Ahmed Itrat1  ( Medical Students, Class of 2008, )
Ather Mohammed Taqui  ( Medical Students, Class of 2008, )
Fahd Qazi  ( Medical Students, Class of 2008, )
Waris Qidwai  ( Department of Family Medicine,4, The Aga Khan University Hospital, Karachi. )

Objective: To know the present status of family systems in Pakistan, changes they are undergoing and implications of such trends on health of the elderly population.

Methods: A cross-sectional study was carried out at the out-patient clinics, AgaKhan University Hospital, using convenience sampling method. Verbal informed consent was taken from the participants. The questions included demographic profile, satisfaction with current family system, opinions about changing trends of family systems, and their implications on health. Analysis was done using SPSS 13.0.

Results: Four hundred subjects aged 65 and above were interviewed, out of which 226 (56.5%) were living in the joint family system (JFS), whereas 174 (43.5%) were living in a nuclear family system (NFS). A total of 77.5% respondents were in the age class of 65-70 years (mean=69).Majority were men (78%), married (78%), retired (55.8%) and with education below intermediate (61.8%). A total of 366 (91.5%) respondents were satisfied with their family system. 326 (81.5%) respondents said that the trend in family systems in Pakistan was changing and 318 (97.5%) of these subjects thought that it was a JFS to NFS trend. A decline in the proportion of JFS was seen with subsequent generations. 340 (85%) subjects said that a family system has a significant impact on health care.

Conclusion: We have identified changing trends in family systems in Pakistan. Satisfaction with family system and the opinion about the role of a family system on healthcare is documented (JPMA 57:106;2007).

The advances in the field of medicine over the past fifty years have lead to an increase in the average lifespan of the population. An increase in the elderly population requires continued provision of good quality support services for them.1
In the developing countries, ageing issues have only recently begun to emerge as a cause for concern.1 A great deal of support for the elderly comes from within their households. Indeed, several ASEAN (Association of Southeast Asian Nations) surveys conducted have shown that most of the support for the elderly in Asian countries came from their children and/or grandchildren.2,3 However, it is likely that before long, family nucleation would create voids in the traditional joint family systems that have persisted in Asia. Mason has suggested that further economic growth and urbanization are likely to erode the family's ability or willingness to care for elderly members.4 So far, no attempt has been made to determine how important a role a family plays in providing support for the elderly. Therefore, it is imperative that we identify the factors in a family system that the elderly think are important in their support and care, and to find out their opinions about changing trends in the family structures.

Patients and their attendants aged 65 and above visiting the Aga Khan University Hospital, Karachi were interviewed over a period of one month. The interviews were questionnaire based. The initial questionnaire was developed based on issues identified through literature search. A pilot study was carried out on 25 subjects to screen for potential problems in the questionnaire and to get an idea about responses to our open ended questions.

Interviews were conducted using convenience sampling. The interviewers discussed the questionnaire before data collection to eliminate interviewer bias. Written Informed Consent was taken from subjects after they were explained the study. Assurance with regards to confidentiality was provided.

The questionnaire was divided into four short parts. The first part comprised of demography and other relevant parameters. The second part covered the current family system of the subjects, their satisfaction with it and reasons for satisfaction or dissatisfaction. The third part assessed trends in family systems and the subject's opinion on whether the trend they identified was good or bad. The fourth part had questions on the subject's opinion on the impact of each family system on health.

Data entry was performed on Epi-Info v 6 and analyzed using SPSS v 13.0 software.

Definitions
Joint family system (JFS) is two or more nuclear families that form a corporate economic unit.5

Nuclear family system (NFS) is a family unit consisting of parents and their dependent children.6 For our purposes, this definition was extended to include only those families which comprised of parents and their unmarried dependent children. A family unit consisting of a single married or unmarried individual was also grouped under a nuclear family system.

A total of 400 subjects aged 65 and above were surveyed. Majority were married (79.3%), males (78%), presently living in a Joint Family System (56.5%). A 77.5% of the population fell in the age range of 65-70 years, with the mean age being 69 years. Majority of the subjects had an education level below secondary (36.8%). Most of the males were found to be retired (55.8%) from their service. Demographics parameters are provided in Table 1.

Table 1 also lists the major differences among patients with regards to JFS and NFS. Satisfaction with their current family system was expressed by 91.5% respondents. The level of satisfaction was found to be more among people in the JFS group (96.5% vs. 85% in NFS). In the Joint family setting the major reason for satisfaction was given as general support in everyday life provided by the family members (53.7%). Out of those who expressed dissatisfaction with their joint family system (3.5%), majority provided the reason to be frequent arguments between the family members (50%). The major reason for satisfaction among those living in NFS was more peace of mind (53.1%). Out of those who expressed dissatisfaction over their nuclear family system (15%), the major reason for this dissatisfaction was provided as loneliness and boredom (58.3%). Reasons for satisfaction are provided in Table 2.

For the assessment of trends in the family systems, it was observed over 3 generations. For that purpose, only those who knew their parents childhood family system were taken (89.75%) and the major trends in the subsequent generation was found. The percentage of people living in the joint family with each generation was falling (Generation 1 = 92.5%, Generation 2 = 81.2%, and Generation 3 = 58.2%).

As regards the opinions on the trends, 81.5% thought that the trend was changing. Out of these, the majority (97.5%) thought that it was a JFS to NFS trend.
Upon inquiring whether a family system plays any role in health care, majority 340 (85%) said that a family system plays a significant role in health care. JFS was the preferred family system in both acute and chronic illness (91.5% and 89.4% respectively) as well as emergencies (93.5%).

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Figure 1. Trends of family systems among three generations.

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Pakistan has long enjoyed the strong cultural heritage that has been inculcated into the lifestyle of its people for centuries. The value of a strong family system has played an important role in influencing an individual's living, social role, profession and decision making. The elderly form a central beacon in a traditional Asian family, where they are treated with reverence and hold an authoritative place.1 They are looked upon as the primary source of guidance. In return, they are provided with care and support from the family members. In recent times, however, changes have been noted in our family systems, whereby several factors have emerged to influence the way the structure and function of families is evolving. Our objective was to identify these factors, show the changing trends and the way they have influenced the lives of the elderly population. We also assessed the roles family systems play in healthcare for the elderly.

The large sample size of four hundred ensured that the demographic profile of our sample matches the demographic population of Karachi as a whole.7 The male and female ratio of 7 : 2 does not match the actual male : female ratio of Karachi. The major reason for this discrepancy was the higher rejection rate from females, partly because of their lower education level and conservative nature.7 Majority of the population fell in the age range of 65-70, which is consistent with the life expectancy in Pakistan.7

The requirements of an aging population change with time. Due to a drastic change in their lifestyle after retirement, characterized by sudden decrease or loss of income, poor pension and other retirement benefits, and lack of physical work, the elderly are prone to develop mental and physical ailments.8,9 Furthermore, their abrupt transition from head of the family, which is dictated by his or her earning status, to a passive participant in decision making, leads to lower self-esteem. In this vulnerable period, they are susceptible to psychological stress. Conflicts within the family and low self-esteem contribute to the psychological stress. The expectation that their family, especially the children, will look after them, even if they don't live with them, also increases. All these factors call for support from the family in three main aspects: physical, social and financial.1 An elderly person whose family provides such support is likely to express satisfaction with his family system.

We assessed the level of satisfaction of our subjects with their current family system. The level of satisfaction was found to be higher among people living in the joint family group. In the joint family setting, the major reason for satisfaction was given as general support in everyday life provided by the family members, which included all the three aspects - physical, financial and social. These subjects were more dependent on their family members and preferred the JFS because of this advantage. A significant proportion attributed financial support specifically, to be their reason of satisfaction. These subjects ascribed social and physical support to be a less important factor contributing to their care than financial.

Providing reasons for their dissatisfaction, majority of the elderly population in the joint family setting commented that the frequent arguments arising in the family due to a large household size was a major disadvantage. Weakened family ties decrease the quality of care for the elderly. Also, the elderly who had to contribute to the family budget thought the joint family system creates a burden for them as they have limited resources. Indeed, it is known that older persons provided monetary assistance to the family budget from their savings.10 Thus, in such situations, the elderly are likely to express discomfort in a large household encountered in a joint family setting.

Comparing these findings with those in the nuclear family system, one can see how the elderly population accepts independence. A great majority said they were satisfied with their nuclear family system as it provided them more peace of mind. This was a direct reference to the fact that their being away from family arguments decreased psychological stress. This also tells us that they value their psychological well being much more over other types of support they get living in a joint family. Other reasons for satisfaction with the nuclear family included the subjects' independence in taking decisions, and the fact that their children have settled was a fulfillment of one of their essential responsibilities. Coming to reasons for dissatisfaction, a significant proportion said it was loneliness and boredom, once again highlighting the importance of social support in elderly care.

It has been noted that the traditional joint family system is on a decline and that it is being replaced by a newer system of small family units among the population of South Asia. To investigate this, we assessed the opinions from the respondents about whether there are changing trends, and if yes, in which direction. Furthermore, three subsequent generations of the subjects were assessed, and opinions about how this changing trend is influencing the family systems were taken. From the population sample, it was observed that of late, the number of people having a joint family system is falling, with the current generation showing a much sharper fall than the previous one.

Several factors play critical roles in determining what kind of a family system is followed. The size of average households, the propensity of adult children to remain in the parental household, the socio-economic framework of the family, physical as well as psychological health of members of a household, urbanization of the society, intricacies and complexities within a family unit, and the influence of media over the masses have all played a vital role in determining transitions in the family structure and composition.11 Pakistan witnessed a marked increase in the previous two decades with the average household size increasing from 5.7 in the 1970s to 6.7 in the 1990s.12-14 This increase in the household size, has had profound effects on family structure because of increased financial burden on the bread-earners and the intra-familial complexities that arise in a joint family. Urbanization processes tend to stabilize the nucleation of the family system because urban congestion and housing patterns, particularly of the low income groups, discourage large households.15-19 Current statistical data indicates rising unemployment rates. This rise has forced job-seekers to look for opportunities away from home. This, coupled with reluctance of parents to leave home has brought about changes in the family structure, leading to family dispersion, with children's support mostly reducing to mere financial, or even none.

A large percentage of respondents living in both the systems thought the family system trend has changed over the last few years and that the change was towards the nuclear family system. Considerable proportions in both sets of respondents observed this change to be bad, with a significantly higher proportion in the subjects coming from a joint family. About half of the subjects representing nuclear family system thought that the nucleation of family systems was a good change.

Important issues for the elderly are specific health services which are lacking, and most services are hospital oriented rather than home based. Nursing facilities are highly expensive. All these factors indicate a skewed opinion of the elderly towards the role of a family system as regards their health needs. Additionally a great majority of respondents confirmed that in both chronic and acute forms of illnesses as well as emergencies, a joint family system was suited better to cope with such an eventuality. Reasons noted for these responses indicate that social, more than any other form of support seems to be the primary reason why joint family systems are preferred by the elderly to cater to their health needs.

Concluding the questionnaire with the opinions about the respondents' ideal family system, we observed that a greater proportion were willing to accept the traditional joint family system despite some drawbacks. Also majority of the elderly population preferred the joint family system but because of intra familial conflicts chose to live in a nuclear setup.
Conclusion

From our findings, it can be concluded that a major change is occurring in the family systems, with most people shifting from a joint family to a nuclear family setting, despite the preference for the joint family. The reason for this change can be explained by the convergence theory which states that households become less extended, more nuclear as societies industrialize and urbanize.11 Other interrelated factors that influenced the shift towards NFS were size of average households, the socio-economic status of the family, physical and psychological health of household members and the influence of media over the masses. Further studies would need to be conducted to measure the contribution of each factor towards the shift from JFS to NFS.

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15 De Silva WI. United Nations: "Demographic and Social Trends Affecting Families in the South and Central Asian Region," Major Trends Affecting Families.May 2003. p 4. (Accessed 2006 June 27). Report archived at: http://www.un.org/esa/socdev/family/Publications/mtdesilva.pdf Tables archived at: http://www.un.org/esa/socdev/family/Publications/mtscatables. pdf

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