ROSALIEA. CAFFREY
F A M I L Y CARE OF THE E L D E R L Y IN N O R T H E A S T T H A I L A N D : CHANGING PATTERNS
ABSTRACT. Using exchange theory, the effects of the change from a kin-based to a cash-based economic system on family care to the elderly in rural Northeast Thailand are examined. Eighty-nine households from three sites representing three levels of development were analyzed in relation to family and household membership, as well as economic and employment status. In addition, 32 elders from two old age homes were interviewed. This study found that, in general, the more land a household owns, the more likely the traditional pattern of elder caregiving will be maintained. When land is limited, children leave to find employment elsewhere and will try to send money to help their parents as they are able. Poverty plays a major role in the perceived quality of life of these elders. Key Words: culture change, elderly, exchange theory, family care, modernization,
Thailand
INTRODUCTION During this past century, we have witnessed major changes in world population. One of the most unique features of these changes has been the increase in the number of older people. While one may view this as evidence of a successful outcome of a world-wide effort to promote health, the results may be a mixed blessing. As these elderly are especially vulnerable to chronic health problems, countries must decide how to distribute their limited resources in providing care to them. In 1980, the percentage of elderly over the age of 65 in the total population of the world was 5.8%. In the more developed regions, the percentage was 11.4%, and in the developing regions, it was 3.9% (Kinsella 1988). By the year 2020, elderly over the age of 65 will constitute 13% of the total population in the more developed regions and 4.6% in the developing (Myers 1982). In actual numbers, in the developing regions alone, this is an increase from 128 million to 470 million, over three and one-half times as many people (Kinsella 1988). Thailand has had one of the most successful family planning programs of any developing country. This program, which began in 1970, will eventually result in a higher percentage of elderly in the total population as well as a decreasing number of caregivers. The population of Thai elderly over the age of 65 has been almost doubling every 20 years, going from 709,000 in 1960, to 1,569,000 in 1980 (Ministry of Public Health 1985), and" estimated to increase to 3,000,000 in the year 2000 (Myers 1982) and to 6,800,000 by the year 2020 (Kinsella 1988). This represents an increase from 3.5% of the total population in Thailand in 1980 to 8.3% in the year 2020. This dramatic increase in the elderly population in Thailand will have important implications for the distribution of resources. Journal of Cross-Cultural Gerontology 7:105-116, 1992. © i 992 Kluwer Academic Publishers. Printed in the Netherlands.
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Thailand is rapidly undergoing modernization, and the elderly are especially vulnerable to the negative effects of modernization, according to some theorists (Cowgill 1974; Cowgill and Holmes 1972; Press and McKool 1972; Sheehan 1976; Treas 1977). Modernizing factors especially affecting family relationships of the elderly include: 1. The migration to urban areas by younger family members in search of jobs; 2. The changing roles of women as they also become involved in the job market; 3. A decreased birthrate eventually resulting in fewer potential caregivers for elderly parents; 4. Changing norms and values which emphasize individualism and competition rather than the interdependent relationships characteristic of extended families; 5. Increased education of the young, thereby decreasing the elderly's value as cultural experts. Modernization theory, as a predictive model of the status of the elderly, has been criticized for the inability to account for variability in outcomes (Dowd 1981, 1983; Goldstein and Beall 1981, 1982, 1986; Goldstein, Schuler and Ross 1983; Rhoads 1984; Sangree 1986). This study, therefore, proposes that exchange theory is a more appropriate model for understanding the differential effects of modernization on the elderly. Exchange theory is based on the cultural norm of reciprocity. Each partner in an exchange relationship is expected to reciprocate in an equitable manner for services rendered by another. Thus, each partner must possess resources which can be drawn on to exchange for needed services (Blau 1964). It has been assumed that with modemization, formerly valued resources are lost to the elderly, thus rendering them relatively powerless in their relationships with their families (Dowd 1980). THE ELDERLY IN RURAL NORTHEAST THAILAND In rural Thailand, traditional exchange resources held by the elderly have included: I. Economic resources, especially inheritance of land, but also including the elder's house; 2. Contributions made by the eider to household activities, including caring for grandchildren, cleaning, cooking, and general household maintenance; 3. An advisory role based on knowledge of traditional skills associated with farming and of traditional Thai behaviors, values and beliefs; 4. Performance of ritual activities associated with the Buddhist religion. In addition, the traditional Thai cultural norm of filial obligation requires repayment to parents for their care when one was a child. This norm acts as a powerful enforcer since violation results in shame and social ostracism. To be ungrateful to one's parents is considered one of the greatest sins a child can commit (Klausner 1987). The rural Northeast Thai family life cycle supported this system of
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reciprocity. After marriage, daughters were expected to bring husbands into their family system and continue to cultivate their parents' land. Sons moved into the wife's family system. It was expected that the youngest daughter would remain in the household after her marriage to care for her parents until their death. At that time she inherited the parent's house. If there were no daughters, the youngest son brought his wife into the household as the caregiver. Distribution of land through inheritance was generally equal among all children, although sons often sold their land to their sisters. Thus sufficient land to give to children was essential for enticing children (especially daughters) to remain nearby and provide for their parent's care (Cowgill 1986; deYoung 1955; Foster 1975; Lux 1969; Mizuno 1968, 1978). This study examined the effects of modernization on the traditional exchange resources of the elderly and found that changes are indeed affecting their exchange values. While potential for negative impact on the elderly is evident, these changes may not necessarily be negative, especially if the elderly are able to develop alternative exchange resources of equal value. Whether this might be possible for rural Thai elderly was an area of concern of this study. Northeast Thailand (Isaan), where this study was done, is the largest of the five (or four if Bangkok Metropolis and the Central Region are combined) regions in Thailand. In 1980, elderly over the age of 65 constituted only 2.8% of the population in this Northeast region, as compared to 3.9% in the total population. But 34.8% of the total population of all Thai elderly lived in Northeast Thailand, the largest percentage of the total population in Thailand (Ministry of Public Health 1985). In 1988, it was estimated that 84% of the elderly over the age of 65 were located in the rural areas (Kinsella 1988). Northeast Thailand was selected as the research site for the following reasons: 1. The region is primarily an agricultural setting that continues to preserve the matrilocal post-marital residence pattem and Buddhist-based ideology of filial obligation. 2. The erratic rainfall and the limited water-holding capacity of the soil severely limit agricultural production and make it the poorest region of Thailand. 3. Modernization is only gradually making an impact on this region, thus providing an opportunity to study the variable effects of the modernization process on the elderly population. 4. Northeast Thailand is characterized by an expanding population, heavy deforestation, and progressively limited agricultural land available for the younger generation. 5. Excessive pressure on available resources is resulting in the movement of young people to urban areas in search of jobs. Thus Northeast Thailand provided an ideal setting to examine the question, "What impact does the change from a kin-based to a cash-based economic system have on family care of the elderly in Northeast Thailand?"
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The information presented in this paper is based on an analysis of data collected over a nine month period, 1988 to 1989. This research took place in Soongnern District in Nakom Rajisima Province. Nakom Rajisima is the largest of the 71 provinces in Thailand and is the most populated province outside of the Bangkok area. It is located in the southeastem part of the Northeast Region and is about 200 kilometers from Bangkok. Korat is the largest city in the province. Soongnem District is about 30 kilometers south of Korat on the Friendship Highway, the main highway connecting Bangkok with the Laotian border. Three research sites containing two villages in each were selected based on their level of infrastructural development. The two most developed villages were those with a village piped water supply, electricity, waterseal toilets, and easy transportation access to urban settings by way of paved roads. These two villages are primarily dependent on agriculture and have wealthier families than the other two research sites. Much of the financial backing providing the basis for these developments came from previous overseas employment by the village men in Saudi Arabia. The primary dialect spoken by these villagers was LaoThai. The total sample size in this site was 30 households. The two least developed villages were fairly new, having been established within the last thirty years on deforested land. Residents had originated from a variety of locations in Korat Province and spoke both Lao and Central Thai. These villages were characterized as relatively inaccessible to urban settings because of distance and poor roads, had no electricity, obtained water from local ponds or canals, were primarily agriculturally based, and were economically the poorest of the three village sites. Less than one-half of the families surveyed had waterseal toilets. A total of twenty-seven households were interviewed in this site. The two intermediate villages contained speakers of the Korat Thai dialect, an ethnic group who originated from the intermarriage of Khmer and Thai soldiers in the fourteenth century (Smith, Bemier, Bunge, Rintz, Shinn, Teleki 1968). These villages had fairly easy access to urban settings (some dirt and some paved roads), electricity, no village water supply (but some families had individual wells and/or pumps for their water), and most had waterseal toilets. Income from agriculture was limited due to the limited amount of agricultural land, and more household income was obtained from employment outside the village. Thirty-two households were interviewed in these villages. In addition, elderly in two old age homes in Korat were interviewed. Criteria for admission into these homes included an age requirement (60 for women and 65 for men), no chronic or contagious diseases, no handicaps, and at least one of the following conditions: poverty, lack of family, or poor family relationships. A total of 89 households with elderly age 65 and over were interviewed in the six villages. A Thai translator with language skills in all three dialects assisted in the interviews. Puyaibaans (village headmen), their wives or a designated assistant often provided assistance and facilitated access to households.
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Approximately 44% of the eldedy were male and 56% were female. Over one-half were widowed and the majority of these were women. Mean age was 74 and 72% had retired at a mean age of 65. In addition, a sample of 32 elderly were interviewed in the old age homes (10 males and 22 females). The mean age of this group was 77 and contained about one-third divorced or single elders. Mean number of living children for the village elderly was 4.75 while the old age home elderly had only 2.3 currently living children. Finally, monks, social workers in the old age homes, nurses and other health personnel, puyaibans and their wives were also interviewed. A total of 24 variables were used to determine whether the selected households were accurately classified in one of the three village sites. These variables included level of infrastructural development (i.e. water supply, toilets, house construction), household membership, employment and economic variables. Results from the discriminant function analysis supported the accurate classification of 91% of the households in the appropriate site. Households in the intermediate villages were the most frequently misclassified. A factor analysis was attempted but because of the relatively low correlations between the variables, relevant components were not identifiable. The three village sites were considered as independent variables for the determination of differences in family care of the elderly. All villages were found to have similar traditional Thai cultural beliefs and practices regarding filial behavior. Any differences in current caregiving behavior were then attributed to other variables. Chi-square and Anova were the primary statistical tests used to test for significant differences among households from the three village sites. In general, it was found that both the most and the least developed villages were more dependent on an agriculturally based economy and households obtained most of their income from farming their own land. In the developed villages, rice was the primary crop, although mung beans are grown during the dry season. The main crop year-round in the less developed villages was cassava, which brought a much lower price in the marketplace, causing less overall income in these villages. Both the developed and less developed sites had more children living nearby than the intermediate village, and more children (as well as current household members) were involved in agriculture. On the other hand, households in the intermediate village owned significantly less land, had more children living outside the village and involved in non-farm labor. They also had fewer household members involved in agricultural work. Over 50% of household income was derived from non-agricultural sources as compared to 2/3 of household income derived from agriculture in the other two village sites. However, total income amount was intermediate. Health status of the elderly was assessed in order to determine if differences existed among the three sites which may affect family care. While the health status of these rural elderly was generally poor, it did not differ significantly among sites. A surprising finding (in light of the overall poor health status of these elderly) was the fact that only two elderly of the total of 89 interviewed
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needed assistance with most daily activities. The remainder were able to perform most basic daily activities unassisted. Interviews revealed two phases in the traditional lifecycle of the elderly and mean ages at which they go through these phases. These ages are based on estimates given by the elderly and reflect a broad variability. But it is striking that the ages identified seem to show a consistency over a broad range of similar activities and for all three village sites. The first phase identified was that of retirement. For both groups of elders (in the villages and in the old age homes) who had retired, the average age was 65. After retirement, the elder briefly continues to maintain primary responsibility for the household, including farming. But by age 67 those elders who are in a position to do so have turned over household and agricultural responsibilities to the primary caregiver and her husband. These elders continue to contribute to the household by caring for grandchildren and helping with housework. They also become more involved in religious activities. The second phase begins about age 75, when most have withdrawn from active involvement in household chores and childcare, have made inheritance arrangements, and have ceased attending activities at the w a t (temple). Sickness, however, may occur at any time and necessitates more intensive involvement by family members in caregiving. Caregiving, then, involves a gradual assumption of household management as well as management of household agricultural production by the caregiver and her husband, with, perhaps, some intensive involvement in sick care of the elder for short periods of time. How, then, is modernization affecting this traditional pattern of caregiving? FINDINGS Elders were asked to identify who was currently their primary caregiver. Onefifth of the 89 village elders interviewed identified themselves as primary caregiver. Slightly over 25% identified youngest daughter. Spouse was the third most frequently identified caregiver (14.6%) with another daughter or granddaughter sharing fourth place (12.4%). When comparing village sites, over one-half (56.7%) of those elders who identified themselves or their spouse as primary caregiver were in the intermediate villages as compared to one-fifth in the developed and one-fourth in the less developed villages. The largest percentage of youngest daughter as caregiver was found in the developed villages (36.7%), while one-fourth in the less developed villages and only 18.7% of the elders in the intermediate villages were being cared for by youngest daughter. Further examination of relevant variables found that household size, amount of land cultivated, and yearly income played important roles in whether the elders were responsible for themselves or whether someone else in the family had taken on responsibility for their care. Households in which the elder was responsible for him/herself were significantly smaller, had less land, and less
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yearly income, while those households which maintained the traditional pattern of youngest daughter remaining in the home as caregiver had a larger household size, more land being cultivated and a higher yearly income. This latter situation was more commonly found in the most developed villages, while the former situation was more characteristic of the intermediate villages. Elders were asked whether they thought caregiving by children was better in their parent's lifetime, better now, or the same. A little more than half of the elders (56.7%) in the less developed villages, almost one-half (48.4%) in the intermediate villages and only 22.2% in the developed villages thought it was better before. These differences were statistically significant. Five variables were found to differentiate those who felt care was better before from those who felt it was better now. Those who felt care was better before had: (1) smaller household size (3.7 versus 5 persons); (2) less annual income 14,000 baht ($560) versus 26,000 baht ($1040); (3) worried more (28% versus 10%); (4) felt that their lives had turned out worse than their expectations (34% versus 8.5%); and (5) felt less satisfied overall with their lives (38% versus 18%). Further analysis of the question of how well the elders' own expectations for their lives had been met revealed that slightly over one-half (52.4%) of all elderly felt their lives had turned out the same or better than they had expected, but 47.6% felt their lives had tumed out worse. Again, village site was significantly related to these findings. Over two-thirds of those in the less developed villages had unmet expectations as compared to two-thirds of those in the intermediate villages who felt that life had turned out the same or better for them. Fifty-five percent of those in the developed villages felt positively about their expectations, while 45% did not. What do the above results mean in relation to family caregiving to the elderly? For those elders who identify themselves or their spouse as primary caregiver, three situations were possible: 1. In a few very rare instances, the elder chose to remain independent even though children were nearby and available as caregivers. 2. More commonly, the children have gone elsewhere to find work and have left their elderly parents behind. Usually these children did contribute financially to their parents' welfare (although only about 45% of the elders felt that those children who send money send enough and one-half of those elders were in the intermediate villages). 3. Also fairly common were those elders who do live with their children or kin, but who must care for themselves because of the poverty of the household. In these situations, daughters must work daily in order to make ends meet and the elders either take over responsibility for the home in order to help their daughters, or continue to work themselves so as to not be a burden on an already financially burdened household. Comments from the elders as to why care was better before help to clarify what elders view as problems with caregiving. These comments fell into four
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groups: 1. (Most common) Children were leaving their parents. A. In search of jobs. A typical comment illustrates this view: Before when older people were 60, they stopped working and let their children take care of them. But now old people take care of themselves because their children go away and work. People work until they are in their 70s and 80s. Before parents had one child to take care of them. Now sometimes they visit only. Sending money is not good. It is better to live with their parents and take care of them. B. Education. This concem was more commonly expressed in the intermediate village where advanced education was more possible for the young: Elderly now feel lonely. Many children have education. After they pass a test, they work in another district. Before they were farmers and stayed to help their parents work the farm. Now the children live away. 2. A felt erosion in the value of respect for o n e ' s elders. Comments such as the following came from elders in all three village sites. For example: Children have less respect. They don't obey or listen to their parents. They say, "You're too old. I study in high school and have more education." They drink alcohol and spend much money foolishly. 3. Dependence on the cash economy making life especially difficult for poor families. Elders in all three village sites commented on this. A woman in one of the less developed villages stated: Before we could exchange labor, but now people want money. You can't always get them to work and help out. Also before when food was all over, you could hunt. Now children cannot find work. They need money to buy food. There is no food for hunting and collecting as before. A n d from a woman in a developed village: Before children took care of elderly people. But now it is difficult for children to find a job and they spend much money for their own family. It is difficult for them to care for the elderly. Before it was cheaper, but now it is expensive. Children must work and there is no time to care for older people. Now I have to put my hands in my pocket many times a day (for money). Before, I never did. A woman from one of the less developed villages described the loneliness felt by the elderly who are left at home while children work: Before children would choose one child to stay or take care of old people, but now they go to work on the farm. They feed us well and give us money, but they leave us alone. I feel very much alone.
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4. L a c k o f concern by children when their elders were sick. A man from one o f the intermediate villages said: It was better before because children lived nearby and when their parents were sick, they came and stayed with them. They went out to gather herbs themselves, or ran to get the herbal doctor. Kin and neighbors gathered and discussed the situation. The elderly felt good because many people were concerned and the children did everything themselves. Now they just take them to the doctor and let the doctor and the nurses take care of them. A couple o f elders felt that the children were more concerned about their j o b s than about their sick parents. Those elderly who thought that care given by families was better now than the care their parents had received attributed this to modernization which brought them a wider variety o f foods, health care, and m o d e m conveniences making life easier. Obviously, one first needed an adequate income to enjoy these fruits o f modernization, and this was more likely in the developed and intermediate villages. Examination o f reasons given for why elders feel their lives turned out worse than expected reveal that poverty, health, and disappointment with their children were the primary areas identified. Poverty was the most c o m m o n disappointment according to 62.5% o f those elders. Many said that they had expected to become rich, but they were still poor and so were their children. They had hoped to have land to give to their children, but did not. Those who identified health as their primary problem had hoped to continue working, but were unable to do so. This was especially a problem where the household was poor and the elder felt they were a burden on the family. Disappointment in children included either the fact that their children were not good workers and/or they were not taking care o f them as the elders would have liked. W h e n elders were asked about who would care for them in the future, only one was not sure if someone would care for her. By far the largest majority identified youngest daughter as their primary caregiver (36%). About 20% indicated that someone other than a child would take care for them. O f these, about 8% indicated a grandchild. Approximately 6% had no children and identified a niece or sister as future caregiver. It can be concluded that about 80% o f elderly expect that the norm o f filial responsibility will b e fulfilled at some point in their lives when they need care, even though (for some o f them), their children are not necessarily nearby. A n d most o f the remainder expect someone to care for them.
Old Age Home Elderly Interviews with the 32 elderly in the old age homes were done to determine what factors resulted in a f a m i l y ' s inability to fulfill the caregiving role. Ten o f the elders stated that they were there because o f discord in the family. In-law problems were the most commonly identified causes, but also alcoholism,
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second marriages or greedy relatives who had taken advantage of the elderly by taking their lands. A second common reason given by nine elders for their residence in the old age homes was that the home environment had been unsatisfactory - either too quiet because everyone was gone most of the time, or too noisy because of too many people (especially older grandchildren). A third reason identified by seven old age home elders was that there was no one to care for them. They had either not married or were childless. A fourth reason identified by three elders was the poverty of their children. In these cases, the elders had made the decision to enter the old age homes because they knew they were a burden on their children. Usually their children had objected because of concern about how others would view this violation of the norm of filial obligation, but the elders were firm in their decisions. Overall, the old age homes filled an important need for meeting the daily living requirements of these elderly. Thirty of the 32 respondents were happy living in the old age homes. The most difficult aspect of living there was getting along with other residents who had different values or were mentally disturbed. CONCLUSIONS Possession of land is critical to maintenance of the traditional extended family system; and the quality of care the elderly perceive they are receiving is very much influenced by the economic status of the family. Fortunate, indeed, are the elderly who have their children nearby and who are also doing well economically. Also fortunate are those elderly whose children are living elsewhere, but are eaming a good income and supporting their parents well. The traditional system allows the elderly to continue to use their traditional exchange resources to maintain family care into their old age. However, elderly who do not have sufficient land, or have land that is only "marginally" productive, have limited exchange resources to entice children to remain nearby. This situation results in limited opportunities to contribute to household activities, or to be an advisory resource for traditional skills, knowledge, and values. Some parents have adapted to this reality by supporting their children in obtaining an advanced education, often at great sacrifice to themselves. But for most of those parents who did so, the returns in financial support from a well-employed child were worth the effort. The Thai cultural value of filial obligation is still strong and continues to be cultivated through the Buddhist teachings and to play a powerful role in family decisions regarding the elderly. The elders' roles in traditional Buddhist rituals still allow elderly to maintain a certain amount of social status, but as cultural values change, these roles are also losing their exchange value. In the future, while it may become more common for children to leave their elders alone until perhaps age 75 or so, it may be anticipated that these children will still try to do what they can to care for their decrepit or ill elders. As several villagers said, most families will try to leave at least one child at home with the
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parents. This may well be the youngest daughter, but it may just as well be another daughter who is single or recently divorced, or it could be a granddaughter. In some situations, youngest daughters (or another daughter) who left home will return when their own children are grown in order to fulfill their filial obligations to their aging parents. Thus a variety of adjustments to accommodate changing economic needs of children are currently being made. The impact of effective birth control which has decreased family size will be felt after the year 2010 when fewer children will be available as caregivers. This predictably will make the situation more critical for the elderly. Whether Thailand learns from experiences of the more developed countries and develops strategies for dealing with this problem remains to be seen. ACKNOWLEDGEMENTS This study was supported by a grant from the National Science Foundation, the Center for the Study of Women in Society at the University of Oregon, a Carpenter Grant through Southern Oregon State College and Sigma Xi. The National Research Council of Thailand gave permission to conduct the study. Special thanks go to Dr. Geraldine Moreno-Black, University of Oregon, Dr. Prabha Leeprasert at Mahidol University, Bangkok, the staff at Soongnem Rural Health Research and Training Center, and to my husband, Paul, for their support during this research. REFERENCES Binstock, R., W. Chow and J. Schulz, eds. 1982 International Perspectives on Aging: Population and Policy Challenges. New York: United Nations Fund for Population Activities. Blau, P. 1964 Exchange and Power in Social Life. New York: John Wiley and Sons, Inc. Cowgill, D.O. 1974 Aging and Modernization: A Revision of the Theory. In Late Life Communities and Environmental Policy. J. Gubrium, ed. Pp. 123-146. Springfield, II1.: Charles C. Thomas. Cowgill, D.O. 1986 Aging round the World. Belmont, CA: Wadsworth Publishing Co. Cowgill, D.O. and L. Holmes 1972 Aging and Modernization. New York: Meredith Corp. deYoung, J. 1955 Village Life in Modern Thailand. Berkeley: University of California Press. Dowd, J.J. 1980 Exchange Rates and Old People. Journal of Gerontology: 35:596--602. Dowd, J.J. 1981 Industrialization and the Decline of the Aged. Sociological Focus 14(4):255-269. Dowd, J.J. 1983 Social Exchange, Class and Old People. In Growing Old in Different Societies: Cross-Cultural Perspectives. J. Sokolovsky, ed. Pp. 29--42. Belmont, CA: Wadsworth Publishing Co. Foster, B.L. 1975 Continuity and Change in Rural Thai Family Structure. Journal of Anthropological Research 31:34-50. Goldstein, M.C. and C.M. Beall 1981 Modernization and Aging in the Third and Fourth World: Views from the Rural Hinterland in Nepal. Human Organization 40(1):48--55. Goldstein, M.C. and C.M. Beall 1982 Indirect Modernization and the Status of the Elderly in a Rural Third World Setting. Journal of Gerontology 37(6):743-748.
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Goldstein, M.C. and C.M. Beall 1986 Family Change, Caste, and the Elderly in a Rural Locale in Nepal. Journal of Cross-Cultural Gerontology 1:305-316. Goldstein, M.C., S. Schuler and J.R. Ross 1983 Social and Economic Forces Affecting Intergenerational Relations in Extended Families in a Third World Setting: A Cautionary Tale from South Asia. Journal of Gerontology 38(6):716-724. Kinsella, K. 1988 Aging in the Third World. Bureau of the Census, International Population Reports, Series P-95, No. 79. Washington, DC: U.S. Government Printing Office. Klausner, W.J. 1987 Reflections on Thai Culture. Bangkok: Amarin Printing Group Co., Ltd. Lux, T.E. 1969 The Thai-Lao Family System and Domestic Cycle of Northeastern Thailand. Journal of the National Research Council of Thailand 5:1-17. Ministry of Public Health 1985 Thai Public Health Statistics. Bangkok: Division of Health Statistics. Office of the Permanent Secretary. (In Thai and English) Mizuno, K. 1968 Multihousehold Compounds in Northeast Thailand. Asia Survey 7(10):842-852. Mizuno, K. 1978 The Social Organization of Rice-Growing Villages. In Thailand: A Rice-Growing Society. Y. Ishii, ed. Pp. 83-114. Honolulu: The University Press of Hawaii. Myers, G.C. 1982 The Aging of Populations. In International Perspectives on Aging: Population and Policy Challenges. R. Binstock, W. Chow, J.H. Schulz, eds. Pp. 1-39. New York: United Nations Fund for Population Activities. Press, I. and M. McKool 1972 Social Structure and Status of the Aged: Toward Some Valid Cross-Cultural Generalizations. Aging and Human Development 3:297-306. Rhoads, E.C. 1984 Reevaluation of the Aging and Modernization Theory: The Samoan Evidence. The Gerontologist 24)3-:243-250. Sangree, W.H. 1986 Role Flexibility and Status Continuity: Tiriki (Kenya) Age Groups Today. Journal of Cross-Cultural Gerontology 1:117-138. Sheehan, T. 1976 Senior Esteem as a Factor of Socioeconomic Complexity. The Gerontologist 16(5):433--440. Smith, H.H., D.W. Bernier, F.M. Bunge, F.C. Rintz, R. Shinn and S. Teleki. 1968 Area Handbook for Thailand. Washington, DC: U.S. Printing Office. Treas, J. 1977 Family Support System for the Aged: Some Social and Demographic Considerations. The Gerontologist 17(6):486--491.
School of Nursing and Health Southern Oregon State College Ashland, OR 97520, USA
F A M I L Y CARE OF THE E L D E R L Y IN N O R T H E A S T T H A I L A N D : CHANGING PATTERNS
ABSTRACT. Using exchange theory, the effects of the change from a kin-based to a cash-based economic system on family care to the elderly in rural Northeast Thailand are examined. Eighty-nine households from three sites representing three levels of development were analyzed in relation to family and household membership, as well as economic and employment status. In addition, 32 elders from two old age homes were interviewed. This study found that, in general, the more land a household owns, the more likely the traditional pattern of elder caregiving will be maintained. When land is limited, children leave to find employment elsewhere and will try to send money to help their parents as they are able. Poverty plays a major role in the perceived quality of life of these elders. Key Words: culture change, elderly, exchange theory, family care, modernization,
Thailand
INTRODUCTION During this past century, we have witnessed major changes in world population. One of the most unique features of these changes has been the increase in the number of older people. While one may view this as evidence of a successful outcome of a world-wide effort to promote health, the results may be a mixed blessing. As these elderly are especially vulnerable to chronic health problems, countries must decide how to distribute their limited resources in providing care to them. In 1980, the percentage of elderly over the age of 65 in the total population of the world was 5.8%. In the more developed regions, the percentage was 11.4%, and in the developing regions, it was 3.9% (Kinsella 1988). By the year 2020, elderly over the age of 65 will constitute 13% of the total population in the more developed regions and 4.6% in the developing (Myers 1982). In actual numbers, in the developing regions alone, this is an increase from 128 million to 470 million, over three and one-half times as many people (Kinsella 1988). Thailand has had one of the most successful family planning programs of any developing country. This program, which began in 1970, will eventually result in a higher percentage of elderly in the total population as well as a decreasing number of caregivers. The population of Thai elderly over the age of 65 has been almost doubling every 20 years, going from 709,000 in 1960, to 1,569,000 in 1980 (Ministry of Public Health 1985), and" estimated to increase to 3,000,000 in the year 2000 (Myers 1982) and to 6,800,000 by the year 2020 (Kinsella 1988). This represents an increase from 3.5% of the total population in Thailand in 1980 to 8.3% in the year 2020. This dramatic increase in the elderly population in Thailand will have important implications for the distribution of resources. Journal of Cross-Cultural Gerontology 7:105-116, 1992. © i 992 Kluwer Academic Publishers. Printed in the Netherlands.
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Thailand is rapidly undergoing modernization, and the elderly are especially vulnerable to the negative effects of modernization, according to some theorists (Cowgill 1974; Cowgill and Holmes 1972; Press and McKool 1972; Sheehan 1976; Treas 1977). Modernizing factors especially affecting family relationships of the elderly include: 1. The migration to urban areas by younger family members in search of jobs; 2. The changing roles of women as they also become involved in the job market; 3. A decreased birthrate eventually resulting in fewer potential caregivers for elderly parents; 4. Changing norms and values which emphasize individualism and competition rather than the interdependent relationships characteristic of extended families; 5. Increased education of the young, thereby decreasing the elderly's value as cultural experts. Modernization theory, as a predictive model of the status of the elderly, has been criticized for the inability to account for variability in outcomes (Dowd 1981, 1983; Goldstein and Beall 1981, 1982, 1986; Goldstein, Schuler and Ross 1983; Rhoads 1984; Sangree 1986). This study, therefore, proposes that exchange theory is a more appropriate model for understanding the differential effects of modernization on the elderly. Exchange theory is based on the cultural norm of reciprocity. Each partner in an exchange relationship is expected to reciprocate in an equitable manner for services rendered by another. Thus, each partner must possess resources which can be drawn on to exchange for needed services (Blau 1964). It has been assumed that with modemization, formerly valued resources are lost to the elderly, thus rendering them relatively powerless in their relationships with their families (Dowd 1980). THE ELDERLY IN RURAL NORTHEAST THAILAND In rural Thailand, traditional exchange resources held by the elderly have included: I. Economic resources, especially inheritance of land, but also including the elder's house; 2. Contributions made by the eider to household activities, including caring for grandchildren, cleaning, cooking, and general household maintenance; 3. An advisory role based on knowledge of traditional skills associated with farming and of traditional Thai behaviors, values and beliefs; 4. Performance of ritual activities associated with the Buddhist religion. In addition, the traditional Thai cultural norm of filial obligation requires repayment to parents for their care when one was a child. This norm acts as a powerful enforcer since violation results in shame and social ostracism. To be ungrateful to one's parents is considered one of the greatest sins a child can commit (Klausner 1987). The rural Northeast Thai family life cycle supported this system of
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reciprocity. After marriage, daughters were expected to bring husbands into their family system and continue to cultivate their parents' land. Sons moved into the wife's family system. It was expected that the youngest daughter would remain in the household after her marriage to care for her parents until their death. At that time she inherited the parent's house. If there were no daughters, the youngest son brought his wife into the household as the caregiver. Distribution of land through inheritance was generally equal among all children, although sons often sold their land to their sisters. Thus sufficient land to give to children was essential for enticing children (especially daughters) to remain nearby and provide for their parent's care (Cowgill 1986; deYoung 1955; Foster 1975; Lux 1969; Mizuno 1968, 1978). This study examined the effects of modernization on the traditional exchange resources of the elderly and found that changes are indeed affecting their exchange values. While potential for negative impact on the elderly is evident, these changes may not necessarily be negative, especially if the elderly are able to develop alternative exchange resources of equal value. Whether this might be possible for rural Thai elderly was an area of concern of this study. Northeast Thailand (Isaan), where this study was done, is the largest of the five (or four if Bangkok Metropolis and the Central Region are combined) regions in Thailand. In 1980, elderly over the age of 65 constituted only 2.8% of the population in this Northeast region, as compared to 3.9% in the total population. But 34.8% of the total population of all Thai elderly lived in Northeast Thailand, the largest percentage of the total population in Thailand (Ministry of Public Health 1985). In 1988, it was estimated that 84% of the elderly over the age of 65 were located in the rural areas (Kinsella 1988). Northeast Thailand was selected as the research site for the following reasons: 1. The region is primarily an agricultural setting that continues to preserve the matrilocal post-marital residence pattem and Buddhist-based ideology of filial obligation. 2. The erratic rainfall and the limited water-holding capacity of the soil severely limit agricultural production and make it the poorest region of Thailand. 3. Modernization is only gradually making an impact on this region, thus providing an opportunity to study the variable effects of the modernization process on the elderly population. 4. Northeast Thailand is characterized by an expanding population, heavy deforestation, and progressively limited agricultural land available for the younger generation. 5. Excessive pressure on available resources is resulting in the movement of young people to urban areas in search of jobs. Thus Northeast Thailand provided an ideal setting to examine the question, "What impact does the change from a kin-based to a cash-based economic system have on family care of the elderly in Northeast Thailand?"
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The information presented in this paper is based on an analysis of data collected over a nine month period, 1988 to 1989. This research took place in Soongnern District in Nakom Rajisima Province. Nakom Rajisima is the largest of the 71 provinces in Thailand and is the most populated province outside of the Bangkok area. It is located in the southeastem part of the Northeast Region and is about 200 kilometers from Bangkok. Korat is the largest city in the province. Soongnem District is about 30 kilometers south of Korat on the Friendship Highway, the main highway connecting Bangkok with the Laotian border. Three research sites containing two villages in each were selected based on their level of infrastructural development. The two most developed villages were those with a village piped water supply, electricity, waterseal toilets, and easy transportation access to urban settings by way of paved roads. These two villages are primarily dependent on agriculture and have wealthier families than the other two research sites. Much of the financial backing providing the basis for these developments came from previous overseas employment by the village men in Saudi Arabia. The primary dialect spoken by these villagers was LaoThai. The total sample size in this site was 30 households. The two least developed villages were fairly new, having been established within the last thirty years on deforested land. Residents had originated from a variety of locations in Korat Province and spoke both Lao and Central Thai. These villages were characterized as relatively inaccessible to urban settings because of distance and poor roads, had no electricity, obtained water from local ponds or canals, were primarily agriculturally based, and were economically the poorest of the three village sites. Less than one-half of the families surveyed had waterseal toilets. A total of twenty-seven households were interviewed in this site. The two intermediate villages contained speakers of the Korat Thai dialect, an ethnic group who originated from the intermarriage of Khmer and Thai soldiers in the fourteenth century (Smith, Bemier, Bunge, Rintz, Shinn, Teleki 1968). These villages had fairly easy access to urban settings (some dirt and some paved roads), electricity, no village water supply (but some families had individual wells and/or pumps for their water), and most had waterseal toilets. Income from agriculture was limited due to the limited amount of agricultural land, and more household income was obtained from employment outside the village. Thirty-two households were interviewed in these villages. In addition, elderly in two old age homes in Korat were interviewed. Criteria for admission into these homes included an age requirement (60 for women and 65 for men), no chronic or contagious diseases, no handicaps, and at least one of the following conditions: poverty, lack of family, or poor family relationships. A total of 89 households with elderly age 65 and over were interviewed in the six villages. A Thai translator with language skills in all three dialects assisted in the interviews. Puyaibaans (village headmen), their wives or a designated assistant often provided assistance and facilitated access to households.
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Approximately 44% of the eldedy were male and 56% were female. Over one-half were widowed and the majority of these were women. Mean age was 74 and 72% had retired at a mean age of 65. In addition, a sample of 32 elderly were interviewed in the old age homes (10 males and 22 females). The mean age of this group was 77 and contained about one-third divorced or single elders. Mean number of living children for the village elderly was 4.75 while the old age home elderly had only 2.3 currently living children. Finally, monks, social workers in the old age homes, nurses and other health personnel, puyaibans and their wives were also interviewed. A total of 24 variables were used to determine whether the selected households were accurately classified in one of the three village sites. These variables included level of infrastructural development (i.e. water supply, toilets, house construction), household membership, employment and economic variables. Results from the discriminant function analysis supported the accurate classification of 91% of the households in the appropriate site. Households in the intermediate villages were the most frequently misclassified. A factor analysis was attempted but because of the relatively low correlations between the variables, relevant components were not identifiable. The three village sites were considered as independent variables for the determination of differences in family care of the elderly. All villages were found to have similar traditional Thai cultural beliefs and practices regarding filial behavior. Any differences in current caregiving behavior were then attributed to other variables. Chi-square and Anova were the primary statistical tests used to test for significant differences among households from the three village sites. In general, it was found that both the most and the least developed villages were more dependent on an agriculturally based economy and households obtained most of their income from farming their own land. In the developed villages, rice was the primary crop, although mung beans are grown during the dry season. The main crop year-round in the less developed villages was cassava, which brought a much lower price in the marketplace, causing less overall income in these villages. Both the developed and less developed sites had more children living nearby than the intermediate village, and more children (as well as current household members) were involved in agriculture. On the other hand, households in the intermediate village owned significantly less land, had more children living outside the village and involved in non-farm labor. They also had fewer household members involved in agricultural work. Over 50% of household income was derived from non-agricultural sources as compared to 2/3 of household income derived from agriculture in the other two village sites. However, total income amount was intermediate. Health status of the elderly was assessed in order to determine if differences existed among the three sites which may affect family care. While the health status of these rural elderly was generally poor, it did not differ significantly among sites. A surprising finding (in light of the overall poor health status of these elderly) was the fact that only two elderly of the total of 89 interviewed
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needed assistance with most daily activities. The remainder were able to perform most basic daily activities unassisted. Interviews revealed two phases in the traditional lifecycle of the elderly and mean ages at which they go through these phases. These ages are based on estimates given by the elderly and reflect a broad variability. But it is striking that the ages identified seem to show a consistency over a broad range of similar activities and for all three village sites. The first phase identified was that of retirement. For both groups of elders (in the villages and in the old age homes) who had retired, the average age was 65. After retirement, the elder briefly continues to maintain primary responsibility for the household, including farming. But by age 67 those elders who are in a position to do so have turned over household and agricultural responsibilities to the primary caregiver and her husband. These elders continue to contribute to the household by caring for grandchildren and helping with housework. They also become more involved in religious activities. The second phase begins about age 75, when most have withdrawn from active involvement in household chores and childcare, have made inheritance arrangements, and have ceased attending activities at the w a t (temple). Sickness, however, may occur at any time and necessitates more intensive involvement by family members in caregiving. Caregiving, then, involves a gradual assumption of household management as well as management of household agricultural production by the caregiver and her husband, with, perhaps, some intensive involvement in sick care of the elder for short periods of time. How, then, is modernization affecting this traditional pattern of caregiving? FINDINGS Elders were asked to identify who was currently their primary caregiver. Onefifth of the 89 village elders interviewed identified themselves as primary caregiver. Slightly over 25% identified youngest daughter. Spouse was the third most frequently identified caregiver (14.6%) with another daughter or granddaughter sharing fourth place (12.4%). When comparing village sites, over one-half (56.7%) of those elders who identified themselves or their spouse as primary caregiver were in the intermediate villages as compared to one-fifth in the developed and one-fourth in the less developed villages. The largest percentage of youngest daughter as caregiver was found in the developed villages (36.7%), while one-fourth in the less developed villages and only 18.7% of the elders in the intermediate villages were being cared for by youngest daughter. Further examination of relevant variables found that household size, amount of land cultivated, and yearly income played important roles in whether the elders were responsible for themselves or whether someone else in the family had taken on responsibility for their care. Households in which the elder was responsible for him/herself were significantly smaller, had less land, and less
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yearly income, while those households which maintained the traditional pattern of youngest daughter remaining in the home as caregiver had a larger household size, more land being cultivated and a higher yearly income. This latter situation was more commonly found in the most developed villages, while the former situation was more characteristic of the intermediate villages. Elders were asked whether they thought caregiving by children was better in their parent's lifetime, better now, or the same. A little more than half of the elders (56.7%) in the less developed villages, almost one-half (48.4%) in the intermediate villages and only 22.2% in the developed villages thought it was better before. These differences were statistically significant. Five variables were found to differentiate those who felt care was better before from those who felt it was better now. Those who felt care was better before had: (1) smaller household size (3.7 versus 5 persons); (2) less annual income 14,000 baht ($560) versus 26,000 baht ($1040); (3) worried more (28% versus 10%); (4) felt that their lives had turned out worse than their expectations (34% versus 8.5%); and (5) felt less satisfied overall with their lives (38% versus 18%). Further analysis of the question of how well the elders' own expectations for their lives had been met revealed that slightly over one-half (52.4%) of all elderly felt their lives had turned out the same or better than they had expected, but 47.6% felt their lives had tumed out worse. Again, village site was significantly related to these findings. Over two-thirds of those in the less developed villages had unmet expectations as compared to two-thirds of those in the intermediate villages who felt that life had turned out the same or better for them. Fifty-five percent of those in the developed villages felt positively about their expectations, while 45% did not. What do the above results mean in relation to family caregiving to the elderly? For those elders who identify themselves or their spouse as primary caregiver, three situations were possible: 1. In a few very rare instances, the elder chose to remain independent even though children were nearby and available as caregivers. 2. More commonly, the children have gone elsewhere to find work and have left their elderly parents behind. Usually these children did contribute financially to their parents' welfare (although only about 45% of the elders felt that those children who send money send enough and one-half of those elders were in the intermediate villages). 3. Also fairly common were those elders who do live with their children or kin, but who must care for themselves because of the poverty of the household. In these situations, daughters must work daily in order to make ends meet and the elders either take over responsibility for the home in order to help their daughters, or continue to work themselves so as to not be a burden on an already financially burdened household. Comments from the elders as to why care was better before help to clarify what elders view as problems with caregiving. These comments fell into four
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groups: 1. (Most common) Children were leaving their parents. A. In search of jobs. A typical comment illustrates this view: Before when older people were 60, they stopped working and let their children take care of them. But now old people take care of themselves because their children go away and work. People work until they are in their 70s and 80s. Before parents had one child to take care of them. Now sometimes they visit only. Sending money is not good. It is better to live with their parents and take care of them. B. Education. This concem was more commonly expressed in the intermediate village where advanced education was more possible for the young: Elderly now feel lonely. Many children have education. After they pass a test, they work in another district. Before they were farmers and stayed to help their parents work the farm. Now the children live away. 2. A felt erosion in the value of respect for o n e ' s elders. Comments such as the following came from elders in all three village sites. For example: Children have less respect. They don't obey or listen to their parents. They say, "You're too old. I study in high school and have more education." They drink alcohol and spend much money foolishly. 3. Dependence on the cash economy making life especially difficult for poor families. Elders in all three village sites commented on this. A woman in one of the less developed villages stated: Before we could exchange labor, but now people want money. You can't always get them to work and help out. Also before when food was all over, you could hunt. Now children cannot find work. They need money to buy food. There is no food for hunting and collecting as before. A n d from a woman in a developed village: Before children took care of elderly people. But now it is difficult for children to find a job and they spend much money for their own family. It is difficult for them to care for the elderly. Before it was cheaper, but now it is expensive. Children must work and there is no time to care for older people. Now I have to put my hands in my pocket many times a day (for money). Before, I never did. A woman from one of the less developed villages described the loneliness felt by the elderly who are left at home while children work: Before children would choose one child to stay or take care of old people, but now they go to work on the farm. They feed us well and give us money, but they leave us alone. I feel very much alone.
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4. L a c k o f concern by children when their elders were sick. A man from one o f the intermediate villages said: It was better before because children lived nearby and when their parents were sick, they came and stayed with them. They went out to gather herbs themselves, or ran to get the herbal doctor. Kin and neighbors gathered and discussed the situation. The elderly felt good because many people were concerned and the children did everything themselves. Now they just take them to the doctor and let the doctor and the nurses take care of them. A couple o f elders felt that the children were more concerned about their j o b s than about their sick parents. Those elderly who thought that care given by families was better now than the care their parents had received attributed this to modernization which brought them a wider variety o f foods, health care, and m o d e m conveniences making life easier. Obviously, one first needed an adequate income to enjoy these fruits o f modernization, and this was more likely in the developed and intermediate villages. Examination o f reasons given for why elders feel their lives turned out worse than expected reveal that poverty, health, and disappointment with their children were the primary areas identified. Poverty was the most c o m m o n disappointment according to 62.5% o f those elders. Many said that they had expected to become rich, but they were still poor and so were their children. They had hoped to have land to give to their children, but did not. Those who identified health as their primary problem had hoped to continue working, but were unable to do so. This was especially a problem where the household was poor and the elder felt they were a burden on the family. Disappointment in children included either the fact that their children were not good workers and/or they were not taking care o f them as the elders would have liked. W h e n elders were asked about who would care for them in the future, only one was not sure if someone would care for her. By far the largest majority identified youngest daughter as their primary caregiver (36%). About 20% indicated that someone other than a child would take care for them. O f these, about 8% indicated a grandchild. Approximately 6% had no children and identified a niece or sister as future caregiver. It can be concluded that about 80% o f elderly expect that the norm o f filial responsibility will b e fulfilled at some point in their lives when they need care, even though (for some o f them), their children are not necessarily nearby. A n d most o f the remainder expect someone to care for them.
Old Age Home Elderly Interviews with the 32 elderly in the old age homes were done to determine what factors resulted in a f a m i l y ' s inability to fulfill the caregiving role. Ten o f the elders stated that they were there because o f discord in the family. In-law problems were the most commonly identified causes, but also alcoholism,
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second marriages or greedy relatives who had taken advantage of the elderly by taking their lands. A second common reason given by nine elders for their residence in the old age homes was that the home environment had been unsatisfactory - either too quiet because everyone was gone most of the time, or too noisy because of too many people (especially older grandchildren). A third reason identified by seven old age home elders was that there was no one to care for them. They had either not married or were childless. A fourth reason identified by three elders was the poverty of their children. In these cases, the elders had made the decision to enter the old age homes because they knew they were a burden on their children. Usually their children had objected because of concern about how others would view this violation of the norm of filial obligation, but the elders were firm in their decisions. Overall, the old age homes filled an important need for meeting the daily living requirements of these elderly. Thirty of the 32 respondents were happy living in the old age homes. The most difficult aspect of living there was getting along with other residents who had different values or were mentally disturbed. CONCLUSIONS Possession of land is critical to maintenance of the traditional extended family system; and the quality of care the elderly perceive they are receiving is very much influenced by the economic status of the family. Fortunate, indeed, are the elderly who have their children nearby and who are also doing well economically. Also fortunate are those elderly whose children are living elsewhere, but are eaming a good income and supporting their parents well. The traditional system allows the elderly to continue to use their traditional exchange resources to maintain family care into their old age. However, elderly who do not have sufficient land, or have land that is only "marginally" productive, have limited exchange resources to entice children to remain nearby. This situation results in limited opportunities to contribute to household activities, or to be an advisory resource for traditional skills, knowledge, and values. Some parents have adapted to this reality by supporting their children in obtaining an advanced education, often at great sacrifice to themselves. But for most of those parents who did so, the returns in financial support from a well-employed child were worth the effort. The Thai cultural value of filial obligation is still strong and continues to be cultivated through the Buddhist teachings and to play a powerful role in family decisions regarding the elderly. The elders' roles in traditional Buddhist rituals still allow elderly to maintain a certain amount of social status, but as cultural values change, these roles are also losing their exchange value. In the future, while it may become more common for children to leave their elders alone until perhaps age 75 or so, it may be anticipated that these children will still try to do what they can to care for their decrepit or ill elders. As several villagers said, most families will try to leave at least one child at home with the
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parents. This may well be the youngest daughter, but it may just as well be another daughter who is single or recently divorced, or it could be a granddaughter. In some situations, youngest daughters (or another daughter) who left home will return when their own children are grown in order to fulfill their filial obligations to their aging parents. Thus a variety of adjustments to accommodate changing economic needs of children are currently being made. The impact of effective birth control which has decreased family size will be felt after the year 2010 when fewer children will be available as caregivers. This predictably will make the situation more critical for the elderly. Whether Thailand learns from experiences of the more developed countries and develops strategies for dealing with this problem remains to be seen. ACKNOWLEDGEMENTS This study was supported by a grant from the National Science Foundation, the Center for the Study of Women in Society at the University of Oregon, a Carpenter Grant through Southern Oregon State College and Sigma Xi. The National Research Council of Thailand gave permission to conduct the study. Special thanks go to Dr. Geraldine Moreno-Black, University of Oregon, Dr. Prabha Leeprasert at Mahidol University, Bangkok, the staff at Soongnem Rural Health Research and Training Center, and to my husband, Paul, for their support during this research. REFERENCES Binstock, R., W. Chow and J. Schulz, eds. 1982 International Perspectives on Aging: Population and Policy Challenges. New York: United Nations Fund for Population Activities. Blau, P. 1964 Exchange and Power in Social Life. New York: John Wiley and Sons, Inc. Cowgill, D.O. 1974 Aging and Modernization: A Revision of the Theory. In Late Life Communities and Environmental Policy. J. Gubrium, ed. Pp. 123-146. Springfield, II1.: Charles C. Thomas. Cowgill, D.O. 1986 Aging round the World. Belmont, CA: Wadsworth Publishing Co. Cowgill, D.O. and L. Holmes 1972 Aging and Modernization. New York: Meredith Corp. deYoung, J. 1955 Village Life in Modern Thailand. Berkeley: University of California Press. Dowd, J.J. 1980 Exchange Rates and Old People. Journal of Gerontology: 35:596--602. Dowd, J.J. 1981 Industrialization and the Decline of the Aged. Sociological Focus 14(4):255-269. Dowd, J.J. 1983 Social Exchange, Class and Old People. In Growing Old in Different Societies: Cross-Cultural Perspectives. J. Sokolovsky, ed. Pp. 29--42. Belmont, CA: Wadsworth Publishing Co. Foster, B.L. 1975 Continuity and Change in Rural Thai Family Structure. Journal of Anthropological Research 31:34-50. Goldstein, M.C. and C.M. Beall 1981 Modernization and Aging in the Third and Fourth World: Views from the Rural Hinterland in Nepal. Human Organization 40(1):48--55. Goldstein, M.C. and C.M. Beall 1982 Indirect Modernization and the Status of the Elderly in a Rural Third World Setting. Journal of Gerontology 37(6):743-748.
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Goldstein, M.C. and C.M. Beall 1986 Family Change, Caste, and the Elderly in a Rural Locale in Nepal. Journal of Cross-Cultural Gerontology 1:305-316. Goldstein, M.C., S. Schuler and J.R. Ross 1983 Social and Economic Forces Affecting Intergenerational Relations in Extended Families in a Third World Setting: A Cautionary Tale from South Asia. Journal of Gerontology 38(6):716-724. Kinsella, K. 1988 Aging in the Third World. Bureau of the Census, International Population Reports, Series P-95, No. 79. Washington, DC: U.S. Government Printing Office. Klausner, W.J. 1987 Reflections on Thai Culture. Bangkok: Amarin Printing Group Co., Ltd. Lux, T.E. 1969 The Thai-Lao Family System and Domestic Cycle of Northeastern Thailand. Journal of the National Research Council of Thailand 5:1-17. Ministry of Public Health 1985 Thai Public Health Statistics. Bangkok: Division of Health Statistics. Office of the Permanent Secretary. (In Thai and English) Mizuno, K. 1968 Multihousehold Compounds in Northeast Thailand. Asia Survey 7(10):842-852. Mizuno, K. 1978 The Social Organization of Rice-Growing Villages. In Thailand: A Rice-Growing Society. Y. Ishii, ed. Pp. 83-114. Honolulu: The University Press of Hawaii. Myers, G.C. 1982 The Aging of Populations. In International Perspectives on Aging: Population and Policy Challenges. R. Binstock, W. Chow, J.H. Schulz, eds. Pp. 1-39. New York: United Nations Fund for Population Activities. Press, I. and M. McKool 1972 Social Structure and Status of the Aged: Toward Some Valid Cross-Cultural Generalizations. Aging and Human Development 3:297-306. Rhoads, E.C. 1984 Reevaluation of the Aging and Modernization Theory: The Samoan Evidence. The Gerontologist 24)3-:243-250. Sangree, W.H. 1986 Role Flexibility and Status Continuity: Tiriki (Kenya) Age Groups Today. Journal of Cross-Cultural Gerontology 1:117-138. Sheehan, T. 1976 Senior Esteem as a Factor of Socioeconomic Complexity. The Gerontologist 16(5):433--440. Smith, H.H., D.W. Bernier, F.M. Bunge, F.C. Rintz, R. Shinn and S. Teleki. 1968 Area Handbook for Thailand. Washington, DC: U.S. Printing Office. Treas, J. 1977 Family Support System for the Aged: Some Social and Demographic Considerations. The Gerontologist 17(6):486--491.
School of Nursing and Health Southern Oregon State College Ashland, OR 97520, USA
