies can't even appear before the head of the family”. Everybody preferred higher marital age and elderly participants during FGDs suggested that the time of marriage can depend the job availability and personal preferences.
      As more women got employed and earning the gender roles and relations were reported to be changing. The following quote is on gender equations within the family.“In olden days' husbands were seen as the God to wives and they got much protection from their husbands. Now a day’s both partners are considering themselves as equal.” Elderly, Kozhikode- Urban, QQ No- 1Marital disharmony and broken marriages was reported to be more common. Postponement of first pregnancy was reported as a new phenomenon. Marriage related expenses and extravaganzas were reported to be increased. All age groups expressed concern on marital disharmony. The quote below is about a case of separated married life.
      I know a couple both having their second marriage. The women had already a son on previous marriage and got a daughter in the present marriage. One day after a quarrel for simple reason, she left her husband asking him to look after their daughter. Husband stated that he was not ready for it. Thus couples simply fight for silly issues and children suffer. –Academician, Trivandrum-Rural, QQ No-2.

      3.1 Changed lifestyles

      Majority of the health care providers said that media influenced the food habits of the new generation and advertisements influenced their lifestyle. The elderly also shared the same view. (See the quote below)“Everybody understands the value of mother’s food when they start preparing food by themselves”. Middle age, Thrissur-Rural, QQ No- 3
      The generation gap was most obvious in breastfeeding practices. Few health care providers reported that compared to the olden days, babies were getting sufficient feeding because of the wide gap between pregnancies. About the declining breastfeeding trends, the elderly opined that during their days’ mothers used to breastfeed till three years or the next pregnancy. But later on ladies became more figure conscious. The quote below is an example of such revealing.“Previously mothers used to breastfeed their children everywhere, every times and whenever their babies cried. Now a day’s mothers are hesitant to breastfeed in public places and work place because no facilities or privacy are available for breastfeeding and alternatives to breast feed is easily available.” Health care provider-Trivandrum- Urban, QQ No- 4
      Motorized means of transport resulted in decreased physical activity. Household purchase changed to mostly online mode, making the present generation less physically active.
      Most of the new generations was said to prefer living in flats. Social interaction of the present generation was reported to be less. The residential associations and religion-based gatherings were suggested as the platforms for interaction. The introduction of new technologies into household had potentially changed the quality of family interaction and relationships. The Internet, the telephone, television, movies, radio, etc. all have made it possible to interact with the world without actually confronting the world face-to-face.

      3.2 Child disciplining and parenting practices

      Parenting practices were also reported to be more authoritarian than authoritative and permissive. This needs to be understood in the context of family nuclearization. Few of them said that parents were more caring and loving in nuclear families as there were fewer children.
      The following quote indicates the helplessness of the older generation regarding this.Children are addicted to mobile and laptops. They spent time with it till night.
      While eating, walking and doing anything the earphones will be on their ears. Even they don't give attention to their elders. It seems the elderly as well as the parents are afraid of these children”. Middle Aged- Trivandrum -Urban, QQ No-5.
      Few of the academicians pointed out that parents were not spending enough time with their children or expressing their love and affection. This was the reason attributed to children growing up in their own world.
      Majority expressed the difficulty in defining the margin between abusive and normative disciplining. Everybody wished the parents to be role models for their children.
      As the proportion of single-child and nuclear families was increasing, problems like academic competition and unrealistic parental aspirations became important. Peer pressure, habit disorders, behavioural and emotional issues were the important psychological problems reported among young adults. Similarly, behavioural problems like substance abuse were more reported among adolescents. Social interactions were reported to be less for children leading to deteriorating social health. Participants across all categories attributed this to the extreme use of mobile phones and electronic media.
      Majority of the middle aged participants reported that lack of motivation and mobile addiction resulted in character disorders among children.“More children are having mental issues and learning problems. Creative thinking is less. They will only do what their parents tell”- Health provider, Trivandrum-Urban, QQ No- 6

      3.3 Care of the elderly

      Majority of stakeholders reported that the main issue related to the elderly population was delay in seeking health care. Few expressed their ignorance about various health programs of government and new services available at health care facilities. Poor interaction among family members, loneliness, and health problems were reported as important by the elderly. The number of old age homes was reported to be increasing. The elderly were reported to seek shelter there for various reasons; having nobody to look after them, difficulty getting along with their children, no source of income of their own, etc. Many participants said that it would be better to have short stay-day homes (“Pakalveedu”) than full-time old age homes.
      The bonding between generations was reported to be less and less which was perceived as an indicator of widening generation gap. Children never bothered to mind the elderly. The disintegration of the joint family system and sense of individualism and lonely behaviour were reported as causes of decreased bonding.
      Majority of academicians were of the view that disabled were getting maximum benefits from the schemes of Government as compared with the olden days. The same opinion was shared by other stakeholder groups also.“Today people are getting affected with chronic diseases before they reach middle age, all because of their life style. Without making food in house they used to buy food from outside. Foods that they buy from shops are not good for health. - Middle aged- Thrissur- Urban, QQ No-7
      Increasing consumption of high-fat diet, frequency of eating outside, and sedentary habits were reported as major factors leading to obesity among children. Most of the young adults reported that boys liked to go out and eat. They were not concerned about the nutritive value of food.

      3.4 Utilization of health services

      The majority of stakeholders across all categories reported that health care facility has improved a lot. Accredited Social Health Agents (ASHA) workers were reported to be doing a better job in improving the overall health of society.
      All participants asked for more health education classes. The attitude of the public hospital staff should be more humane. Participants acknowledged the availability of experienced doctors at government hospitals. Convenient timings and proximity were reported to be the two important reasons for preferring private hospitals.“I won’t say that our Government system is insufficient, but little more improvement is needed in facilities. Nobody knows about the mental health services, there is no system existing for improving awareness”. Middle age, Thrissur-Urban, QQ No- 8
      The ASHA workers needed to be transformed for more advocacy role. Most of the elderly participants suggested that an alert system to signal their health problems, exclusively for the elders could be developed by the Govt. to improve elderly care. Door delivery of drugs and essentials, efficient home care for the bed ridden were the few suggestions stated.
      There were resistant groups for immunization. For example, from Calicut and Thiruvananthapuram the participants of FGD reported that, in spite of the home visit and persuasion of the medical officer as per “Indradhanuss program” (a program by Govt. to bring back defaulters and complete catch-up vaccines), few parents were reluctant to come for immunization. The reasons attributed to vaccine hesitancy in their own words “this vaccine is coming from outside, now our children are not having any health issues, then why should we inject this simply. There are many adverse cases reported after vaccination”.
      Agreeing with the opinion on increased availability of health care facilities, majority of elders said that diseases were more nowadays because people were observed to be not as healthy as before. This was not the opinion of the young adults (See Table 1 for more details).
      Table 1The extent of the agreement on the debating points emerged during discussions.
      Sl. noAreasRespondentsExtent of agreement
      1Taking care of the elderly in the family Vs. institutions (Pakalveedu) and people are less healthy compared to the elder generationsYoung Adults++
      Married++
      Elderly+
      Academician++++
      Health care worker++++
      2Doorstep delivery of drugs and supplies to the targeted group Vs. to the bedridden and dependent peopleYoung Adults+
      Married+++
      Elderly++++
      Academician++++
      Health care worker++++
      3Love marriage is a natural phenomenon and not to be discouragedYoung Adults++++
      Married+++
      Elderly+
      Academician++++
      Health care worker+++
      4Deviance from traditionality and yielding to consumerismYoung Adults+
      Married++
      Elderly++++
      Academician+++
      Health care worker+++
      5Increased availability of health care facilities was reported. But diseases were also more reported because people were observed to be less healthy than those of previous generations.Young Adults+
      Married++
      Elderly++++
      Academician+++
      Health care worker+++
      Percentage of the group agreed: ++++maximum (>75%), +++ (51–75%), ++ (25–50%), + (<25%).
      Family safety net was discussed as a means of financial protection. Most of the stakeholders reported that the existing financial protection schemes were not adequate. This was a concern of the elderly than the younger respondents.

      4. Discussion

      The study explored salient changes in the family structure and functions and the strong drive of family resilience or adaptation over time which was evident from the statements of stakeholders. This adaptation is a unique survival capacity that other researchers also have reported.
      • Walsh F.
      A family resilience framework: innovative practice applications.
      Nuclearization is an inevitable happening and elements of adaptation happen around the changed system of nuclearization.
      Different theories are given as an explanation for the disintegration of the joint family system and matriliny in Kerala.
      • Menon A.S.
      Kerala District Gazetteers.
      The influence of Christianity was described by other studies and Syrian Christians also followed matriliny.
      • Krishnan P.
      Family and household structure among the nineteenth-century Christians of Kerala, India.
      Factors that led to the disintegration of the joint family system in Kerala have been well Studied.
      • Jette A.M.
      From person-centered to family-centered health care.
      ,
      • Taukeni S.G.
      Bio psychosocial model of health psychology and psychiatry.
      ,
      • Menon V.
      Matriliny, patriliny and the postmodern condition: complexities of “family” in Kerala.
      ,
      • Niranjan S.
      • Nair S.
      • Roy T.K.
      A socio-demographic analysis of the size and structure of the family in India.
      Family level decision-making was another theme that evolved during discussions. Other studies also noted this change in household-level decision-making.
      • Kochar A.
      • Nagabhushana C.
      • Sarkar R.
      • Shah R.
      • Singh G.
      Financial access and women's role in household decisions: empirical evidence from India's National Rural Livelihoods project.
      The new culture of choice marriages was viewed as a romantic phenomenon. This has undercurrents of social equity due to the diminishing economic and social complexities of the dowry system.
      • Anderson Siwan
      The economics of dowry and bride price.
      Child care practices including parenting were explored. Researchers already reported childrearing as a major function of family and character development was noted to happen in the family environment.
      • Maccoby E.E.
      Middle Childhood in the Context of the Family. Development During Middle Childhood: The Years from Six to Twelve.
      Single child norm was reported to be increasing and considered as a dangerous phenomenon by the elderly in the society.

      4.1 Reasons reported by parents for children becoming unmanageable in the family environment

      • a)
        Giving extra money
      • b)
        Parents not spending enough time with them
      • c)
        Lack of bonding with elder generation
      • d)
        Misuse of social media, mobile
      • e)
        Parents not role models for children
      Other researchers also found that social media influence affects the social health of youngsters.
      • Beal J.A.
      Impact of social media on adolescents.
      Within the household, there has been a process that was referred to as “domestication”. National Crime Record Bureau reports that more suicide among youth in Kerala and the reason in many cases was a failure in exams.
      The National Crime Records Bureau (NCRB)
      Exam failure major trigger for student suicides.
      Being a single child adds fuel to the fire and single children face many psychological issues.
      Care of the elderly as a function of the family was discussed in detail. In the Indian scenario, family-level care was seen as an integral part of old-age care.
      • Ponnuswami I.
      • Rajasekaran R.
      Long-term care of older persons in India: learning to deal with challenges.
      The WHO model of active aging defining care pathways in the family can be considered suitable for Kerala.
      • Paúl C.
      • Ribeiro O.
      • Teixeira L.
      Active ageing: an empirical approach to the WHO model.
      The majority appreciated the health services especially the introduction of link workers called ASHA. Along with lot of applauds, there were criticisms also. The attitude of health functionaries and lack of signalling for emergencies among the elderly were the reasons for dissatisfaction. There was request for more advocacies by the link workers and cases of vaccine hesitancy were also reported. All this indicates the fact that people are concerned about the services and have their own demands. From this, we can conclude that there should be more social penetration of health programs and door delivery of services to make the public health system totally people-oriented. This need was reported in spite of the democratic decentralization process and the present concept of family health centers in Kerala.
      The concept of family medicine has been established in most countries and India also is not an exception.
      • Menon A.S.
      Kerala District Gazetteers.
      The patient-centered care model has been transformed into the Bio-psychosocial care model which is a sustained partnership model at the family level.
      • Krishnan P.
      Family and household structure among the nineteenth-century Christians of Kerala, India.
      When primary health care is changed to family-oriented primary health care which is the current concept, the role of the family has been redefined with more relevance and applications in health system functioning. For emerging problems like pandemics, third-generation health problems like trauma, psychiatric burden as well as the classical non-communicable diseases like cardiovascular and cancer the modification of human behavior towards changed life like diet, physical activity and entertainment is the only preventive option. Targeting the services to the family level and involvement of the family members in health programs is the necessity along with the bio psychosocial approach.
      The high coverage of social security programs was appreciated by the stakeholders. Still, there was a demand for more financial protection and widening of the safety-net. The demand for a wider family safety net is shared by other studies related to high out-of-pocket spending.
      • Karan A.
      • Yip W.
      • Mahal A.
      Extending health insurance to the poor in India: an impact evaluation of Rashtriya Swasthya Bima Yojana on out-of-pocket spending for healthcare.
      The opinion expressed in the present study that the elderly was seen as a liability can be easily changed by widening the safety net.
      • Pittman L.
      How well does the “Safety Net” work for family safety nets? Economic survival strategies among grandmother caregivers in severe deprivation.
      The concept of a safety net was popularized in the context of economic liberalization and is relevant in the Kerala context also.
      • Paitoonpong S.
      • Abe S.
      • Puopongsakorn N.
      The meaning of “social safety nets”.
      The neoliberal market influences on family life, described in 4th Viennese Conference on Mediation, Vienna
      • Pais S.
      Globalization and its Impact on Families.
      can explain many changes in Kerala culture. The global financial crisis was reported to result in many social security measures like the ‘Bank of Mum and Dad’
      • Hantrais L.
      • Brannen J.
      • Bennett F.
      Family change, intergenerational relations, and policy implications.
      to improve quality of life. A productive safety net program is a similar experience reported in Ethiopia.
      • Endris G.S.
      • Kibwika P.
      • Obaa B.B.
      • Hassan J.Y.
      How social capital can inform targeting formal social safety net interventions in vulnerable communities in eastern Ethiopia: an ethnographic case study.
      In the event of joint family disintegration and weakening of family ties such new models of neighbourhood support can be tried. Studies already noted the purpose of safety net as to prevent catastrophic spending.
      • Pais S.
      Globalization and its Impact on Families.
      This protection from the safety net can be extended to social adversities also and social support and neighbourhood support are a few terminologies related to this.
      • Young Mc Chesney K.
      Absence of a family safety net for homeless families.
      The basic idea of all this was to protect the vulnerable.
      • Cherlin A.J.
      • Seltzer J.A.
      Family complexity, the family safety net, and public policy.
      Local initiatives as support groups need to be developed and this collective can improve the care of vulnerable.

      4.2 Replacements as adaptations and elements of family resilience

      Changing family means differences perceived by stakeholders across different generations and these changes can be viewed as adaptations which are the elements of family resilience. These elements of adaptation also can be termed replacements in the society. The results highlighted the view of stakeholders on generation gap, and the important replacements that happened in the family. Many of these replacements are inevitable happenings in the society and few can be manipulated for positive health attainment. The important replacements are discussed below.
      The replacements across time as indicators of change, reported by the participants during IDIs were the modernization of families, more female-headed households, more filo-centric and single-child families, mechanization of the kitchen, outside eating and fast-food culture, etc.
      The replacement of natural food was reported to be with processed and ready-to-eat foods like noodles and other snacks which contain more saturated fat. The quotable quote regarding outside food habit gives an account of origin of lifestyle diseases in the words of respondent. Which replacements are salubrious and which are adverse on health in the specific local context are areas for further research.

      4.3 Major replacements

      • Joint family to nuclear family
      • Arranged marriage to choice marriage
      • Home level care of elderly to institutional care
      • House maker role of women to decision maker and bread winner's role
      • Natural and home-made food only to more processed, junk and outside purchases
      • Physically active pedestrian transport to motorized transport

      4.4 Key suggestions for policy

      • Health services need to be more family focussed
      • Services for elderly need to be delivered at doorstep
      • ASHA workers need to have more advocacy role for motivating beneficiary for utilization of public health programs
      • More day care home (pakal veedu) for elderly needed
      • Counseling hubs for parents needed
      • More and effective coverage of financial protection schemes needed (expansion of family safety-net)

      5. Conclusions

      The study explored changes in the family structure and functions that happened in contemporary families in Kerala and the stakeholder perspectives on utilization of health services.
      Nuclearization of the family and its consequences, suboptimal levels of breastfeeding, changed women's roles consequent to new job positions and educational involvement, non-communicable disease-promoting lifestyle changes, intergenerational gap in communication, marital extravagances and dowry practice, increased stress to parents needing counseling, pressure on children leading to academic stress and suboptimal service utilization were the major problems reported by respondents.
      The study showcased the suggestions from respondents like scaling up counseling facilities for young adults, counseling services for parents, establishing and scale-up of services for children with special needs, care of the elderly through more door delivery of drugs and other essential materials, home care of the elderly, arrangements for short-stay homes etc.
      The stakeholders appreciated efforts taken by Govt. to increase the quality of services and efforts for more access and utilization through ASHA workers, new facelifts given to public health services, palliative care initiatives, and financial protection schemes for the elderly and disabled.
      The overall utilization of public health services was reported to be more increased. Outpatient facilities need more customization according to the convenience of end-users in terms of timing, behavior modification of staff, and supplies and facilities. The necessity for family focused health care was strongly urged. In spite of the appreciations for health system there was also suggestions for more advocacy role of ASHA workers. These were reported to facilitate more community participation in health programs, home-level delivery of drugs, and motivation to use health services.

      Funding

      The project was an intramural research project fully funded by the Kerala University of Health Sciences , Thrissur, Kerala.

      Declaration of competing interest

      None.

      Acknowledgments

      We sincerely acknowledge the support and valuable suggestions (academic) for the smooth conduct of the study given by Dr. Harikumaran Nair, Former Dean Research. We acknowledge the support and administrative oversight of Hon’ Vice-Chancellor, Registrar, and Pro-Vice Chancellor- Kerala University of Health Sciences.

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