Children and family breakdown: report on a WHO meeting, Kiel, 4–7 December 1984

( t v 0( G • l ' World Health Organization 1t,-\) Regional Office for Europe ~ . . ~ Copenhagen~ r/! EURO Reports and Studies 101 Children and family breakdown Report on a WHO meeting Kiel 4-7 December 1984 IC P/ 1-ISR .10 1/ m0J ISBN 92 890 1267 6 ISSN 0250-87 10 © World Health Organi za ti o n 1986 Publi ca ti o ns o f the Wo rld H ea lth Orga ni za ti o n enj oy co pyri ght p ro lccti o n in acco rd a nce with the provi sio ns of Protoco l 2 o f th e Uni ve rsa l Co pyri g ht Co nve n- ti o n. Fo r rights o f rep rod uctio n o r tra nsla ti o n. in part o r in 10 10 . o f publi ca ti o ns iss ued by the WHO Regio na l Office fo r Euro pe a ppli cati o n sho uld be made to th e Regio nal Offi ce fo r Euro pe, Sc herfigsvej 8, DK-2 100 Co penh age n 0 . Denma rk . The Regio nal Office welco mes suc h appli ca ti o ns. The design a ti o ns empl oyed a nd th e prese nt a ti o n o f the ma teri a l in this pu bli - cati o n do no t impl y the ex press io n o f a ny o pini o n wh a tsoever o n the pa rt o f th e Secreta ri a t o f th e Wo rld Health Orga ni za ti o n co ncernin g th e lega l sta lUs o f a ny co untry. te rri to ry, cit y o r a rea o r of its a utho rit ies. o r co nce rnin g th e delimit a ti o n o f its fro nti ers o r bo unda ri es . Th e menti o n o f specifi c co mpa ni es o r o f ce rt a in manufa cturers' p rodu cts docs no t impl y th a t th ey are en do rsed o r reco mm end ed by th e Wo rld Hea lth O rga ni z- a ti o n in preference to o th ers ofa si mil a r na ture t ha t a re no t menti o ned . Er ro rs a nd o mi ss io ns excepted , the na mes o f prop rieta ry produ cts a rc di stin gui shed by initi a l ca pit a l lett ers. The vi ews ex pressed in this pu b lica ti o n arc those o f th e pa rti cipa nt s in the meetin g and do no t necessa ril y rep rese nt th e decisio ns o r the stat ed po li cy of th e Wo rld Hea lth Orga ni zat io n. l'RIN l"ED IN llLNMi\RK CONTENTS Page Introduction Organization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Fami ly breakdown 4 A health issue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 The innuence on chi ldren . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 A framework for action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Family support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 A comprehensive service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 The nursing contribution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I 0 A political dimension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 A future perspective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Conclusions and recommendations ......................... 12 Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Coord ina ti on of services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Int erventi on and prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Nursing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 A political dimension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Annex I. Projects and sche mes in the informal sector . . . . . . . . 20 Annex 2. Participants .. .. .......... ........ .. ........ . . ... 23 Summaries in French, German and Russian ....... .... . . .. .. 27 INTRODUCTION The W orking Group on C hildren a nd Fa mil y Brea kdow n: the Pos iti ve Ro le o f Nurses and Midwi ves, co nvened by the WHO Regional Office for Europe in collaboration with th e Federal Republic o f Germany and th e In stitut fur Ges undh eit ssys tem- Fo rsc hun g, Kiel, was a tt ended by members of a number of hea lth di sc iplin es, represe nt a tives of co mmunity gro ups and jo urnali sts fro m th e nurs in g a nd po pul a r press. The participants a re li sted in Annex 2. The purposes of th e meeting were to : s upplem ent th e availa bl e data a nd perceptions o n the hea lth iss ues rela ted to family breakdown within the Regio n; review the implicati o ns of these iss ues in rel a tion to the hea lth for all targets o f th e WHO Europea n regi on; se nsitize health workers and th e community to the ma ny as pect s of these issues so th a t they will exa mine the ro le of nurses , midwives and the community in the prevention o f the ill effects of famil y brea kd ow n and in the promotio n of family hea lth; encourage discu ss io n about these hea lth issues among the formal and informal hea lth sys tem s and representatives of the community; and demonstrate an alternative way of involving members oft he community in WHO meetings by organizing the meeting in an innovative way. The meeting was opened by Dr M . Farrell, Regional Officer for Nursing, on behalf of the Regional Director, Dr L.A. Kaprio . Professor F. Beske, Director of the ln stitu t fur Gesundheitssystems- Forschung welcomed th e participants to Kiel and introduced Mrs A. Schuster, Parliamentary Secretary of th e Sozialministe- rium des Landes Schleswig-Holstein. Mrs Schuster discussed the importance of family life and said how pleased her Government was to be associated with th e meeting. Organization During the meeting the participants were divided into three groups. The community representatives and the health professionals formed two panels, with the press group as their audience. The idea was to crea te a dialogue between the two panels, with the addition of pertinent questions from the press. The journalists were also asked to prepare a booklet on family breakdown, based on the discussions and papers they had heard during the meeting. At the outset, the two panels clearly held different opinions on the issues and each had difficulty in coming to terms with the standpoint and contribution of the other. Towards the end of the meeting, both groups acknowledged this gap and decided to meet together to thrash out some of the issues. They did reach some agreement and in the end both were anxious to encourage greater collaboration between statutory services and voluntary groups. This theme runs through the whole report. Background During the last 40 years there has been a quiet social revolution in Europe. The family, which for generations was the focal point of social cohesion and the basic unit for reproduction, sociali za ti on and economic production, has been transformed. Social, political and economic developments have altered its structure and functi on, leaving a more complex and, in the public mind, a more confusing pattern of fami ly groups. 2 Before the 1940s a large number of people did not marry. Those who did marry commonly waited until their late twenties to do so, and childbearing was extended over many years. The roles of dif- ferent members of the family were usually clear, and religion played a prominent part in family life across the continent. Recently a radically different and more complicated picture has emerged. More people marry now than in the past, but they do so at a younger age and have fewer children over a much shorter period. Moral codes based on formal religion appear to have a decreasing influence. At the same time, forms of cohabitation other than marriage have become more common. In Sweden, for ex- ample, 40% of the population lived in official marriages in 1968 while 0. 7% just lived together. By 1981 only 17% were in official marriages while 23% had what have been called "concensual unions". As the structure of the family has changed, so has its function. For the most part it is no longer an economic unit. Therefore, members of a family cannot share the experiences and problems they have at work. Indeed, a husband today is likely to know more about events on the other side of the world than about his wife's job. Increased mobility exacerbates this trend and leads to more oppor- tunities for married people to meet alternative partners. The traditional male and female roles in marriage have also changed . Today childbearing takes up a smaller proportion of women's lives, and women are more likely to work and be finan- cially independent of their husbands. These are only two of a host of factors that have affected women's attitudes towards marriage and domestic work. Also, improved contraception has not only helped decrease the number of children in the family but has encouraged women to seek a satisfying sexuality of their own. One consequence of these changes has been to deprive men and women of clearly defined role models upon which to base their behaviour as parents and spouses. The increase of self-confidence in women has been accompanied by a general rise in expectations among both sexes. The aim of most people today is to be happy, whereas in the past much of life was spent avoiding different kinds of suffering. The modern family is not bound together by the need to survive or the economic interdependence of its members but by emotional ties . The key ingredients for these are love, support, intimacy and sexuality. 3 FAMILY BREAKDOWN Given this background, it is hardly surpnsmg that the greatest change of all has been the enormous increase in the number of fami lies breaking up. A break-up is the separation of fami ly mem- bers; a breakdown occurs before the break-up when a family's internal support system stops working. Official divorce statistics describe only a part of the picture, since they do not cover the separation of unmarried couples and, of course, provide no information on the impact of divorce on the lives of those concerned. Nevertheless, they reveal a major social phen- omenon that clearly has repercussions for the health and social services. Although the incidence of divorce is similar for all socio- economic groups, it varies significantly among the countries of Europe. The rates are highest in the northern and eastern nations and lowest in the southern countries, while those in central Europe fall between these extremes. A health issue We may be able to count the number of divorces, but it is far from easy to gauge the effect of family break-ups on the men , women and children who live through them. It is clear, however, that a divorce is not necessarily a sign of failure. Too often we view separation as the worst possible option, when in reality it can successfully resolve an unsatisfactory situation. At least some of the pressures on one- parent families and other divorcees derive from social attitudes that describe them as failures , odd or second-rate. This is unjust and inaccurate. Apart from anything else, these people are no longer exceptional. For example , one million single-parent family units , with 1.6 million children, now live in the United Kingdom. Along with other kinds of assistance to the family, society must recognize the changes in family structure and, with this understanding, show greater tolerance of alternative social groups. Although we should recognize that a break-up can be a positive event, some evidence links it to ill health. However, the data should be interpreted carefully. We have to accept the difficulty of isolating divorce as a factor in illness and it is especially hard to determine 4 whether the increased vulnerability of divorcees is due to extraneous soc ial or eco nomic pressures, to psycho logica l traum a, or to some combination of these factors. A pe rso n's risk o f ill hea lth depe nd s o n ma ny varia bles, in- cluding th e number o f siblings, socioeco nomic status, soc ial net- works, th e nature and duration o f the breakdown process a nd th e person's stra tegies for coping wit h it. Several stud ies o n adu lt s show higher rates of morbidity and mortality a mong divorcees than a mong married, widowed or single people. Divorcees have higher rates of death from ca ncer, diabetes, pneumon ia, hype rt ension, ischaemic heart disease and suicide, as well as increased morbidity from alcoholism, infections a nd psycho- soma tic disorders ( /). Men a ppear to have a higher risk of ill health fo ll owin g separ- ation than women. This may be because the change in their lives is grea ter, due to lone li ness, a reduced standard of living and the loss of domestic service and contact with their children . They are a lso more likely to suffer psycho logical disorders and to abuse alco- hol (2). In one survey, researchers found that many divorced men felt they had been abandoned. This resu lted in strong feelings of ag- gression towards their ex-wives. The risk of violence is greater among men with low self-esteem and those without support from fr iends and relatives (2). The influence on children The short-term effect of family breakdown on children is well documented and, as might be expected, the children's ages are important in determining how the separation will affect them. Even an unborn child is at greater risk since its health depends on that of its mother. A woman is more likely to have a premature baby or one with a low birth weight if she is single, and such children have increased rates of morbidity and mortality in both the short and long terms. A family separation immediately after birth can also be critical (3). For exa mpl e, loss of co ntact with th e father in the fi rst years of life can cause identification problems, particularly for boys. Al- though at thi s stage family brea kdown often ca uses developmental and behavioural reta rdati o n res ulting in lasting damage, young 5 children have a remarkable ability to make up lost ground and in the long term, if the crisis is managed, they will probably show no health deficiencies. Further, children from three to five years old can exhibit considerable distress through regression, and behavioural and psychological disorders such as aggression, fear and sleeping disorders. However, these children also have a high recovery rate , and almost no long-term effects are discernible 5-10 years later. When they are between six and ten, children are more likely to react to family breakdown with sorrow and depression. Even when the family history seems clearly to favour a divorce, as in cases of vio lence in the home, the children may have a strong sense of loss and guilt (4). Amazingly, children of this age can give emotional support to their parents, although they are also susceptible to parental manipulation. Separation tends to affect boys more than girls in this age group. During puberty and adolescence children feel intense pain, along with anger at their parents for having let them down at such a crucia l point in their lives. Again, boys appear to experience more problems but can recover fully. Those who are able to detach themselves from the separation have the best prognosis (5). When assessing the impact of family breakdown on children, one must bear in mind the differences between individuals and the nature of the separations that they endure. The process can take many forms and has not been adequately explored in research. Long-term effects, such as criminality, problems with sexual be- haviour, low self-esteem and psychopathological reactions, need further study. More population-based studies should be done, and the data of existing studies should be used more fully (6). Again, family breakdown is only one result of modern living patterns, and effects attributed to separation possibly depend on other factors within and outside the family. If social attitudes to- wards divorce change, perhaps the pressures that lead to ill health will diminish. A framework for action This report will not explore in detail the complex theories that seek to explain and describe crises or breakdowns and methods of man- aging them. However, the stages through which a fami ly will pass during the breakdown process can be identified. Then appropriate 6 preventive or remedial services can be devised. Health professionals are sometimes criticized for providing haphazard aid or, at best, emergency first-aid responses . If families are to receive positive help, health professionals must offer planned and evaluated services. The family can be seen as having a natural equilibrium (7). The family essentially regulates itself, maintaining its balance and coping with the stresses and strains put upon it. A family breaks down when this balance is lost and the system is disrupted. This can occur because the external stresses on the family are too great or when its ways of coping are weak . In the initial stages of breakdown , family members may well be aware that things are going wrong and look for information and skills to enable them to bring themselves back into balance. The fami ly is said, therefore, to be in a teachable moment, when short- term help can be extremely effective (7). Without such help, the family may continue to react in a disorganized way and these ineffective patterns of behaviour will become habits. Intervention at this later stage, when the family is in crisis, is often more prolonged and complicated. Prevention With this framework, three distinct stages of intervention can be set up to plan services, using the notion of primary, secondary and tertiary prevention. Primary prevention should be undertaken with all families and even with children, and would attempt to prevent problems from arising. This would involve extensive health edu- cation in schools about the roles and responsibilities of parenthood, information for couples before marriage and guidance for families that would identify the periods when they are most at risk of breakdown, such as during pregnancy, when the first child goes to school, and when al l the children reach adolescence. Primary pre- vention would have three aims: to identify stresses that are likely to lead to breakdown, to reduce their impact, and to build up the family's ability to cope with th em (8). Secondary prevention would detect a potential breakdown when the family is likely to be receptive and at its most teachable moment (7) . This would require some form of continuing surveil- lance, a system for identifying families at special risk and a mechan- ism for early intervention when a problem is suspected or detected. 7 Tertiary prevention services would tackle the problem when the family has entered the breakdown process and is already in crisis. Obviously, ways must be found to identify these families and offer support that will help them eit her to rebuild themselves or to break up in the least harmful way. At present most health and social care is a kind of tertiary prevention, although the problem of family breakdown has received few services of any kind. Health professionals should use primary and secondary prevention because intervention is most effective in these stages. Family support Little is known about the range and variety of services available to help families in Europe. The availability and quality of services seem to be uneven, but many examples of good practice and inno- vation exist and should be revealed and encouraged. A descriptive study of family support services in Europe is a necessary first step towards improved provision. In this report a distinction is made between formal and informal services. Formal services are those provided by the state or those governed by some form of statute. Informal services are all those not in the formal sector, including those provided by national voluntary organizations, self-help groups and local community bodies. The informal sector also encompasses the unorganized social networks that help support most individuals and families. Four examples of informal services are given in Annex I. Neither system can answer all the needs of the family. The state system, because it is held accountable, is generally less flexible and reacts slowly to new demands. On the other hand, it tries to provide services as a right and must spread its limited resources as far as possible. The informal system is naturally varied, since there will be different services in every area, but it can change more easily, and it will often appear more accessible and responsive. The line between the two is not clear, and the systems can overlap. For example, a state system sometimes assists in setting up self-help groups or provides a counselling service similar to one run by a voluntary organization. However, a good relationship must exist between the formal and informal systems, and bringing the two together and fostering better understanding and cooperation 8 between them will be an enormous task . Each system must maintain its own strengths; the informal sector has no desire to adopt the responsibilities of the state. Only if both operate effectively will families have a choice. The formal and informal health systems, then, must strike a balance. Services should be contructed to meet defined local needs . The formal and informal sectors should make a loca l, coordinated plan of services for families. This would encourage cooperation between them and identify limitations in the existing services. As part of the plan, the formal sector could give practical help to small local groups, such as providing rooms for meetings and admin- istrative support. Such a plan would also establish guidelines for a free exchange of referrals between all agencies and set up ways of sharing information and knowledge. Above all, the people in each sector must be willing to recognize the contribution of the other. To achieve this, professional staff working in the formal sector could be attached to local groups and projects. Their training programmes could be adapted to include a study of the role of the informal sector. Finally, to avoid duplication of services, professiona l staff could aid and advise community organizations. In addition, people in the informal sector should make greater use of statutory services and seek the cooperation and help of professionals working in it. Not only health professionals and activists, but also the families in need, must be aware of all the services offered in their area. A comprehensive service A universal blueprint for family services would be impractical and undesirable, because local services should be constructed to meet local needs. The programmes should respond to new demands as they arise and must be in tune with the culture and traditions of the people they serve. Informal systems will naturally take on different tasks in different areas and cannot be standardized. Significant gaps clearly exist in current services, and, although a comprehensive review of available services has not yet been made, one or two areas where new services might be developed can be identified. Primary prevention work with schoolchildren and young couples has already been mentioned . The neighbourhood family centres 9 esta bli shed in a few places in the United Kingdom may offer a new kind of support to families by making them aware of services and helping to deflect potential problems. Few countries see m to have adequate services for fam ilies in cris is a nd specia lized services are urgently needed to offer help and support at th is critical stage. In addition, when considering a break-up in volving the legal profession, a fami ly must too often endure a prolonged and painful process of separation. Ma ny cou ntri es need to develop effective concili at ion services. These shou ld not simply encourage fami lies to stay together but should help them reach the most satisfactory sett lement for all concerned. The nursing contribution The public has a we ll known and limited view of nurses and the media tend to show stereotyped images of them (9). These mis- co nceptions must be cha llenged if nurses are to be effective agents work ing with families throughout Europe . Nurses have been seen as practitioners who tend the s ick in hospitals , an image a long way from the idea of a fami ly or community health nurse in a number of European countries (JO). Nurses can make a specia l contribution towards the prevention of fami ly brea kdown simply because they are there . Nurses who work in ante- and post-natal care, in child health clinics, in the school health serv ice, in district health clinics and in other se ttings wi ll encounter families going through breakdown in all of these sit uations. With the trend towards primary care and the policy of transferring resources into the community, the opportunities for and expectations of th e nursi ng profession will increase. Where they exist, family o r community health nurses have been useful and effective sources of family services . Such a nurse has the advantage of working with families at times of greates t stress, such as births, children's formative years and the last years of life, and she is often more acceptable to the family than some o th er health professionals. For example , in some cou ntries less socia l stigma is attached to being seen by the nurse than by a psychiatrist or a social worker. Also, clients can approach the nurse with a physical prob- lem a nd th en allow the emotional co ncern behind it to emerge 10 during th e consu lt ation. Often th ere is less of a social gap between nurses a nd th eir c li ents and, again, this may m a ke an a pproach eas ie r and the relation ship more relaxed . The community health nurse also has the advantage of see in g many fami lies and deve loping contacts with them at times of calm, as we ll as being available when things go wrong. Further, she sees the fa mil y a long with th e individua l in her work. For example, she would see both a handicapped ch ild a nd the effects of the chi ld's problems o n o th er members of the family. She can a lso help to set up loca l ac ti vi ti es, such as mothers' support gro ups, family dis- cuss io ns a nd pl aygro ups. Fina ll y, the co mmunity hea lth nurse has the benefit of a pos t bas ic training in cou nse llin g, teaching skills and lia iso n with ot her age ncies. Such a professional ca n provide primary and secondary pre- vent io n serv ices and mainta in co nta ct with and support for the family when breakdown occu rs. H owever, to be effec ti ve she shou ld no t o pera te a lone. H er approach mu st include multidisciplinary tea mwo rk a nd invo lvement with th e co mmunit y as a whole. An impo rt a nt pa rt of her work is in refe rrin g clients to ot her age ncies. A political dimension Fam il y brea kd own is a po liti ca l, econo mic a nd socia l issue and sho uld no t be seen as th e excl usive co nce rn of th e peo ple affected. The links betwee n ill hea lth a nd soc ia l d isadvantage are well docu- mented , and improved se rvices a nd fewer financia l penalties co uld miti ga te a fami ly' s problems. Peo pl e mu st bette r und ers tand th e links between social factors, suc h as pove rt y, bad housing a nd poor diet, a nd the in cidence of ill hea lth a nd fami ly tension . Moreover, a ll hea lth profess io nal s mu st join ot hers in political ac ti o n to expose inadequacies in current services a nd to inform th e public of this relati o nship . In pa rti cu la r , peop le must learn how to protect their ow n hea lth. A future perspective Prediction is a t bes t a hazardous activity, and the pace of change today t urns yes terday's pred iction int o today's history. However, so me trends can be identified. The rise in the number of family separat ions is too recent to a ll ow people to judge whether the II upward curve will continue. In the Federal Republic of Germa ny and Sweden , divorce rates a re actually falling , although the signifi- ca nce of this ca nnot yet be assessed. At leas t a part of th e dram atic increase in di vo rces may have been caused by the libera lization of laws in so me countries and this would help to explain the present levelling off of the di vo rce rate. However, other forms of cohabit- at ion seem to be here to sta y, and societ y may eve ntually accept a lternative family groups. The choice for hea lth ca re is sta rk: either services will be shifted towards preve ntive work in the com munity, or the prese nt poli cy of investing huge sums in remed ia l high technology will continue. These o ptions are not mutually exclusive , but the former would be more useful for family hea lth . No famil y is an island; the family's future structure and function will be determined by technologica l advances, economic and socia l policies, employment patterns a nd leis ure opportunities, and by the degree to which men and women are permitted to direct their own lives. CONCLUSIONS AND RECOMMENDATIONS Research Conclusions The increased rate of family b reakdown is o nly one sy mptom oft he many innuences of modern industrialized societ y. It is a co mplex phenomenon an d its contribution to ill health is extre mely hard to isolate from othe r factors. Hard data on divorce rates are avai lable in a number of coun- tries but they do not cover the separations of unmarried couples nor ca n they provide any information about the impact of family break- down on the lives of those concerned. More information is needed about the services that a re ava ilable in different countries and a bout the most effecti ve ways of p roviding support. Much exist ing re- sea rch material can be used to ex tend understanding and develop policies in this area. 12 Reco111111e11da1ions I. A desc riptive study o f famil y support se rvices in Europe should be made . 2. Further research should be done o n the relati o nship between the factors associated with family breakdown. 3. Support services a t different stages of family brea kd ow n should be studied and evaluated. 4. Grea ter use shou ld be made of existing researc h data . Coordination of services Co11c/usions The formal and inform al family health sys tem s mu st work wi llin gly toge ther to coo rdin a te community serv ices. Bo th sys tem s ca n help families in respo nse to famil y breakdowns. In most countries, the se rvices o f both sec to rs ove rl ap and it is clea r th a t different m ode ls o f service provis ion a re a pplicable in different se ttings. Also, peo ple should have th e o ppo rtunity to choose th e se rvices that they believe are most suit ed to their needs. Neith er secto r has a mon o po ly of good practice, a nd eac h should learn fro m the other. Th e for mal sys tem has to a ttem pt to mee t an enormous range of needs a nd thi s ca n inhibit its capacity to innovate and be n exib le. It mu st a lso id ent ify priorities and perhaps reassess the current provision of se rvices for families . The in for mal sec tor has no wish to ass um e th e respo nsibil iti es of th e state and a coo rdin a ted plan of serv ices shou ld use the s trengths of both sys- tems. Further, people from both the formal and in forma l systems mu st recognize s itu at io ns in which th eir intervention wou ld be in effec ti ve or inappropr iate. F in al ly. even w hen a problem is identi- fi ed, every family has th e right to refuse intervention. Reco111111 e11da1 io11s I. Loca l coord in ated plans o f services for families should be made. 2. The forma l sector should give practical assistance to small local gro ups, such as offeri ng rooms for mee tings and administrative support . 13 3. The formal and informal sectors should freely exchange infor- mation , knowledge and referrals . 4. The role and scope oft he informal sector should be included in the training of all health professionals . 5. Each sector should show a greater willingness to recognize the contribution of the other. 6. Agencies providing services should acknowledge the right of families to refuse help and recognize situations in which their inter- vention would not be effective. Children Conclusions Although every adult and every child will react in an individual way to a family breakdown, some common patterns of behaviour exist and should be further researched and understood. In particular, boys will often react quite differently from girls and may, for example, become aggressive. It is clearly important to be aware of these differences and to develop ways of helping children and young people to overcome this traumatic period in their lives without lasting damage. The effects of separation on children in the short term are well documented, but this data has not been used. Material dealing with the longer term is required. The rights of children in separating families should be stated explicitly. These should include the right to be informed and be heard when decisions are made at the time of separation, although the parents will make the decisions. Clearly , the interests of children do not always come first. Especially when the legal profession becomes involved, the separation itself can become a long, harrow- ing, antagonistic process. Some countries have conciliation services, designed not necessarily to bring couples back together, but to reach a settlement in the best interests of their children, that attempt to solve this problem. 14 Recommendations I . C hild deve lo pment a nd a ll phases o f fa mil y deve lo pment sho uld ta ke a central pl ace in a ll bas ic nursing curricul a . 2. Mo re resea rch sho ul d be co ndu cted o n th e reac ti o ns of children to sepa ra ti o n, a nd current resea rch da ta, pa rti cul a rl y existin g lo ngi- tudin a l studi es, sho uld be access ibl e a nd studied . 3. The Unit ed Na ti o ns Chi ldre n's C ha rt e r should inclu de a sec ti on deta ilin g th e rights of chil dren d uring fa mil y b rea kd ow n. 4. S pecia li zed co ncili a ti o n services sho uld be es tab lished to ensure th a t pa rent s" decisio ns a t th e tim e o f se pa ra ti o n se rve th e bes t int eres ts o f the child re n. Intervention and prevention Conclusions Fa mil y brea kdo wn is a p rocess d uring which a fa mil y's int e rn a l suppo rt sys tem sto ps wo rkin g. A famil y b rea k-up is th e po int a t whi ch se pa ra ti o n occ urs. Stages in life in whic h fa milies a re a t mo re ri sk ca n be identified a nd p rim a ry preve nti o n progra mmes shou ld be es tabli shed fo r these times , na mely during pregna ncy, when the first child goes to sc hoo l and wh en th e children a ll rea ch ad o lesce nce. Ways mu st be found to id entify famili es a t spec ia l ri s k a nd to a ll o w se rvices to res po nd qu ickl y wh en a proble m a ri ses. A lso, effecti ve servi ces a t th e c ri sis po int see m to be lacking, a nd th ese need to be investigated and tes ted . Families sho uld be aware o f loca l se rvices, be a ble to co ntac t th em easil y a nd no t fee l intimida ted by them . Fa mil y neighbo ur- hood suppo rt ce ntres, o fferin g se lf-help groups a nd suppo rt fro m ma ny health p ro fess io ns, ca n p rov ide such a se rvice. The communit y can d o a g rea t dea l to suppo rt fa mili es if the rig ht initi-Hives are ta ken a nd reso urces ma de ava il a ble. Na ti o na l government s sho uld have a co here nt a nd pos iti ve po li cy to wards th e famil y. In pa rti cul a r , m o re help co uld be pro- vided fo r yo ung co upl es in ma ny co untri es. 15 Men in separating families also need more help, and so me efforts must be made to develop acceptable and accessible serv ices for them. Recommendations I. Much greater emphasis should be placed on primary and sec- ondary prevention. This sho uld include work in schools and the roles and responsibilities of marriage and parenthood, work with mothers who have young children, high-risk families and people in mid-life crises. 2. New services should be se t up to give support to fam ili es at the crisis point. 3. More information should be made availab le, to families and to coup les before marriage, about the periods of greater risk of break- down. 4. Neighbourhood support centres should be established, with support from different kinds of health professional and easy access for families. 5. Information about local services should be distributed more effectively. 6. Governments should give more practical help to young coup les. 7. New and appropriate services should be developed for men facing family breakdown . Nursing Conclusions In some countries, community health nurses work in a special position in the community and as a first point of contact for many families with problems. Their visits do not carry the stigma that is sometimes associated in the public mind with contact with social workers or psychiatrists. Often clients can approach a nurse with a 16 physical symptom and on ly later reveal the emotional concern behind it. Unfortunately, some people hesitate to approach a nurse with a non-physical problem. The pattern of health care is changing, however, and the nurses of the future will have to develop the knowledge a nd sk ill s to work in the community and therefore to respond to the increasing number of families facing breakdown. This is a lready happening in some countries but addi tional post basic training programmes wi ll be needed in ot hers. As nurses change, so must society's perception of their role . The basic and continuing education of health professionals sho uld inc lud e more emp hasis on multidisciplinary teamwork. Problems of communication between professionals remain a major obstac le to rational and effective services. Recommendations I. General nurse training sho uld be shifted towards primary health care and, in parti cular, the problems faced by modern family groups. 2. Special pos t bas ic training sho uld be availab le to nurses wishing to specialize in family health nursing. 3. Different professional groups shou ld share training more ofte n , to improve multid iscip lin ary teamwork. 4. Nurses and their employers shou ld initiate a campaign to in- form the public of their actual and potential ro le as sources of first-l ine prevention and support. A political dimension C onc!usions Health professionals and community groups must not simp ly re- spond to the immediate problems of families in breakdown. Society must have a much greater understanding of the relationship be- twee n social factors, such as poverty, bad housing, unemployment and lack of adequate diet, and ill health and family tension. If the public is to recognize this relationship, nurses and other health I 7 professionals must join with community groups in political action at the national and local level s . Divorce or separation does not necessarily mean failure; on the co ntrary, it can successfully resolve an unsatisfactory situ at ion. Alternative family arrangements that depart from the traditional model of two parents and one or two ch ildren sho uld no longer be regarded as deviant. At leas t some of th e pressures on th e o ne- parent family come from social attitudes. Such parents and their children a re ofte n regarded as odd or second-rate. People must recognize that family structures are changing in many co untries. When this truth is accepted, a greater tolerance of alternative social groups should develop. Recommendations I. Health professionals shou ld join the informal sector in high- lighting inadequacies in services a nd identifying publicly the social causes of ill health. 2. H ea lth professionals and community groups should challenge prejudices against non-traditional family groups. 3. Services sho uld continue to be provided and new ones should be developed as needed for a ll fami ly groups. REFERENCES I. Ader, R. Psychosomatic and psychoimmunologic research. Psy- chosomatic medicine, 42(3): 307-321 ( 1980). 2. Nystrom, S. The use of somatic hospita l care among divorced. Scandinavian journal of social medicine, Suppl. No. 17: 1-48 ( 1980). 3. Bowlby, J. Maternal care and mental health, 2nd ed. Geneva, World H ea lth Organization, 1952 (Monograph Series, No. 2). 4. Little, M. Family breakup: understanding marital patterns and the mediating of child custody decisions. San Francisco, J ossey Bass, 1982 (Social and behavioral science series). 18 5. Bridgewater, C.A. Divorce: the lo ng term effec ts on chi ldren. Psychology 1oday, 18(7): 9 ( 1984 ). 6. Fogelman, K. Groll'ing up in Crea l Bri1ain: papers from 1he Na1ional Child Developmen/ S!Udy. London, Macmillan, 1983. 7. Barzilay, R. Families in precrisis. Nursing limes, 80(14): 36-39 (1984). 8. Caplan, G. Principles of prevenlive psychiany. New York, Basic Books, 1964. 9. Rayner, C. What do the public think of nurses? Nursing limes, 80(35): 28-31 (1984). 10. Farrell, M. & Flynn, B. The role of nursing in primary heal!h care. Copenhagen, WHO Regional Office for Europe, 1982 (unpub- lished document EURO/NU RS 82.1). 19 Annex 1 PROJECTS AND SCHEMES IN THE INFORMAL SECTOR The Asian Mother and Baby Campaign (United Kingdom) This two-year campaign is run by the Save the Children Fund to improve the health services provided for the Asian community in the United Kingdom. Apart from being a health education cam- paign with material in five Asian languages, the project employs special link workers who act as support and liaison staff between the National Health Service and the Asian community. They are trained and supported by a central campaign team and one of their main functions is to ensure that National Health Service staff develop a greater understanding of the needs of the Asian community. Where services are lacking, the project team tries to exert influence to improve the situation. The Gingerbread Movement (United Kingdom) The Gingerbread Movement is a national network of over 400 local self-help groups run by and for parents who are raising their children alone. The majority of Gingerbread members are divorced or separ- ated mothers and the rest are divorced or separated fathers with children, widows, widowers and unmarried mothers. Since 1976, the United Kingdom's Department of Health and Social Security has provided approximately 50% of the cost of maintaining Gingerbread's national office and a staff team of eight to give advice, information, training and support to its network of groups. 20 All groups must provide: a meeting place for single parents and their children opportunities for friendship and relief from isolation information and advice on a wide range of issues co-counsel lin g and emotiona l support practical help with bringing up children . Sixty Gingerbread groups have chosen to extend their voluntary se lf-h elp activities into more formal service provision projects. These groups have usually started with the aim of meeting one specific need but then gone on to establish support centres that offer a combina ti on of advice and information services, day care for the children under five and of school age, housing for the tempo rari ly homeless and informal drop-in facil ities . A few have also developed educati o nal or employmen t projects. On the who le, these groups have obtai ned resources through gra nt s from loca l government and their own fund-raising efforts. Parents' Forum (France) Pare nt s' Forum is an open-house for child spec ia li sts and parents in Pa ri s. It aims to enco urage exc ha nges of information and knowledge amo ng parents and professionals. It is open to anyone concerned with the development of chi ldren, and its members include parents, grandpa rents, psychologists, nurses, midwives, socia l workers, doc- tors and teachers. All of them live loca ll y and people can drop in to Pare nts' Forum at any time. This provides a n ou tl et for parents to talk abo ut their children, whether they are infants, young children or adolescents. Open discussions are held every month o n topics such as toil et training, aggress io n and childhood health problems. The Parents' Forum also encourages parents who share a com- mon interes t in o ne topic to set up sma ll er discussion groups, with a profess iona l in the releva nt field. There is also a library and a contact service for baby-sitting, excha ngi ng ch ild care items and o th er activities. Motherhelp (Denmark) The Mot herhelp scheme is designed to provide information and professional advice to families in need. Most of its work is with women bringing up children on their own , many of them struggling 21 after family breakdown. The scheme puts eight different professional disciplines at the disposal of clients and acts as a point of referral to the state system of services. An important feature of the Motherhelp scheme is its cam- paigning role. Its members are not content to ameliorate the in- adequacies of the formal sector but draw public attention to the plight of their clients as an important part of their work. 22 Annex 2 PARTICIPANTS Temporary advisers Dr N. Akdemir, Editor, Turkish journal of nursing, Hacettepe University, Ankara, Turkey Mrs R. Barzilay, Department of Nursing, Sackler Facu lt y of Med icine, University of Tel Aviv, Israel Professor F. Beske, Director, lnsti tut fur Ges undheitssys tems- Forsch un g, Kiel, Federa l Repub lic of Germany Ms H. Bild, Hea lth Visitor/ Nurse Tutor, Sentralvn. 23 B, As, Norway Ms M. C hriste nsen, Journa li st, Snndags B. T., Copenhagen, Denmark Mrs J. Clark, Heal th Visitor/Senior Nurse (Research), West Berksh ire Health Authority, Reading, United Kingdom Mr N. Dickson, Editor, Nursing times, London , United King- dom (Rapporteur) Mrs C. Fonsagrive, Maison des Parents, Paris, France Dr H .-J. Gehrmann, Zweites Deutsches Fernsehen, Mainz- Lerche nberg, Federal Repub lic of Germany Miss A. Grauhan, Editor, Deutsche Krankenpflegezeitschrift, Stuttgart, Federal Republic of Germany (Chairman) 23 24 Professor K. Jork, Leiter des In stitutes fur Allgemeinmedizin, Klinikum der Johann Wolfgang-Goethe-Universitat , Frank- furt, Federal Republic of Germany Mrs S. Kastholm Hansen, Midwife, Motherhelp, Ballerup, Denmark Mrs I. Torok Katalin, Journalist, Nok /apja, Budapest, Hungary Mrs J. Kaufmann, General Secretary, Gingerbread Movement, London, United Kingdom Dr B. Lenneer-Axelson, Assistant Professor in Psychology, Uni- versity of Gothenburg, Sweden Dr B. Lindstrom, Research Assistant, Nordic School of Public Health, Gothenburg, Sweden Professor E. Maier, Social Paediatrician, Cologne, Federal Re- public of Germany Mr B. Miklavcic, President, Republic Committee for Health and Social Welfare, Ljubljana, Yugoslavia Ms A. Mostyn-Owen Servadio, Journalist, Grazia, London, United Kingdom Mr P. O'Neill, Third World: EEC Media Consultancy, London, United Kingdom Mrs B. Rakovec, Editor-in-Chief, Jana, Ljubljana, Yugoslavia Mrs A. Randal, Journalist, Elle, Paris, France Ms C. Sandberg, Journalist, Alias veckotidning, Malmo, Sweden Mrs B. Westphal Christensen, Nursing Research Consultant, Danish Nurses' Organization, Copenhagen, Denmark Mr M. Whitlam, Deputy Director, Save the Children Fund, Child Care UK, London, United Kingdom M r W. W ilk en, Directo r-Ge nera l, Federa l C hil d ren 's Welfare Assoc ia ti o n , Ha no ve r, Federa l Republic o f Ge rm a ny Ms P. va n der Za lm , J o urn a li st , Utrechts nieull'sblat, The Hague, Nethe rl a nds Observers Mrs E. Beikirch , Paedi a tri c N urse, Externa l Nursin g Service, Berlin (Wes t ) Mrs M . Hipp , Na ti o na l Offi ce of Ge rm a n Midw ives, Ka rl sruh e, Fede ra l Republic o f G erma ny WHO Regional Office for Europe Dr M . Fa rrell, Regio na l Office r fo r Nursing 25 RESUME A cette reunion du groupe de travail ont pris part vingt-six conseillers temporaires (six infirmieres, trois medecins, un psychologue , un politicien, cinq representants des groupes communautaires et dix journalistes}, ainsi que deux fonctionnaires du Bureau regional. La reunion se proposait les objectifs ci-apres : completer les donnees dont on dispose, et analyser la percep- tion des problemes de sante souleves lors de la dissolution de la famill e dans la Region europeenne de l' OMS; etudier les incidences sur ces questions des strategies mon- diale et regionales, ainsi que celles du document de l'OMS sur les buts; sensibiliser les professionnels de la sa nte , ainsi que la col- lectivite, aux multiples aspects que prese ntent ces questions, dans l'optique d'une etude du rol e des infirmieres, des sages-femmes et de la collectivite visant a prevenir les effets nefa stes de la dissolution de la famille, et a promouvoir la san te des families; etablir un dialogue sur ces questions entre les services de sa nte officiels et paralleles et les representants de la collect ivite; experimenter une approche alternative aux efforts de l'OMS destinee a permettre a la co llect ivite d'y participer en orga- nisant la reunion so us une forme novatrice, a savoir en reunissant des professionnels de la sante et des representants 27 de la collectivite, ensuite reunis en deux groupes d'experts ap peles a repondre a des questions, l'un d'entre eux ctant appe le a representer la presse specialisee et la grande presse ("audience active"). Discussion La dissolution de la famille est desormais un phcnomcne social important dans toute !'Europe et a des repercussions parfois meme lointaines sur la sante. Bien qu'il soit diffici le de determiner des rapports de causalite simple entre separation des conjoints et accroissemcnt de la morbidite, ii n'est pas doutcux quc !es divorces sont plus vulnerables a la mauvaise sante et que leur taux de mor- talite est plus eleve. Les enfants aussi souffrent pendant la periode de dissolution, mais ii convicnt de proceder a des etudcs plus poussecs pour determiner !es effets a long tcrme sur eux. II nc faudrait pas ccpcndant considerer le divorce commc un signe d'echcc. L'eclatement d'une famille peut constituer un eve ne- mcnt positif, e t ii faut etre beaucoup plus tolerant pour !cs so lu tio ns s'eca rtant du groupement familial traditionnel de deux parents avec un ou deux enfa nts. On pcut definir des strategies d'intervcntion fondees sur des soins de sa nte preventive. Les infirmieres, ai nsi que d'autrcs pro- fessionnels de la sa nte et travaillcurs soc iau x, so nt a meme de mi eux conseiller !es families qui ne sont pas encore en crisc. II faudrait crecr des conditions de nat ure a eviter que !es families ne se dis- solvent et depister celles qui risqucnt de le faire. Le systeme de sante officiel, en d'autres termes l'Etat , ne sa urait connaitre toutes les reponses, et scs services devraicnt etre appeles a communiqucr ct a collaborer davantage avec !es groupes de toute nat ure dans la collectivite. Un plan coordonne a l'echcllc loca le, entre services offic iel s ct autres, constituerait un point de depart valable pour le travail en commun. Les infirmie res ont un ro le important a joucr. A mesure que se developpcnt les soins de san te primaires, un plus grand nombrc d'infirmiercs travailleront dans la collec tivite, et des infirmieres specialisees en sante familia le assurent d'ores ct deja dans certains pays des services d'une portec capita le. Une tell e approche devrait et re adoptee dans toute !'Europe. 28 La dissolution de la famille et la separation comporte des pro- blemes sociaux, politiques et economiques et !es difficultes que rencontrent !es families ainsi brisees sont essentiellement d'origine exterieure. II est du devoir des professionnels et des groupes com- munautaires de faire connaitre !es liens entre facteurs sociaux et mauvaise sante et de se mettre en campagne ensemble pour am e- liorer !cs services inadequats. Organisation de la reunion Les participants se sont repartis en trois groupes : le groupe de la collectivite et celui des professionnels de la sante eta it observe par le groupc de la pressc, qui faisait fonction d'audience. On etait parti s de l'idee que la presse devait stimuler le dialogue entre les deux groupes d'experts en posant des questions pcrtinentes. Les jour- nalistes avaient ete de leur cote invites a preparer une brochure sur la dissolution de la famille, fondee sur !es debats et sur !es communi- cat ions echangees en cours de reunion. II est apparu des l'abord que des differences d'accent significa- tives ex istai ent entre les deux groupes d'experts et que chacune des parties eprouvait de la difficulte a "digerer" le point de vue et la con tribution de l'autre. En derniere analyse, !es groupes eux-memes ant fait etat de cette lacune et decide de se reunir pour tenter de repondre a quelques-unes des questions. II n'est pas douteux que !es positions se soient ainsi rapprochees et, a la fin de la reunion, l'un et l'autre groupes etaient tres desireux de mettre !'accent sur la neces- site d'une collaboration accrue entre services officie ls et groupes benevoles. Conclusions et recommandations Recherche Le rythme croissant de la dissolution des familles n'est que l'une des manifestations des nombreuses pressions qui s'exercent sur la societe industrielle moderne. II s'agit d'un phenomene complexe, et sa contribution a la mauvaise sante est extremement difficile a isoler des autres facteurs. On dispose dans la plupart des pays de donnees sur !es taux de divorcialite, mais !es statistiques ne font pas etat de la separation de 29 couples non maries ni ne peuven t renseigner sur ('incidence de la dissolution de la famille s ur la vie de ceux qui sont en cause. II faut aussi obtenir davantage d'informations sur les services disponibles dans les divers pays et sur les fai;:ons les plus rationnelles d'assurer le so utien. En outre, de grandes quantites de donnees de recherche so nt evidemment disponibles, sa ns toutefois servir a a meliorer la connaissance ou a elaborer les politiques dans ce domaine . I. II conviendrait de proceder a une etude desc riptive des services de soutien familial en Europe. 2. II faudrait poursuivre les recherches sur les rapports ex istant entre les differents aspects de la dissolution des families. 3. II conviendrait d'evaluer le role des services d'appui a differents stades de la dissolution des fam ilies. 4. II conviendrait de tirer un meill eur parti des donnees de rec herche existan tes. Coordination des services II importe de coordonner d'urgence les services dans la com- munaute et de developper la cooperation et la comprehension entre services officiels et informels. Les unset les autres sont en mesu re d'apporter une contribution positive des !ors qu'il ya dissolution de la famille. Dans la plupart des pays, certains services font double emploi et ii est clair que differents types de services sont sou- haitables selon les circonstanccs . Le choix importe aussi, et les individus devraient avoir la possibilite de recourir aux services qu'ils estimen t repondre le mieux a leurs besoins. Aucun des deux secteurs, public ou prive, n'a le monopole des bonnes pratiques et ii leur faut se concerter pour apprendre les uns aux autres. Le systeme officiel doit s'efforcer de faire face a un eventail enorme de besoins , et cela risque de mettre en echec son aptitude a innover et a se montrer sou pie . 11 lui faut aussi determiner les priorites, et l' on devra peut-etre remettre en cause les modalites actuelles de la prestation des services aux families. Le secteur informel ne souhaite en aucune fai;:on se charger des responsabilites qui incombent a l'Etat et ii est necessaire, autant que 30 fa ire se peut , d'eta blir des p riorites, d 'e lu cider le ro le d es unset des a utres et de tirer le meilleur pa rti possible d es as pec ts positi fs de l'u n et d e l' a utre. Le sys te me o ffi ciel a reco nnu com me le sys teme p ri ve que da ns ce rta ines situati o ns !es p rofess io nnels o u a u co ntra ire les a ides benevo les ne sa ura ient interven ir effi cace ment , e t !'o n sera it a lo rs ma! av ise d' y fa ire a ppel. Me me face a un p rob le me c haque famill e a le d ro it de re fu ser !' interve nti o n . I . II co nviendra it d 'e la bo re r des pl a ns loca ux po ur ass urer a ux fa milies des se rvices coo rd o nnes. 2. Le sec teur o ffi ciel devrai t a ppo rter un e ass ista nce pra tiqu e a ux petit s gro upes loca ux en metta nt a leur di spositio n des sa lles de reuni o n , des se rvices d'a ppui admini stra tif, etc. 3. On devra it po uvo ir p roceder lib rement a des ec ha nges d'i nfor- ma ti o ns, d e conna issa nces et d' o ri ent a ti o n entre sec teurs offi ciel e t in fo rm el. 4. La fo rm a ti o n de to us les p rofess io nnels de la sa nte devrai t co m po rt er d es renseignements sur le ro le et le cha mp d'ac ti vit es d u sec teur in fo rmel. 5. L'un et l' a utre sec teurs d evra ient se mo ntrer plus des ireu x de reco nn a itre la contribut io n de l' a utre. 6. Les o rga ni sa ti o ns de services devra ient admettre le dro it des famili es d e refu se r un e a ide et reco nn aitre que da ns ce rta ines cir- co nsta nces leur interve nti o n ne sera it pas efficace. Les en/ants C haqu e adulte et chaq ue enfa nt reagit a sa ma ni ere en cas de di sso luti o n de sa fa mille; ii ex iste ce penda nt des schemas co m muns de co mpo rte ment , qui do ive nt fa ire l'o bje t de recherches plus pous- sees et qu 'i l fa ud ra it pouvo ir mi eux co mprendre . En pa rti culier , les ga n;ons reagisse nt souve nt de fa<;o n to ut a fait d iffere nte des fi lles et ii leur arrive, par exemple, de deve nir agressifs. II es t ev idem ment importan t d'avo ir conscience de ces d iffe rences ct de mett re au po int des moye ns d'a ider les enfan ts et les adolesce nts 3 I a surmonter cette periode traumatique de leur vie sans en conserver des sequelles durables . Les effets a court terme de la separation sur les enfants sont bien documentes. On manque , par contre, de documentation sur les repercussions a long terme; de nombreuses donnees disponibles n'ont pas ete utilisees . Les droits des enfants dans Jes fam ilies en cours de separation devraient etre enonces de fac;:on explicite, y compris le droit d'etre informe et ecoute lorsque des decisions sont prises au moment de la separation. Quant aux decisions elles-memes, elles doivent bien evidemment etre prises par l'un et l'autre parents. II est c lair que Jes interets des enfants ne viennent pas toujours au premier rang. En particulier, lorsqu'on a recours aux hommes de loi, la procedure elle-meme devient parfois un conflit long et penible. Dans certains pays, des services de conciliat ion existent, non pas necessairement pour reunir Jes conjoints mais pour les amener a se mettre d'accord dans l'interet de leurs enfants. On devrait consacrer aux hommes une attention accrue, et ii faudrait s'efforcer d'elaborer des fac;:ons de proceder qui so ient acceptables pour eux et qui leur soient accessibles. 1. Le developpement des enfants devrait faire partie de tous Jes programmes fondamentaux de formation des infirmieres. 2. II faudrait proceder a des recherches plus poussees sur les reactions des enfants en cas de separation, et Jes donnees existantes devraient etre diffusees et utilisees. En particulier, ii existe certaines etudes longitudinales dont on devrait tirer tousles renseignements q u 'ell es contiennent. 3. La charte de l'enfant, elaboree par les Nations Unies, devrait comporter une section relative a la dissolution de la fami lle. 4. Des services de conciliation specialises devraient etre etablis pour s'assurer que les decisions prises au moment de la separation le soient dans l'interet des enfants. 5. II faudrait elaborer de nouveaux services appropries pour les hommes amenes a faire face a la dissolution de leur famille. 32 Intervention et prevention La rupture des families est un processus a u cours duquel le sys teme d'appui interne cesse de fo ncti onne r. II ne s'agi t pas se uleme nt du po int dans le temps o u la se para ti o n se produit. On peut determi ner les s tades de la vie au cou rs desquels les fami lies sont le plus vulnera bles, et ii importe d'etablir des p rogrammes de prevention primaire pour ces situations (par exemple, pendant la grossesse, lo rsqu e le premi er enfant va a l'eco le et lorsq ue to us les enfants so nt adolesce nts). II conviendrait d'etablir des mecanismes permettant de deceler les families pa rticulierement vulnerables et creer des services capables de repo ndre ra pidement lo rsq ue se produit un probleme. II semble a ussi que l'o n ma nque de services efficaces a u moment de la cri se, et une analyse, ainsi qu'une mise a l'epreuve de tels se rvices, s'imposent d'urgence. Les families devraient etre au courant de l'exis tence des services loca ux , etre en mesure de les contacter aisement et ne pas se se ntir intimidees par eux. Des centres d'appui de quartier, avec des groupes d'auto-assista nce et des se rvices de so utien multiprofes- sionnels, sont de nature a assurer un tel service. La collectivite peut intervenir de fa<;:on utile pour aider les families, a condition que !'on prenne des initiatives valables. Des activites de projets peuvent aider a elaborer de nou vea ux se rvices. Les go uvernements natio na ux devraient adopter des politiques coherentes et positives en matiere familiale, et l' o n pourrait notam- ment aider davantage les jeunes co uples. I. II faudrait mettre bien plus !'accent sur la preve ntion prima ire et seco ndaire. A ce titre, ii conviendrait d'envisager des activ ites scolaires sur le ro le et la responsabilite en mati ere de mariage et de vie pa rentale et tra va iller avec les meres de jeu nes enfants, Jes fa milies tres vulnerables, les individus en crise de maturite , etc. 2. II co nviendra it d'etablir de nouveaux services pour aider les families en crise. 3. II fa ud rai t mieux in fo rm er les co uples avant leur mariage et preve n ir Jes fa milies de l'epoque a laq uell e elles risquent davantage la dissolution. 33 4. II faudrait creer des centres d'appui de quartier assurant un so uti en multiprofessio nnel; ces centres devraient etre d 'acces a ise. 5. Les informa tions sur les services loca ux devraient etre diffu sees de fac;:on plus efficace. 6. Les gouvernements devraient ass urer dava ntage de se rvices d'appui pratique aux jeunes couples . Les soins infirmiers Dans certains pays, des infirmieres specia lisees dans la sa nte fa miliale a nt un acces pri vilegie a la collecti vite et co nstituent le premier po int de co ntact avec de no mbreuses fa milies a p ro blemes. Elles possedent l'avantage de ne pas po rter les sti gma tes qui so nt pa rfoi s associes da ns l'esprit du publi c a ux ass ista ntes socia les o u a ux psycho logues. Les clients prennent so uvent co ntact avec une in fi rmiere en lui indiqua nt to ut d'a bord un probleme d 'ordre ph ys iq ue, po ur ne reve ler une p reocc upa ti o n emoti o nnel le q ue pa r la suite. On a reco nnu en o utre que les in fir mi eres ne sont pas to uj o urs co nsiderees co m me le mieux armees face a un probleme d 'o rd re non ph ys ique. Le profil des so ins de san te evolue ce pend a nt , et Jes infirmieres devront ul te rieurement deve lo pper leurs co nna issa nces et leurs competences en vue d' un travail da ns la co llect ivite. Ce fai sa nt , ell es se ro nt en mes ure de repondre a u no mbre croissa nt de famili es co nfro ntees a la disso lution . II es t cla ir q ue da ns ce rta ins pays ii en est deja a insi, mais en reg le genera le, des p rogra mm es de form a ti o n superieure sero nt necessa ires. Simulta nement , la perce p- t io n qu e l'o n a da ns la societe du ro le de l'infirmiere devra se modifier p rofo ndement. II fa udra it a ussi preter davan tage d 'at tentio n a u trava il d'equipe multidisciplina ire, penda nt la for mat io n de base et l'educat io n co ntinu e des profess io nnels. Les pro blemes de co mmunica ti on entre eux demeu rent l' un des principaux o bstac les a la p res ta t io n de se rvices ra ti o nn els et efficaces. I . La fo rm at io n ge nera le des infirmi eres devra it etre reo rie ntee vers Jes soins de sa nte p rima ires et pl us pa rticulierement Jes pro- blemes a uxquels a nt a fa ire face !cs groupements fa rnilia ux modernes. 34 2. Une formation superieure devrait etre offerte aux infirmieres desireuses de se specialiser dans les soins de sante familiale. 3. La formation devrait etre davantage repartie entre differents groupes professionnels de maniere a favoriser le travail en equipe multidisci plinai re. 4. Les infirmieres et leurs employeurs devraient entreprendre une campagne pour informer le public sur leur role actuel et potentiel en tant que professionnels de la prevention et de l'appui en premiere ligne. La dimension politique II ne suffit pas que les professionnels de la sante, ou meme les groupes de la collectivite, repondent aux problemes immediats des families en dissolution. Une meilleure comprehension accrue des rapports existants entre d'une part les facteurs sociaux tels que la pauvrete, les logements mediocres, le chomage, le defaut d'une nourriture appropriee et, de l'autre, la mauvaise sante et les tensions familiales, devra s'instaurer. Si !'attention du public doit etre attiree sur ces relations, une action politique conjointe s'impose tant au plan national que local, menee par les infirmieres, d'autres profes- sionnels de la sante et les groupes dans la collectivite. Divorce ou separation ne signifie pas necessairement echec; au contraire, cela peut amener a resoudre de fa~on positive une situa- tion insatisfaisante. Les groupements familiaux qui se demarquent du mode le traditionnel des deux parents avec un ou deux enfants ne devraient plus etre consideres com me des deviations. Certaines des pressions auxquelles sont soumises les families monoparentales decoulent a tout le moins des attitudes de la societe. Elles sont considerees sou vent, avec leurs enfants, com me etant "bizarres", "originales" et, en quelque sorte, de seconde categorie. II importe de reconnaitre d'urgence que les structures familiales evoluent dans de nombreux pays. Une fois que cela aura ete admis et accepte, une tolerance majeure des groupements sociaux autres devrait s'instaurer. I. Les professionnels de la sante devraient, en commun avec le secteur informel, s'attacher a mettre en lumiere les faiblesses 35 des se rvices et a ident ifi e r pu b liqu ern ent les ca uses soc ia les de la rn a uva ise sa nt e. 2. Les p rofess io nnels de la sa nte et les gro upes dans la co ll ec ti vite devra ient I utter co ntre les p rej uges qui s'a ttac hent a ux gro upernents fa rnilia ux no n profess io nnels. 3. II faudra it continuer d'ass urer les se rvices et d 'en o ffrir de no uvea ux po ur to us les groupernents fa rnili a ux. 36 ZUSAMMENFASSUNG Die Arbeitsgruppe bestand aus 26 Beratern auf Zeit (sechs Kran- kenschwestern, drei Arzte, ein Psychologe, ein Politiker, funf Ver- treter von Privatinitiativen und Verbanden, zehn Journalisten) und zwei Mitarbeitern des Regionalbi.iros. Zweck der Tagung war: das in der Europaischen Region der WGO bestehende Da- tenmaterial i.iber die gesundheitlichen Aspekte der Fami- lienzerri.ittung zu erweitern und die diesbezi.iglichen An- schauungen zu i.iberpri.ifen; die Auswirkungen der globalen und regionalen Strategien der WGO sowie des WGO-Zieldokuments auf diesen Pro- blembereich zu pri.ifen ; das Gesundheitspersonal und Gemeinwesen im Hinblick auf die vielschichtigen Aspekte dieses Problemkomplexes zu sensibilisieren, genauer, die Rolle der Krankenschwestern, Hebammen und der Bevolkerung in bezug auf die Praven- tion nachteiliger Auswirkungen der Familienzerri.ittung und hinsichtlich der Forderung de r familiaren Gesundheit zu untersuchen; zwischen Vertretern des offiziellen und des inoffiziellen Gesundheitsversorgungssystems sowie Vertretern der Of- fent lichkeit einen Dialog i.iber diese Gesundheitsproble- matik einzuleiten; im Rahmen der Bemi.ihungen der WGO um Einbeziehung der Allgemeinheit hier einen neuen Weg einzuschlagcn, indem die Tagung auf eine neue Weise durchgefi.ihrt wird; 37 es wurden zwei Expertengruppen gebildet; die eine umfa(he Vertreter des Gesundheitsbereichs und die andere Vertreter der Privatinitiativen und Verbande. Eine dritte Gruppe bil- deten Vertreter der offentlichen und der Fachpresse - sie spielten die Rolle einer aktiv teilnehm enden Zuhorerschaft. Diskussion Die Zerri.ittung der Familienverhaltnisse stellt in ganz Europa bereits ein ernstes soziales Phanomen dar und hat weitreichende gesundheitliche Folgen . Auch wenn es sc hwerfallt, zwischen der Los ung der Familienbande und einer Zunahme der Krankheitsfa lle eine einfache kausale Verbindung herzustellen, wird nicht bezwei- felt , dal1 Geschiedene haufiger krank werden und eine hohere Mo r- talitatsziffer aufweisen. Auch die Kinder !eider unter der Auflo- sungsphase, doch mi.issen die langfristigen Folgen bei ihnen noch genauer untersucht werden. Trotzdem sollte eine Scheidung nicht unbedingt als ein Versa ge n betrachtet werden. Die Auflosung der Familienbeziehungen kann durchaus eine positive Entwicklung darstellen; den Alternativen zum herkommlichen Familientypus (zwei Elternteile und ein oder zwei Kinder) sollte man mit mehr Toleranz begegnen . Es besteht die Moglichkeit, im Rahmen der praventiven Ge- sundheitsbetreuung Interventionsstrategien zu entwerfen. Kran- kenschwestern und andere Fachkrafte aus dem Gesundheits- und Sozialbereich konnen besser eine Familie beraten, die noch nicht das Krisenstadium erreicht hat. Es sollten deshalb Anstrengungen unternommen werden , um Verhaltnisse zu schaffen, die eine Fami- lienzerri.ittung verhindern, und die es ermoglichen, dal1 eine sich abzeichnende Zerri.ittung entdeckt wird. Das offizielle Gesundheitswesen kann nicht alle Probleme Ibse n und sollte sich deshalb mehr mit den bevolkerungsnahen Gruppen aller Art zusammentun. Ein zwischen dem offiziellen und inoffi- ziellen Sektor koordinierter Plan fi.ir ortlich begrenzte Bereiche ware eine gute Ausgangsbasis fi.ir die Zusammenarbeit. Den Krankenschwestern fallt eine umfa~greiche Rolle zu. In dem Mal1e, wie die primare Gesundheitsversorgung aufgebaut wird, werden zunehmend mehr Krank ensc hwestern im Gemeinwesen 38 eingesetzt; in e1nigen Liindern gibt es bereits Fachkrankenschwe- ste rn fur Familiengesundheit, die sehr wichtige Dienstleistungen erbringen. Ein solches Yorgehen ist fur ganz Europa zu empfehlen. Die Zerruttung und Auflosung einer Familie hat soziale, poli- tische und wirtschaftliche Seiten; die Belastungen der auseinander- gehenden Familienmitglieder sind grof3tenteils nicht selbst ver- schu ldet. Es obliegt den Fachleuten und bevolkerungsnahen Grup- pen, die Offentlichkeit auf die Verbindung zwischen sozialen Faktoren und Gesundheitsmangeln hinzuweisen und gemeinsam offentlich fur eine Besserung unzureichender Dienste einzutreten. Organisatorische Durchfiihrung der Tagung Die Teilnehmer zerfielen in drei Gruppen: Vertreter der Privatin- itiativen und Yerbande , Yertreter der Gesundheitsberufe und Pres- severtreter, die die Rolle der Zuhorerschaft spielten . Die letztge- nannte Gruppe sollte sachdienliche Fragen stellen und dadurch den Dialog zwischcn den erstgenannten beiden Gruppen anregen. Die Journalisten wurden auf3erdem gebeten, auf Grundlage der Diskus- sionen und eingereichten Beitriige eine Broschure uber die Fami- lienzerruttung auszuarbeiten. Von Anfang an zeigte es sich, da/3 in der Haltung der beiden Gruppen die Schwerpunkte verschieden gelagert waren; es erwies sich als schwierig, sich mit den gegenseitigen Standpunkten und Beitragen abzufinden. Die beiden Gruppen wurden sich stufenweisc der Diskrepanzen bewuf3t und cntschlossen sich, einige Probleme auszudiskutieren. Dadurch kamen sie sich zweifelsohne niiher und forderten am Ende der Tagung gemeinsam, da/3 die Zusammenar- beit zwischen den offiziellen Diensten und Privatinitiativen ver- starkt werden musse. Schlussfolgerungen und Empfehlungen Forschung Das steigende Ma/3 der Familienzerruttung ist nur eines der Sym- ptome, die durch den Druck der modernen lndustriegesellschaft entstehen. Die Familienzerruttung ist ein kompliziertes Phanomen; ihre gesundheitsgefahrdende Wirkung laf3t sich nur schwer von anderen Faktoren isolieren. 39 Die E hesc heidungsziffern sind in den meis ten Landcrn ve rfi.ig- ba r , d och erfasse n sie n icht d ie A un os ung eheah nlicher Ge mein- schaften u nd geben ke inen Aufschl u/3 uber die A uswirk u ng de r Ze rruttu ng a uf d ie Beteil igten. Ein ln forma ti o nsnachholbedarf be- steht a uch in bezug a uf die in den verschi edenen La ndern vo rzufin- de nden Diens te und die effektivste Art de r H ilfe leistung. Es ste ht a u l3e rde m fes t , dal3 um fa ngre iches Forsc hun gsma teria l vo rli egt , d as leide r ni cht a usgewe rtet wird , um die Kenntni sse in diese m Pro blembereich a uszuweiten bzw. um en tsprec hende G rundsa tz- richtlin ie n zu ent wickeln . I . M a n so llte eine erl a utern de Stud ie uber di e Fam ilienhilfe in Eu ro pa a nfe rtigen . 2. Die Beziehunge n zwi sch en den a n der Fa mil ie nze rruttung be teiligte n Fa kto ren so llten ge na uer unt ersucht werd en. 3. Es sollte untersucht we rden , welche Ro lle di e Fa mili enhilfe in den verschied enen Zerruttungsstadien spi elt. 4 . Die vo rli ege nden Fo rsc hun gsda ten sind grundli cher a uszu- werten. Koordinierung der Dienstbereiche Die verschiedenen Die nstbereic he mussen dringe nd s ta rk er koor- dini ert und zwischen d em offi zie llen und inoffizie ll en Sek to r gege n- seitiges Versta ndnis und Zusa mmena rbeitswille ent wickelt werden . Beide Sekto ren ko nnen einen pos iti ve n Beitrag leisten . In den meisten La ndern uberla p pe n sic h die G ebiete; es steht a uch fest , dal3 d en G egebenheite n entsprec hend versc hi edene Verfa hren de r Lei- stungse rbrin gung a ngewend et werden ko nnen . Es so llte a uch eine Wa hlm ogli chkeit bes tehen , da mit die Klienten d ie ihren Bedurf- nissen a m bes ten e ntsp rec henden Leistunge n a uswa hl en ko nnen. Keiner de r beiden Sektore n ka nn beha upten , dal3 er in bezug a uf gute Prax is eine M onopo lei nstellung einn ehme - beide Sekto ren ko nn en u nd m·usse n vonein a nde r lernen . Der offizie ll e Se kto r ha t ein extre m bre ites Spektrum a n Bedurfnisse n zu befri edige n, wodurch mogli cherweise d ie lnnova ti o nsfreudigkeit und Fl ex i- bil ita t e ingesc hra nkt wird . De r o ffi zie ll e Sektor so lltc a ul3erde m 40 Prioritaten festsetzen und die gegenwartige Entwicklung der Fami- lienbetreuung erneut unter die Lupe nehmen. Der inoffizie lle Sektor zielt nicht darauf ab, die Aufgaben des offiziellen Sektors an sich zu reil3en und sollte ebenfalls, soweit mogli ch, Prioritaten festlegen, Rollen abgrenzen und die Vorteile beider Systeme nutzen . Die Vertreter sowohl des offiziellen a ls auch des inoffiziellen Systems gaben zu, da13 in manchen Situationen weder die Fachkraft noch der Laienhelfer mit Aussicht auf Erfolg eingreifen kann und man es am besten unterlal3t. Auch wenn ein Proble m ausgemacht worden ist , hat jede Familie das Recht , e ine Int ervention zu verweigern. I. Es so il ten Plane fur den lokalen Rah men aufgestellt werden, die eine koordinierte Leistungserbringung gegeniiber den Familien festlegen. 2. Der formate Sektor sollte die kleinen Gruppen am Ort prak- tisch unterstiitzen, indem er beispielsweise Sitzungsraume und administrative Unterstiitzung anbietet. 3. Zwischen dem offiziellen und inoffiziell en Sektor so llte em ungehinderter Informations- und Wissensaustausch sowie Uber- weisungsmoglichkeiten bestehen. 4. In die Ausbildung alter Gesundheitsfachkrafte sollte auch die lnformierung Ober Funktionsrolle und Aufgabenumfang des inof- fiziellen Sek tors ei ngehen. 5. Bei beiden Sektoren so llte eine grol3ere Bereitwilligkeit vor- handen sein , die Leistungen des anderen Sektors anzuerkennen. 6. Die betreffenden Dienststellen soil ten das Recht jeder Familie auf Hilfeverweigerung anerkennen und sich daruber klar se in, dal3 in manchen Situationen eine Intervention erfolglos sein kann. Kinder Auch wenn jeder Erwachsene und jedes Kind subjek tiv auf die Zerriittung ihrer Familie reagieren wurde, gibt es doch Ahnlich- keiten im Verhalten, die genauer zu untersuchen sind . 41 Zurn Beispiel reagieren Knaben oft a nd ers als Madchen und werden beispielsweise aggressiv. Solche Unterschiede so llten be- rucksichtigt werden; es ist auch wic htig, daf) den Kindern und Jugendlichen wahrend dieser traumatischen Periode ihres Lebens geho lfen wird, so daf) sie keine Dauerschaden davontragen. Die kurzzeitigen Auswirkungen einer FamilienauOosungaufdie Kinder sind grund lich erforscht. Dach fehlt es an Unterlagen uber die langfristigen Folgen; auBerdem ist ein GroBteil der Oaten noch nicht ausgewertet warden. Die Rechte der Kinder einer zerbrechendcn Familie sollten klar festgelegt sein und auch das Recht der Kinder umfassen, daB sie informiert werden und man ihre Meinung berucksichtigt, wenn zum Zeitpunkt der FamilienauOosung Entscheidungen getroffen wer- den. Diese Entscheidungen sind naturlich van den beiden Eltern- teilen zu treffen. Selbstverstandlich stehen die Interessen der Kinder nicht immer an erster Stelle. Besonders wenn rechtliche Fragcn zu Ibsen sind , kann die AuOosung der Familie eine langwierige, nervenaufrei- bende Sache werden. In einigen Landern gibt es Ycrsohnungszent- ren , die nicht a usschlieB li ch der Yersohnung dienen, sondern auch auf Losungen zum Besten der Kinder hinarbeiten. Auch die Yater verd ienen eine starkere Berucksichtigung; es so llten Ansatze ausgearbeitet werden, die fur sie akzeptabel sind und deren sie sich auch bedienen konnen. I. Entwicklungspadagogik im Kindesalter sollte a ls Themenbe- reich inj ede Krankenschwesternausbildungaufgenommen werden. 2. Die Reaktionen der Kinder auf eine AuOosung der Familie so llten gena uer erforscht werden; das bereits vorli ege nde For- sc hungsmaterial sollte zuganglich gemac ht und ge nutzt we rden. Zur In format ionsbeschaffu ng so llt e man vorne hmlic h die bereits exis tierenden Langsschnittsstudien benutzen. 3. Die United Na ti o ns Children's Charter sollte Ausfuhrungen uber die Rechte der Kinder wahrend der AuOosung des Fami- lienl ebens en thalten . 4. Es so llten spezie ll e Yersohnungsstellen eingerich tet werden, damit die bei AuOosung der Familie zu treffenden Entscheid un ge n optim a l das Wohl der Kinder berucksichtigen. 42 5. Fur Ehe ma nner , de ren Fa milie sich in de r Ze rrlittungs phase befind et , so llten neu a rtige und zweckdi enliche Betreuungsdienste eingeric htet we rden . Intervention und Pravention Die Famili enze rruttung stellt einen Proze /3 da r , bei dem die fa mili en- interne gegense itige Hilfes tellun g zusamm enbricht , und zwa r nicht erst zum Ze itpunkt des A use ina nderge hens. Ma n ha t bereits di e Lebensphase n ermitt elt, in d enen die Fa milien a m meisten gefahrd et sind . Ma n so llte unbeding t Prima rpra ve nti o nsprog ra mm e ftir d iesc Lebensphase n vorberei ten (z. B. flir Zei ten der Sch wange rsc haft , bei Schulbeginn des e rsten Kindes und wenn all e Kind er e rwachse n sind). Es so il te n Mechani smen zur Fes tstellung beso nd ers gefa hrdeter Famili en und Betreuungsdienste a ufge ba ut werden , di e im Pro- blemfall unve rzuglich reagie ren ko nnen . An sc heinend gibt es a uch keine Betreuung flir den a ktuell en Krise nfall ; es mlisse n dringe nd entsprechende Modelle untersucht und a usp ro biert we rd en . Di e Famili en ihrerseits soil ten wisse n , da/3 derartige Dienste a m Ort bes tehen , da/3 sie sich leicht an sie wenden ko nnen und sich n icht zu scha men brauchen . Fa mili enhilfeze ntren in der na he ren Um- gebung, die a uch Selbsthilfegruppen und mult ip rofess io nelle Un- terstlit zungsa ktivita ten e insc hli e /3 en , ko nn en so lche Di enste er- brin ge n . Das Gem einwese n ka nn viel zum Wo hl e der Fa milie n beitrage n , wenn di e ri chti ge Initia ti ve e rgri ffe n und Resso urce n zu r Verftigung ges te llt werden . Arbeitsp rojekte ko nnen zu r Einrichtung neuer Betreuungsdienste flih ren . Die Regi erungen der La nder sollten gegenliber der Fa milie e ine zusammenhangende und positi ve Po litik ve rfolge n; in vielen Landern sollte besonders den jungen Paa ren mehr ge ho lfe n werden . I. Di e prima re und se kund a re Prave nti on so llte we it sta rk er beac hte t we rden. Bereit s im Schulunterri cht so llte ma n di e Auf- ga ben und Ro ll en in der Ehe und al s Elte rn te il beha ndeln ; a u /3e r- de m so llte ma n mit den Muttern , d ie Kleinkinder habe n, mit Risik o- fa milie n , mit Leuten , die s ich in de r Mi d-Life-C ri sis be find en , und a hnlich en Gruppen zusammena rbeiten . 2. Ma n sollte neua rtige Betreuungsdi enste einri ch ten , die Fa mi- lien in der Kri se Hilfes tellung le iste n ko nnen. 43 3. Es sollte umfangreicheres Informationsma terial fur noch nicht verheirate te Paare und Fami lien vorliegen , worin di e Phasen der gro f3ten Zerriittungsgefahr behandelt werden . 4. Es sollten ortliche Fami li enhilfezentren eingerichtet werden, die multiprofess ion elle Hilfe a nbieten und fur die Bevo lk erung leicht zugiinglich s ind. 5. Es so llte eine besse re lnformierung iiber die loka len Dienst- bereichc erfolgen . 6. Die Regierungen so llten den jungen Paaren mehr praktisc he Hilfe zutei l werden !assen. Krankenpflege In manchen Liinde rn haben die Kranken sc hweste rn fur Familien- gesundheit eine gute Verbindung zur Bevolk erung und stellen fiir vie le Problemfamilien den ers ten Kontakt dar. Die Kra nk enschwe- ster wird von der allgemeinen Bevolkerung nicht mit demselben Mif3t ra uen betrachtet wie a b und zu Sozia larbeiter und Psycho lo- gen. Die Klien ten wenden sic h oft mit ein em ko rperliche n Symptom an die Krank enschwester und beginnen erst nach her, i.iber ihre emot io nellen Probleme zu reden. Zugegebenermaf3e n sind aber di e Krankenschwes tern nich t immer di e a m besten geeignete Berufsgruppe in der Pflegepraxis, wenn es um ein nichtkorperlich es Problem geht. Doch macht die Ges undheitsversorgung ei nen An derungsp rozef3 <lurch, der u.a. beinha ltet , daf3 die zuki.i nftigen Krankenschwestern auch Qualifi- kationen fi.ir die Gemeindearbeit erwerben mi.i ssen. In diesem Zusammenhang werden sie sich zuneh mend mit zerriitteten Fami- li enve rh ii ltnissen befassen miissen. In eini gen Liindern besteht diese Situation bereits, doch ist generell eine Weiterbildung in diesem Bereich not ig. In diesem Zusammenhang gesehe n, mi.issen sich die Anscha uungen der Allgemeinheit i.iber die Krankenschwesterrolle bedeutend iindern. In der Ausbi ldung und Weiterausbildung der Fachkriifte muf3 die multidiszipliniire Teamarbeit starker beachtet werden. Die Kommunikationsmiingel zwischen den Fachdisziplinen behindern stark ei ne rationale und effektive Ausfi.i hrung der Arbeit. 44 I. Die allgemeine Krankenpflegeausbildung so llte mehr auf die primare Gesundheitsverso rgung ausgerichtet sein und sich beson- ders auch mit der Problematik neuer Familienstrukturen befasse n. 2. Fur Krankenschwestern, die sich in der Familiengesundheits- pflege spezia lisieren wollen, sollte es besondere Weiterbildungs- kurse geben. 3. Die Ausbildung der verschiedenen Berufsgruppen sollte gewisse gemeinsame Elemente enthalten, darn it die multidisziplinare Team- arbeit besser wird. 4. Die Krankenschwestern und ihre Arbeitgeber sollten die Offent- lichkeit uber ihre gegenwartige und zukunftige Rolle im Hinblick auf die Erstpravention aufklaren und die anderen Fachrichtungen im Gesundheitssektor unterstiitzen. Die po/itische Dimension Es ist ni cht darn it getan, da/3 die Fachkrafte des Gesundheitswesens oder auch Privatinitiativen sich mit den direkten Problemen der Familienzerruttung befassen. Man sollte sich in einem viel grol3eren Rahmen der Beziehungen zwischen sozialen Faktoren wie Armut , sch lechte Wohnungsverhaltnisse, Arbeitslosigkeit und falsche Er- nahrung einerseits und Erkrankungen sowie Spannungen in der Fami li e andererseits bewul3t sein. Diese Beziehungen konnen nur in das Blickfeld der Offentlichkeit geriickt werden, wenn der Kran- kenschwesternstand, andere Gesundheitsberufe und die Privatinitia- tiven sowie ahnliche bevolkerungsnahe Gruppen ge meinsam auf landesdeckender und lokaler Ebene politisch aktiv werden. Scheidung bzw. Trennung stellt nicht unbedingt ein Yersagen dar, sondern kann die erfo lgreiche Beendigung einer unzulang- lich en Situation bedeuten. Man sollte auch nicht !anger alternative Familienstrukturen, die vom traditionellen Familienmuster (zwei Elternteile und ein bzw. zwei Kinder ) abweichen, als "abweichendes Yerhalten" ansehen. Die Belastung Alleinerziehender und ihrer Kinder hangt zumindest teilweise mit der Haltung der Gesellschaft zusammen. Die Alleinerziehenden und ihre Kinder werden in vielen Fallen als andersartig oder irgendwie zweitrangig angesehen. 45 Man ka n n sich nic ht me h r Hi nger der Tat ac he ve rsch lieBe n , daB sich d ie Fa m ilienst ru kture n in vielen Ui nde rn andern . Wenn man sic h d ieser Lage bewuB t ist und sie a kzept iert , so llte a uch eine to lera ntere Ha ltung gege nuber a ltern a ti ven Sozia lgruppierun ge n ei nt re ten . I. Die Fachkra ft e des Ges un d heit swese ns so lltcn s ich mit dem in o ffi zie ll en Sekt o r zusa mment un und Ma nge l hin sichtlich der Betreuungsdienste a np ra nge rn sowie die gese llsc ha ftli chen Ursa- chen ma ncher Kra nkheiten offc ntli ch untersuchen . 2. Die Fachkra ft e des Ges un d heitswese ns und d ie priva ten Grup- pe n soil te n die Vo rurt eil e gege n untraditi o nell e Fa milienstrukturen beka mpfen . 3. Die vo rha ndenen Die ns te so llten weiter bes tehe n bleiben und zusa tzlich neue fur a ll e Fa mili enformen entwi ckelt we rden. 46 PE31lME B COBell!aHHH PaooqeH rpynrn,J npHH.RJIH ~acrHe 26 BpeMeH- HblX CCB€THHKOB (111ecTl> Me.ocec-rep, TPH spaqa I O,llHH OCHXOJ:Cr, O,llHH noJJHTJ.-NeCKHH ,0€RT€Jlli, nRTI, npe.ocraBHTeJJeH rpynn Hace- r.eHHR H .oecRTb ~ypHaJJHCTOB), a TaK~€ ,OBa C'OTPY.DHJiJ<a PerHCHaJlbHOrc C~po. nepe.o COEe111aHHeM CTORJlH CJl€.DYlallHe 3a.oa,m: pacll!HpHTb OC1>eM HMeEll!eHCR HHq)CPMaUHH H npoaHa.nH3Hpc- BaTb OTHOll!eHHe K M€.DHKO-CaHHTapHb!M npoCneMaM, B03HH- Ka~IIIHM B CBR3H C pacna,ooM C€MbH B CTpaHax EBpcneHCKCro perHoHa eo::; cCcy.DHTb 3HaqeHHe 9THX npoc,neM E KOHT€KCT€ rnoeari1:,HOH H perHOHam,HW< crpa-rerHH 803 H .DOKYMeHTa o 3a.oaqax 803; oCpaTHTb BHHManHe M€~paOOTHHKOE H HaC€11€HHR Ha MHOro- oOpa3HM€ acneKTbl STHX npcCneM, YqJ,!ThJBaR Heo0XO.DHMOCTb onpe,oer.eHHR poJJH Me,ocec-rep, aKY11JepoK H Hacer.eHHR B npe,oynpelk,DeHHH HeCnaronpHRTHMX DOCJ1€,0CTBHH pacna.oa C€MbH H yJ<penneHHH 3.DOPOEbn ee 'l.TleHcB; C03,0aTh yCJJOBHR, cnOCOOCTEY~lllHe oocylk,De~ 9THX Me~HKO- caHHTapl-ll,JX npc:Cr.eM paOOTHHKaMl1 o¢HUJ1aJlbl-ll,JX H Heo¢'HI.J}l- ari1:,HI,1X CHCT€M 3,npaEOOXpaHeHHR H npe.ncTaBHTe.nRMH HaCe.Ti€HHR; noru,rraTbCR HaHTH arn,-repHaTHEHhlH no.oxo.o K ,0€fiT€JlbHCCTH 803, HanpasneHHoH Ha ooecneqeHHe ~acTHR HaceneHHR, 3oKJJ~qaJCIIJHHCR B opraHH3aIJHH COBell!aHHR HOBOro nma, B KOTOpoM npHHHMaJOT ~aCTHe Me,opaCcTHHKH H npe,oc-raBHT€JIH HaceneHHR (B0111€,DIIJHe B COCTaB .DBYX rpyrm 9KcnepTCB) H npe.ncTaBHTeJJH cneUHaJJH3HPOBaHHOH H OOIIJ€CTB€HHOH neqaTH (yqacrBylOll!He B coBe111aHHH B KaqecTBe ttaCn~.naTeneA). 47 .IlHCKYCCHR Pacna.o ceJQ,H - Ball.Hoe coUHaJibHoe RBJleHHe BO ocex CTJ)aHaX EBpomi, HMeIOmee .naneKO H.DYMHe nocne,OCTBHJI Me.DHKO- caHHTapHoro xapaKTepa. 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B TO ~e BP~MR He cne.nyeT aaOhlBan,, 't!TO Me,ncecTep He Bcer.na cq11Ta1CT HaHOOJJee no,DXO,DRllJ€H KaTeropHeH paOOTHl1KOE ,DJJR pehl€Hl1R npo6JJeM, He OTHOCRh!HXCII K oxpaHe ¢11311qecKorc 3,DOpoBbR. 0,n.HaKO B CHCTeMe 3,IlpaBOOXpaH€:Hl1R npOHCXC,IlnT H3MeH€Hl1R, l1 B 0Y.OYhJ€M Me,ncecTpaM npe,DCTOHT pacllll1pl1Tl, CBOH 3HaHW'l l1 OnblT, Hec:OXO,DHMble .DJJR paOCThl B KOMMyHaJU,HhlX yqpe11,neH11RX. 8 STl1X ycnOBl1RX OHH CMOryT COOTB€TCTBYIOllll1M c0pa30M pearnpo.can, Ha npocneML1 pacTyruero q11cr,a Heonarono- JJY't!Hh!X ceMeH. QqeB11~0, qTo STOT npouecc yi,.e Haqa.nCII B pR,De CTpaH. 0,IlHaKO B cO!neM noTpe<SyeTCR yB€J1H't!HTI, 't!HCT.0 54 nporpaMM nOCT,DHI1Jl01"JiOH no.orOTO.BKH • napan11e.m,HO C STHM CJJe,nyeT npo.BO,DHTh paOOTY no KOpeHHOMY H3MeHeHHIO OTHOmeHHR oOmeCTBa K poJJH Me,nHLIHHCKHX cecrep. B nepHO.O OCHO.BHOro H nOCJJ€.DYIOldero 00~€HHR npc¢€CCHO- HaJll,Hh!X paOoTHHJ<o.s oom,me .BHHMaHHR CJJe.oyeT Taiae y.oe11RTb Ha.BblKaM paOonr pa31lH'lli1>1X c::neUHaJJHCTO.B .B cocra.se O,oHOh OpHra,n1,1. npo011eML1 .B3aHMOOTHO- meHHH Me~ HHMH OCTaIOTCR CJlHHM H3 rJJaEHhlX npenRTCT.BHH, CTCRll!HX Ha nyTH cpraHH3aUHH paUHOHaJU:,Hh!X H s¢<l>eKTH.BHbiX CJJyl!IO. 1. npcrpaMMbl OCHOEHCH no~rCTC.BKH M€,J::HUHHCKHX C€CT€P .00.lliHhl Ob!Tb nepeopHeHTHJ)OBaHhl H BKJUOt.laTb npHHUHllhl paOonr B CHCT€M€ nepBH'IBOH Me,DHKO-CaHHTapttOH nOMOlllH' KOTCPLie' B qacTHOC:TH, n03BOMJOT pemaTb npoO.neMbl, C KOTOPLIMH CTaJJKH- Ba~TCR B HaCTORlllee BpeMR ceMbH pa3JJHGHblX KaTeropHH. 2. C11e.oyeT npe.oycMoTpen cneUHaJU:,HylG nocT,I;.Hn110MH~ no.nro- TOBKY M€,I;.HUHHCKHX cecTep, KOTOpble H3DRB1JIUOT l!l€1JaHHe paC'.c- TaTb B CHCTeMe OXpaHbi 3,Dopom,R C€MbH. 3. CJJe,nyeT pacmHpHTh npaKTHKY CCBM€CTHCH nc,nrOTOEKH paOOTHHKCB pa31JH~Hb!X cneuHaJlbHOCTeH, 4TO 003.BOJJHT nC,11HRTb Ha 0011ee BblCOKHH ypoBeHb paCOTY B MHcrcnpc.¢HJU:,HCH OpHra,ne. 4. Me.ocecTpbl H npe.ocTaBHTe.TIH ~pe~eHHH, B KOTOpbiX OHH paooTaK-T, ;:::c.r.l!IHhl cpraHH3CBaTh 1<aMI1al-rn1C no HH¢CpMHpoBaHHIO HaceneHHR O HaCTORmeH H noTeHUHaJlbHCH poJJH Me.ocecrep Kak paOon!HKOB nepBoro 3E€Ha npo¢HliaKTHKH H OOMOIIJH. nOJ1HTHqec1<He acne1<nr PaOOTHHKH 3,DpaBooxpaHeHHR H rpynllhl HaceJJeHHR ,DOJJJ\Hhl He T01lbKO 3aHHMaTbCR HacyroHhlMH npoOJJeMaMH ceMeH, HaXO.DFtlnHXCR Ha rpaHH pacna.na • OHH .0011:m-n,1 JJy'-il!Je 3HaTh O B1lHRHHH Ha 3,DOJ)OEbe H nOJJCllleHHe B ceMbe TaKHX CCUHaJlbHLIX ¢aKTOJ)OB, KaK Cie,DHOCTb, Hey.ooB1JeTBOPHT€IJ.1::,Hhle l!IHJ'MlllHbl€ ycnCBHR, Oe3pa6o- THUa, n11cxoe nHTaHHe. C TeM, GTOObi STH ¢aKTOPbl CTaJlH H3BecTHhl c6IJleCTBY, Me,I;.HUHHCKHe cecTphl, wyrne npo¢eCCHC- Ha1lbHble paOcTHHKH 3,0paBOOXpaHeHWi H rpynm1 HaceJJeHWi ,DO.TmHLI npe.nnpHHRTh COOTBeTCTByJOmHe nCJJHTHGeCKHe .oeHCTBHJI Ha MecTHOM H HaUHOHaJlbHOM YPCBHRX. 55 Pa3BO~ HM pa3,neneHHe ceMeH He BO Bcex CTl~a.RX RBJ111€TCR HeraTHBHh!M RBJJeHHeM; HanpoTHB, OH Mo~eT npHBeCTH K ycnemHOMy pemeHH~ H€Y.DOBJJ€TbOPHTer.bHOro nono~eHHJ'I. AJlbTepHaTHBHhle ceMeHHhle CBR3H, KOTOpwe OTJU,NaJCTCR CT TPa.DHUHCHHOH MO~e.11H ceMbH, COCTCIUlleH H3 .DBYX poµHT€JJ€H H 0,DHOrc-~ByX ~eTeH, He CJJe~yeT Cio.nee CtrnTan, aHTHCOUHaJlbHhlM RBJJeHHeM. no KpaHHeH Mepe HeKOTOpbte H3 crpeccoB, KOTOpb!M no~BepraeTcR ceMbR c o~M po.n.meneM, nopo~~aJCTCR OTHOl!leHHeM K HeH OOllleCTBa. TaKHX po~T€Jl€H H HX ~TeH qacTO paCCMaTPHBalCT KaK JJHU co CTpaHHOCTRMH, OTnHtUil,IMH OT ~PYrHX, .na~e CGHTa~T B H€KOTCPOM poLe rp~,naHa.MH BTCpcro copTa. 0...efil; Ba~HO npH3HaTh, qTo BO MHOrHX CTpaHaX ceMeAHhle CTPYKTYPW MeHRICTCR. Kor~a STO Oy,neT npH3HaHC, K am,TepHa- THBHbIM ceMeHHhlM CBR3RM Oy,nyT OTHOCHThCR C Cio.nbmeH repnH- MOCTh~. 1. Me~paOOTHHKH ,DOJJll\Hl>l OOL€~HHTb CBCH ycH.r.HR c npe,ric-ra- BHTeMMH Heo¢HUHanbHOrO ceKTOpa B TOM, qTO KacaeTCR BWRBne- HHR He~OC'raTKCB B oOCJJy&HBaHHH H CCUHanbHhlX npHGHH yxy.D.111e- HliR 3~0POBbR, 0 KOTOpwx Ha.no roBOpHTb BC Beeb ronoc. 2. Me,npaOOTHliKH 11 rpynnLI HaceneHM ~OJJ~HW BWCTYnan, npo- THB HeraTHBHOro OTHOmeHHR K HeTpa,DHUHOHHWM ¢opMaM. ceMeHHWX CBR3€H. 3. Cne;:;yeT H Bnpe.m, OKa3b!BaTb noMOl!lb BCeM ceMbRM., BHe 3aBHCHM.OCTH OT HX xapaKTepa, C03~aBaTh HOBble CTly~Ow OXpaHbl 3.DOPOBbR C€MbH. 56 SOME OTHER WHO PUBLICATIONS Further studies in family formation patterns and health : an international collabor- ative study in Colombia, Egypt, Pakistan and the Syr ian Arab Rept•blic. Study coordinators and editors: A.R. Omran & C.C. Standley. Principal in vestigators: Colombia - G. Ochoa & A. Gil; Egypt - H. Ham- man & F. El-Sherbini; Pakistan - Batu! Raza & Talat Khan; Syrian Arab Republic - F. EI-Boustani. 1981; 463 pages [E only] ISBN 92 4 156070 3, Sw.fr. 44.- Research on the menopause: report of a WHO scientific group (Geneva 1980). Technical Report Series, No . 670, 1981; 120 pages [Ar,E,F,S] ISBN 92 4 120670 5, Sw.fr. 8.- Adolescent reproductive health: an approach to planning health service research by H.L. Friedman & K. Edstrom. WHO Offset Publicatio n, No. 77, 1984; 53 pages [E,F,S] ISBN 92 4 170077 7, Sw.fr. 8.- Traini ng in family planning for health personnel: report on a WHO meeting (Paris 1981) . Public Health in Europe, No. 20, 1985; 99 pages. ISBN 92 890 1156 4, Sw.fr. IO.- Sex and family planning: how we teach the you ng: repo rt on a study by B. Lewin. Publi c Hea lth in Europe, o. 23, 1984; 170 pages [E] ISBN 92 890 1159 9, Sw.fr. 19.- l-laving a baby in Europe: report on a study. Public Health in Europe, No. 26, 1985; 157 pages, ISBN 92 890 11 62 9, Sw.fr. 13 .- Family planning legislation: report on a survey by Barba ra Swartz. EURO Reports and Studies, No. 85, 1983; 86 pages [E] ISBN 92 890 1251 X, Sw.fr. 8.- Family planning and sex education of young people: report on a WHO meeting (Copenhagen 1982). EURO Reports and Studies , No. 89, 1984; 42 pages [E with summaries in F,G,R] ISBN 92 890 1255 2, Sw.fr. 5.- Targets for health for all : targets in sup po rt of the European regional stra tegy for health for all, 1985; 201 pages [E ,F,G,R] ISBN 92 890 1034 7, Sw.fr. 20.- Care of children in hospital: report on a study by Else Stenbak with illustrations by Lilian Brngger, 1986; 68 pages, ISBN 92 890 1033 9, Sw.fr. 12.- [Ar= Arabic, E = English. F = French , G = German, R = Russ ian. S = Spa nish ] 1111111 11111 11111 11111 111111111111111111111111111 .. 0 0 0 0 I 9 8 7 ..