In the previous lecture, we discussed the importance of family for adolescent health and well-being. Highlighting the need for parents of adolescents to develop a wider set of skills, then is required to parent younger children. In this lecture, we will talk about various policies that influence families, that as a result can influence adolescent health and development. We know that families provide the most important protective factor for adolescence, just like in younger children. However, photos of happy families like these, suggest a very limited concept of what constitutes family. And what constitutes a family has changed and continues to change. Whether in relation to the rise of single parent households in many parts of the world. Including the increasing unmarried mothers, the extend of blended families, and the rise of nontraditional families, with parents who are lesbian or gay, or transgender. While families are themselves changing, the pressures on families are also changing. Longer hours and longer commuting times in a context of increasing urbanization and the growth of mega cities affects family life. Whether in single parent households, or the increasing number of families where both parents are working. Longer working hours, less secure employment results in parents being at risk of more stress, with repercussions for the relationships between parents and children. This is perhaps even more challenging in families affected by unemployment. The flow on effects can be dramatic. Less parent time at home, reduces the likelihood that families eat together. A significant protective factor in young lives. Like a parent time can translate to greater relies on fast foods. With negative health consequences due to higher salt, sugar and fat than in home cooked meals. And reduced parent availability results in fewer opportunities for adolescents to learn and gain skills through participating in family life. What are the implications? Increased family conflict, reduce supervision of adolescence, more unhealthy lifestyles, and reduced opportunities for young people to learn critical life skills. Are all risks, none of which promote adolescent health and development. As Leo Tolstoy wrote in his novel Anna Karenina, all happy families are alike. Each unhappy family is unhappy in its own way. Tolstoy clearly appreciated that in addition to the benefits of happy families, that families can also provide environments that are risky for children regardless of the nature of the family and how this is changed over time. The genetic contributions that each parent passes down is a particular form of family risk with known genetic associations or, for example, mental disorder and substance dependence. However, beyond genetic risks, families who have a past history of a problem such as those shown here, where there is poor family management of problems. Where there is family conflict and where parent attitudes and behaviors condone the behavior are risk factors for each of these outcomes. It is interesting to consider the effect of China's major family planning policy, known as the one child policy on adolescent health. The one child policy, is a population control policy introduced in 1979 with a goal of alleviating social and economic problems in China. The term one child is a slight misnomer, as the policy allows for many exceptions. However, in 2007, 36% of China's population was subject to a strict one child restriction. An additional 53% was allowed to have a second child if the first was a girl. Demographer's estimate that the policy has averted at least 200 million births since it was introduced. Although the extent of policy impact on this reduction is contested. Beyond this however, there are other controversies with accusation of human rights abuses in relation to its implementation, such as foster abortions and sterilization and a range of unintended social consequences. One unintended social consequence is known as the Little Emperor Syndrome which refers to the extent of attention, spoiling and over indulgence from parents and grandparents that single children risk receiving. In addition to the Chinese Emperor, I hope you like the Emperor family penguin group I've shown here. Especially when combined with increased spending power within the family unit. And parents general desire for the child to experience the benefits they themselves were denied. It is interesting to think about the effect of over indulgence on, for example, overweight and obesity. Together with behavioral concerns that persistent spoiling in early childhood, such an interpersonal problems like anger management. Both which will have persistent influence in adolescence. A further unintended consequence is that disturbance to China's sex ratio. Which is widely believed to reflect its one child policy. The sex ratio is the number of boys per 100 girls. A normal sex ratio at birth is between about 103 to 108. That is, there are slightly more males born than females. However, as can be seen here in this figure on the sex ratio of one to four year old in China, there has been a dramatic increase in the ratio, especially in the last decade of the last century, such that 116 boys are now born for every 100 girls in China. Possible implications of this distortion in young adulthood, which results in a relative lack of young women are increased rates of loneliness in males, depression compounded by not being able to find a partner or wife, higher rates of substance use. And high rates even of transactional sex with its risks of unsafe sex. The same pattern of disturbed sex ratios is widely apparent in Asia, with trends shown here for China, India, and South Korea. What do you think might account for such a rapid change in the sex ratio? You may want to pause here and think about it. There are concerns that, in addition to infanticide of female babies, that widespread access to antenatal ultrasound has been responsible for high rates of termination of pregnancy or female fetuses. This slide shows rapidly changing attitudes in South Korea about the preference for sons. In 1985, nearly one in two women reported that they must have a son, in comparison to less than one in five in 2003. However, the sex ratio at birth in South Korea remains high. The belief that one must fulfill one's filial duty to continue the male family line remains significant. And even in 2003, women continued to report significantly higher son preference. If your husband was an only son, and therefore the only source of male descendants. Public policies in these countries are increasingly being put in place with the effort of increasing gender equity through interventions aimed at changing people perceptions that daughters are less desirable than sons and by bringing women increasingly into public life. Interventions to change family and community attitudes about gender roles and equity include legislation in domestic and public health. Vigorous media campaigns and sponsorship of grassroots women's organizations. These are part of the changes required to change gender norms and that will better empower women and girls. Which will have major implications for health, through better education of girls, delayed marriage and parenthood, and reduced interpersonal violence, among many other factors. National laws and policies function to support families. Many of these are with the goal of alleviating poverty. Whether through social welfare policies, employment policies, or gender policies and are thus a mechanism of improving health of adolescence. Conditional cash transfer programs aim to reduce poverty by making welfare programs conditional upon the receivers actions. The government or agency, only transfers the money to specific persons who meet the criteria. These are often oriented towards health and education, such as enrolling children into schools and engaging in preventive health care, such as being vaccinated and having regular health checkups. The aim is to break the cycle of poverty for the next generation. Most conditional cash transfers are made available to women. Which also greatly increases their bargaining power within the family. These programs have been rolled out in many countries especially in Latin America, where conditional cash transfer programs such as Brazil's Basal Familia and Mexico's Opportunitadas, cover millions of households. In Bangladesh and Cambodia, conditional cash transfer programs have been successfully used to reduce gender disparities in school enrollment. There are however, some concerns that while rates of school enrollment have increased, there is less clear evidence for improvements in educational achievement and employment. Suggesting that the quality of the educational and health interventions also need to be considered as well as various complementary, social supports. It is also possible that unconditional cash transfers can generate improvements in health and education without the high costs of monitoring recipients compliance with various conditions. The Zomba study in Malawi compared conditional and unconditional cash transfers to teenage girls and their family's. The researchers explored both direct effects, such as education and indirect outcomes, such as delayed marriage, and HIV prevalence. Among girls who were in school at the start of the program, conditional cash transfers increased school attendance and reduced HIV prevalence. Unconditional transfers were more effective in helping girls delay marriage and childbearing. It appears that the unconditional transfer allowed girls who dropped out of school and therefore would have otherwise stopped receiving conditional payments to support themselves without relying on a husband or having transactional sex with older men, thereby delaying marriage and childbearing. While our methods and results have been challenged slightly, the Zomba study is one of the earliest that have attempted to untangle these impacts of conditionality in cash transfer programs. And these are but some examples of the relevance of family policies for adolescent health.
