Module 3: Personal Relationships and Violence


This Module contains 6 Lessons:
  • Lesson 1: Communication
  • Lesson 2: Intimacy and sexuality
  • Lesson 3: Marriage and relationships
  • Lesson 4: Loss
  • Lesson 5: Parenting
  • Lesson 6: Family and societal violence


Students will be able to –
  • Examine the health benefits of a healthy marriage.
  • Describe the characteristics of a healthy marriage.

Communication among Couples

Source: Can We Talk? Improving Couples' Communication by Eboni J. Baugh and Deborah Humphries, FCS2178, Florida Marriage Preparation series, from the Department of Family, Youth and Community Sciences, Florida Cooperative Extension Service, Institute of Food and Agricultural Sciences, University of Florida. Original publication date November 2001. Reviewed October 2006. Revised December 2009,

Learning and Practicing New Habits

Effective communication isn't easy. Teaching and learning new communication skills take patience, patience, patience, as well as practice, practice, practice.
Taking the time to talk is important. Your relationship provides a safe place to share feelings, thoughts, fears, dreams, and hopes. Make a special effort to find time to talk to your partner more frequently.
In tough times, people feel overwhelmed with worries and responsibilities. Time together as a couple is often the last thing on our minds as we deal with the hassles of daily life. Although you may be busy, stressed, and worried, take the time to focus on your partners' needs and spend quality time together without interruption. Even a few minutes a day talking about what has occurred can be a relief from stress. Be thoughtful by considering whether those difficult or problem-solving discussions could be reserved for other times when you and your partner are not tired or distracted.
You may need to be the one who starts conversations. It is worth it to be the one who initiates conversations. You can find many ways to open the door for communication if you are sensitive to changes in your partner's feelings and needs. Taking the time to listen keeps the lines of communication open and improves your relationship.

Finding Time to Talk

  • Spend time talking with limited interruptions.
  • Make a date to talk to your partner.
  • Plan at least one routine family time each week.
  • Talk instead of watching TV.
  • Talk when you take a walk together.
  • Talk while you work together on household chores.
  • Talk in the car while traveling to activities.

Summing It Up

In good times and bad, couples need each other. Good communication does not mean that your family won't have any problems, or that your partner will always like what you have to say. Good communication means the chances of solving problems are much higher if you and your partner can express yourselves openly and freely with each other.

Marriage and Relationships

Source: Un-Healthy Marital Interactions: What Not To Do and What Can Be Done! Eboni J. Baugh, FCS2247, Family Youth and Community Sciences Department, Florida Cooperative Extension Service, Institute of Food and Agricultural Sciences, University of Florida, August 2006,

For couples today, there is an abundance of information on how to sustain healthy, happy marital relationships. From how-to books to advice given on television and radio, couples are bombarded with strategies, tips, and techniques focused on “what to do” in their relationships. Most of this information assumes that if couples follow a few short rules, then they can have happy relationships. What most fail to realize is that these new, positive practices won't work without recognizing and addressing what has been done and what is not working. Most information available to couples falls short on giving examples of “what not to do” in a relationship. Communication is the key, but it is difficult to apply effective strategies to harmful interactions.

Four negative patterns of interaction have been demonstrated as major destroyers of marital relationships:
  • Criticism
  • Contempt
  • Defensiveness
  • Stonewalling


Criticism is using hurtful or judgmental comments aimed at your partner's character or personality. With criticism, the blame is placed on the person and not the problematic behavior. Criticism tends to be a repetitive cycle—a single critical moment can end up in a continued exchange. Most critical statements can be recognized by the phrases, “you always” or “you never.” The following are some examples of criticism:
  • You never finish any project that you start. You're so lazy.
  • When we go out to eat, you always embarrass me with your table manners.


Contempt is a more complex negative interaction. It is an effort to psychologically abuse your partner through disrespectful statements and actions. Contempt has both verbal and non-verbal deliveries. Verbal examples of contempt include sarcasm, hostile humor, and mockery. For example, nonverbal displays of contempt include rolling of the eyes and sucking of the teeth during conflict. Contempt sends your partner a message of scorn—that they are inferior and worthless.


Defensiveness is often a natural response to receiving criticism and contempt. When faced with criticism and contempt, most people find a need to defend themselves. However, couples can be defensive even when criticism is constructive. Defensiveness may be a response to previous, current, and/or future attacks. If one or both persons are acting defensively, it is most likely the case they are not listening. Defensiveness may take many forms including:
  • Making excuses for behavior
  • Repeating a statement for effect
  • Denying responsibility for actions
  • Answering a complaint with another complaint


The final negative pattern of interaction is stonewalling. As the name implies, this occurs when partners “put a wall” around themselves, either physically or psychologically. Stonewalling is often used to decrease conflict, and when delivered in moderation, can be healthy. On the other hand, continual failure to respond and/or engage in conversation escalates rather than reduces conflict. Examples of stonewalling include:
  • Leaving the room
  • Putting a physical barrier between you and your partner (newspaper, book, child)
  • Focusing intently on something other than your partner during a discussion
  • Failure to actively listen
  • Responding with a blank stare

What can be done!

All of the above become patterns of interaction in which couples may find themselves trapped. One negative interaction leads to another, often in a repetitive cycle. Researchers have determined that couples caught in this vicious cycle may be headed for divorce (Gottman, 1994; Gottman & Levenson, 2000). If you or a couple you know are experiencing any of these problems in a relationship, don't be discouraged. Although these may seem like a death sentence, there are ways that couples can break these patterns and start having more positive interactions. What is most important is to mimic the behaviors of pre-maritial couples and newlyweds. The following suggestions promote a healthy marriage, regardless of whether you're newlyweds or nearing your golden anniversary.
1. Eliminate criticism. Use complaints. It is okay to complain about troublesome behaviors. Discussing your feelings about the behavior is okay as long as there are no personal attacks. Use the word I instead of you and describe how the behavior makes you feel. Talk about the behavior and not the person.
  • Example: “When we go out to eat, you always embarrass me,” becomes “I feel hurt and ashamed when you make fun of me in public.
2. Build on your friendship base.Validate your partner and his/her feelings, thoughts, needs, and desires, etc.
Ex. “I recognize that you need to talk more about our relationship. What is on your mind?”
3. Take accountability and responsibility for your own actions. Do not make excuses. Apologize and correct the behavior (if possible).
  • Example: “I'm sorry that I yelled at you earlier. I've been under a lot of pressure at work, but it is unfair to take it out on you.”
4. Use reflective listening. Repeat what your partner has stated and then respond. Show them that you are listening and hearing them.
  • Example: Partner 1: I would appreciate it if you would talk to me before you discipline the kids. That way we can be a united front."
Partner 2: What I'm hearing is that you would like for us to talk about disciplining the kids before I make any decisions. I think that is a good idea.
5. Continue dating. Make a point to rekindle the dating aspect of your relationship.
  • Ex. Go for walks, hold hands, act silly, etc. Find ways to show appreciation to your partner throughout the day (i.e., e-mails, notes, phone calls, etc.)
6. Seek help if needed. If you can identify these negative interactions in your relationship or you think you may need help, see a licensed marriage and family therapist or other professional. Do not try and fix everything on your own.
  • Example: Talk to a trusted family member, friend, or your local extension agent in order to find resources in your area.


Before a couple can learn and/or practice new routines in their relationship, they must rid themselves of the old ways that aren't working. It is important to first identify negative patterns and destructive behaviors and target them for change. At that point, the couple can begin rebuilding their relationship.

Effective Communication

Source: Written by Victor William HarrisFCS2315, Department of Family, Youth and Community Sciences, Florida Cooperative Extension Service, Institute of Food and Agricultural Sciences, University of Florida. Published January 2012.

Effective communication is critical to successful relationships. Researchers and therapists have found at least nine skills that can help couples learn to talk effectively about important issues (Gottman 1994; Markman, Stanley, and Blumberg 2010; Schramm and Harris 2011). How we interact about issues such as time spent together/apart, money, health, gender differences, children, family, friends, commitment, trust, and intimacy affects our ability to develop and maintain lasting marital friendships. If learned well, these nine skills can help put our relationships on a positive trajectory for success. (Note: The word "marriage" is interchangeable with "relationship," if you are not married.)

Helpful Information about Communication

What do couples talk about?

Time Together/Apart. Both the quantity and quality of time we spend together influence the well-being of our marital friendships. Spending time apart participating in other activities also influences the well-being of our relationships.
Money. How we think and talk about money, our spending habits, and our ability to budget, invest, and plan for the future impact couple financial management processes and practices.
Health. Couples must talk about many health-related issues, including nutrition, exercise, illness, disease, accidents, health care, mortality, and death.
Men/Women. Because men tend to be more task-oriented in their communication styles and women tend to be more process-oriented, men tend to want to solve issues immediately, while women tend to want to talk about them more and come to a consensus about what should be done.
Children. How children develop physically, socially, emotionally, intellectually, and spiritually are often topics of discussion. Focusing on the best ways to consistently meet children's needs is considered being child-centered.
Family/In-Laws/Friends. Couples often talk about situations and circumstances surrounding the interactions they have with their closest relationships.

What do couples communicate when they are communicating?

Commitment. How we "hang in there" and contribute to our marital friendship, even when things aren't going particularly well, is a sign of how committed we are to our relationship. Loyalty and fidelity are aspects of commitment and trust.
Trust. Trusting relationships are relationships in which both partners are dependable, available to support each other, and responsive to each other's needs. An ability to negotiate conflict and a positive outlook about the future of the relationship are also components of trust.
Intimacy. The social, intellectual, emotional, spiritual, and physical connections we make with each other determine the levels of intimacy we experience in our relationships.

What do couples argue about?

Because the items listed above are some of the major topics couples talk about, it follows that they are also the same topics that can spur disagreements. For instance, it is a familiar joke that people can have difficulties in their relationships with in-laws. Take for example, “What is the difference between in-laws and outlaws? Answer: One is 'Wanted!'” Sayings such as these underscore the importance of knowing how your relationships with others can affect your marriage and could potentially become the topic of a marital conflict.
Control and Power. Control and power are highly associated with the topics couples argue about. Indeed, control and power issues are the foundation of most conflicts. Typically, one person (or each person) is bent on having his or her own way. The saying "my way or the highway" is a common phrase used by someone with an inflexible perspective. If we see an issue one way and expect everyone else to see it the same way we do, then we are more likely to try to exert power and control over others and sway them to our perspective. Attempting to exert control and power over our partner typically results in win/lose or lose/lose outcomes for our marital friendships.

Learning Activity 2.1:
Watch this video - Effective Communications in Relationships (3.16 minutes)

  • Do you know how and why to use "I' messages?

Lesson 2: Sexuality and Intimacy

Understanding Healthy Relationships

Learning Activity 2.2:
Watch these two short videos -
Are you satisfied with the depths of the relationships in your life?

Sexuality and Intimacy

Source: Sexual Addiction, USDA,
The idea that sex can be an addiction is new to many people.
The term "addiction" has become a popular metaphor to describe any form of self-destructive behavior that one is unable to stop despite known and predictable adverse consequences. For some people, sexual behavior fits that description. It involves frequent self-destructive or high risk activity that is not emotionally fulfilling, that one is ashamed of, and that one is unable to stop despite it causing repeated problems in the areas of marriage, social relationships, health, employment, finances, or the law.

Recognition that self-destructive sexual behavior can be an addiction has spawned the rapid growth of four nationwide self-help organizations for persons trying to recover from this problem. All are 12-step recovery programs patterned after Alcoholics Anonymous.

One might ask how sex can be an addiction when it is doing what comes naturally and does not involve abuse of a psychoactive substance like drugs or alcohol. The scientific argument for addiction is based, in part, on recent advances in neurochemistry that suggest we carry within us our own source of addictive chemicals.
When pleasure centers in the human brain are stimulated, chemicals called endorphins are released into the blood stream. Endorphins are believed to be associated with the mood changes that follow sexual release. Any chemical that causes mood changes can be addictive, with repeated exposure altering brain chemistry to the point that more of the chemical is "required" in order to feel "normal."

For example, experiments with hamsters have shown that the level of endorphins in their blood increases dramatically after several ejaculations. Experimental rats habituated to endorphins will go through much pain in order to obtain more. In rats, the addiction to endorphins is even stronger than the addiction to morphine or heroin.

The sex addict uses sex as a quick fix, or as a form of medication for anxiety, pain, loneliness, stress, or sleep. Sex addicts often refer to sex as their "pain reliever" or "tension reliever." In a popular novel, the heroine describes sex as "the thinking women's Valium."
Other indicators that sexual behavior may be out of control include: an obsession with sex that dominates one's life, including sexual fantasies that interfere with work performance; so much time devoted to planning sexual activity that it interferes with other activities; strong feelings of shame about one's sexual behavior; a feeling of powerlessness or inability to stop despite predictable adverse consequences; inability to make a commitment to a loving relationship; extreme dependence upon a relationship as a basis for feelings of self-worth; or little emotional satisfaction gained from the sex act.
Compulsive or addictive sexual behavior may take various forms, including what many regard as "normal" heterosexual behavior. The type of sexual activity and even the frequency or number of partners are not of great significance in diagnosing this problem. Some individuals have a naturally stronger sex drive than others, and the range of human sexual activity is so broad that it is difficult to define "normal" sexual behavior. What is significant is a pattern of self-destructive or high risk sexual behavior that is unfulfilling and that a person is unable to stop.

The roots of out-of-control sexual behavior may be quite varied. It may be caused by an underlying personality disorder, an "addiction" to sex, or a physical disorder. The traditional disorders of exaggerated sexuality, nymphomania in the female and satyriasis in the male, are believed to be caused by a disorder of the pituitary gland or irritation of the brain cortex by a tumor, arteriosclerosis or epilepsy. These physical disorders are rare.

Compulsive or addictive sexual behavior is a concern because it may lead to poor judgment or lack of discretion, indicate a serious emotional or mental problem, open one to exploitation, manipulation, or extortion.

Lesson 3: Marriage and Relationship

What is a “healthy marriage?

Source: Why Marriage Matters, Second Edition: Twenty-Six Conclusions from the Social Sciences, September 2005,

There are at least two characteristics that all healthy marriages have in common.

  • First, they are mutually enriching, and
  • Second, both spouses have a deep respect for each other.
It is a mutually satisfying relationship that is beneficial to the husband, wife and children (if present). It is a relationship that is committed to ongoing growth, the use of effective communication skills and the use of successful conflict management skills.

Healthy Marriage Matters

Research suggests that children who grow up in healthy married, two-parent families do better on a host of outcomes than those who do not. Further, many social problems affecting children, families, and communities could be prevented if more children grew up in healthy, married families.

Examples of social science findings include:
  • Married couples seem to build more wealth, on average, than singles or cohabiting couples, thus decreasing the likelihood that their children will grow up in poverty.
  • Children who live in a two-parent, married household enjoy better physical health, on average, than children in non-married households.
  • Healthy marriages reduce the risk of adults and children either perpetrating, or being victimized by, crime.Benefits of Healthy Marriages

For Children and Youth

Researchers have found many benefits for children and youth who are raised by parents in healthy marriages, compared to unhealthy marriages, including the following:
  1. More likely to attend college
  2. Demonstrate less behavioral problems in school
  3. Less likely to be a victim of physical or sexual abuse
  4. Less likely to abuse drugs or alcohol
  5. Less likely to commit delinquent behaviors
  6. More likely to succeed academically
  7. Physically healthier
  8. Emotionally healthier
  9. Less likely to attempt or commit suicide
  10. Decreases their chances of divorcing when they get married
  11. Less likely to become pregnant as a teenager, or impregnate someone.
  12. Less likely to be sexually active as teenagers
  13. Less likely to contract STD's
  14. Less likely to be raised in poverty

For Women

Researchers have found many benefits for women who are in healthy marriages, compared to unhealthy marriages, including the following:
  1. More satisfying relationship
  2. Emotionally healthier
  3. Wealthier
  4. Less likely to be victims of domestic violence, sexual assault, or other violent crimes
  5. Less likely to attempt or commit suicide
  6. Decrease risk of drug and alcohol abuse
  7. Less likely to contract STD's
  8. Less likely to remain or end up in poverty
  9. Have better relationships with their children
  10. Physically healthier

For Men

Researchers have found many benefits for men who are in healthy marriages, compared to unhealthy marriages, including the following:
  1. Physically healthier
  2. Wealthier
  3. Increase in the stability of employment
  4. Higher wages
  5. Emotionally healthier
  6. Decrease risk of drug and alcohol abuse
  7. Have better relationships with their children
  8. Less likely to commit violent crimes
  9. Less likely to contract STD's
  10. Less likely to attempt or commit suicide

For Communities

Researchers have found many benefits for communities when they have a higher percentage of couples in healthy marriages, compared to unhealthy marriages, including the following:
  1. Higher rates of physically healthy citizens
  2. Higher rates of emotionally healthy citizens
  3. Higher rates of educated citizens
  4. Lower domestic violence rates
  5. Lower crime statistics
  6. Lower teen age pregnancy rates
  7. Lower rates of juvenile delinquency
  8. Higher rates of home ownership
  9. Lower rates of migration
  10. Higher property values
  11. Decreased need for social services

Marital Status and Health: United States, 1999-2002

Source: Marital Status and Health: United States, 1999-2002, Centers for Disease Control and Prevention, //

A report from the Centers for Disease Control and Prevention suggests that married adults are healthier than divorced, widowed or never married adults.
The report, “Marital Status and Health: United States, 1999-2002,” was based on interviews with 127,545 adults aged 18 and over as part of the National Health Interview Survey, conducted by CDC’s National Center for Health Statistics. The study looked at health status and limitations, health conditions, health related behaviors according to marital status and also by age, race/ethnicity and socioeconomic factors such as education and poverty status.

Among the findings in the report:
  • Nearly 60% of adults are married, 10.4% are separated or divorced, 6.6% are widowed, 19% are never married and 5.7% are living with a partner. Marital status varies greatly among race/ethnic groups: approximately 61 percent of white adults, 58 percent of Hispanic adults, and 38 percent of black adults are married, according to the survey.
  • Married adults are less likely than other adults to be in fair or poor health, and are less likely to suffer from health conditions such as headaches and serious psychological distress.
  • Married adults are less likely be limited in various activities, including work and other activities of daily living.
  • Married adults are less likely to smoke, drink heavily or be physically inactive. However, married men are more likely to be overweight or obese than other men.
  • Adults who live in cohabiting relationships are more likely to have health problems than married adults and more closely resemble divorced and separated adults.
  • The association between marital status and health is most striking in the youngest age group although it persists throughout the age groups studied.
While the results show that married adults are generally in better health than unmarried adults, the reasons for better health status among married adults cannot be determined with cross-sectional data collected in the National Health Interview Survey.

The Effects of Marriage on Health

Source: The Effects of Marriage on Health, A Synthesis of Recent Research Evidence, U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, Office of Human Services Policy, June 2007,

Understanding the Marriage-Health Connection

The relationship between marriage and health is complex. Marital status can both affect health outcomes and be affected by them. Healthier people may have a better chance of marrying and staying married because they may be viewed as more desirable marriage partners based on their physical attractiveness, earnings potential, mental well-being, degree of self-sufficiency, or likely longevity. Social scientists describe this pattern as the selection of healthy people into marriage. If this is the only reason for the correlation between marriage and health, then marriage is not causing better health. Instead, the observed health differences between married and unmarried people are the result of healthier people being more likely to marry.
Alternatively, there may be a true causal link between marriage and better health. Marriage could improve health outcomes in a variety of ways. It may result in two incomes, as well as economies of scale, improving economic well-being.
Having more income could, in turn, improve health outcomes by enhancing access to health care or lowering stress. In addition, a spouse may play an important role in monitoring and encouraging healthy behaviors (such as good eating habits and regular exercise), as well as in discouraging unhealthy ones (such as smoking or heavy drinking). Marriage may also provide an emotionally fulfilling, intimate relationship, satisfying the need for social connection, which could have implications for both physical and mental health. Most researchers conclude that the association between marriage and health represents a combination of the selection of healthier people into marriage and true health benefits from marriage.

Measuring the Effects of Marriage

Because marriage is likely to be both a cause and a consequence of health outcomes, research must disentangle the influence of selection from the true causal influence of marriage. Distinguishing between these two factors requires careful analysis and advanced statistical methods that have been absent from many studies.
The studies providing the strongest evidence use longitudinal data and examine the association between changes in health outcomes and transitions into and out of marriage. Studies of this type provide more convincing evidence of a causal relationship between marriage and health because sample members serve as their own control group, and the effect of marriage is measured by comparing their outcomes before and after marriage. This method avoids comparing two groups that may have different background characteristics in particular, people who marry and people who do not which may lead to misleading and inaccurate results.
Some health outcomes are not well suited for this type of analysis, however. For example, many physical health outcomes cannot be examined in this way, because changes can unfold over a long time and may not be apparent immediately after a marital transition.

Effects on Health Behaviors

Marriage may influence health through its effect on behaviors such as alcohol consumption, drug use, cigarette smoking, diet, and exercise. Recent research suggests that marriage has significant effects on the health behaviors of both men and women, but the pattern is mixed marriage is associated with healthier behaviors in some cases and less healthy behaviors in others. Studies consistently indicate that marriage reduces heavy drinking and overall alcohol consumption, and that effects are similar for young men and young women, and for both African Americans and whites. Although the research is less extensive, marriage is also associated with reduced marijuana use for young men, but less so for women. Less is known about the effects of marriage on the substance use of older adults. Studies of marriage and smoking reveal no consistent pattern of results, suggesting that marriage may have little or no influence on this behavior.
In contrast to studies of alcohol and drug use, studies of the effect of marriage on weight and physical activity suggest that marriage may have negative effects on healthy behaviors and may encourage a more sedentary lifestyle. Several rigorous studies find that marriage leads to modest weight increases for both men and women; typically averaging less than five pounds. The research on the effects of marriage on physical activity is less conclusive because it is not based on longitudinal analysis and does not fully adjust for differences between those who marry and those who do not. The evidence that is available suggests marriage may lead to reductions in physical activity, particularly for men.
For certain health behaviors in particular, substance use among younger adults and weight gain among all adults the influence of marriage has been well studied and is well understood. For other behaviors, less is known and additional research is needed before stronger conclusions can be drawn.

Effects on Health Care Access, Use, and Costs

Marriage may influence physical health through its effects on health care access and use. Studies of the link between marriage and health insurance suggest that by offering access to coverage through a spouse's policy marriage increases the likelihood of having insurance and reduces the likelihood of becoming uninsured after a job loss or other major life event. Limited evidence also suggests that marriage may increase the use of preventive care such as cancer screenings.

Because of its effects on health care use, marriage is also associated with lower health care costs among older adults. For example, studies show that, because marriage reduces the risk of nursing home admission, marriage may also lead to reduced nursing home costs. The effect of marriage in shortening hospital stays may also lead to reductions in health care costs. Research indicates that the effect of marriage on health care costs exists independent of the effect of marriage on physical health. Specifically, many married people rely on their spouses for informal care, and thus require fewer long hospital stays and nursing home admissions, resulting in lower health care costs even if married and unmarried older adults are equally likely to get sick. These studies find that wives are especially likely to provide informal care for their husbands at home, so the effect of marriage on health care costs may be larger for men.

Effects on Mental Health

Marriage may affect many aspects of mental health. The most recent rigorous research suggests that marriage reduces depressive symptoms for both men and women. In particular, these studies find that getting married decreases depressive symptoms, while getting divorced increases them. Research has also documented that increases in depressive symptoms after divorce are long-lasting and that the prevalence of these symptoms remains elevated years after the marital breakup. In addition, studies comparing the mental health of stably married adults to those who remain unmarried find that those who are stably married have fewer depressive symptoms (and smaller increases in these symptoms as they grow older), even after controlling for baseline mental health.

Effects on Physical Health and Longevity

Many studies have documented that people who marry live longer and enjoy better physical health than those who do not marry. However, methodological issues require caution in interpreting this pattern, because most of the research in this area relies on descriptive methods that do not adequately control for the possible selection of healthier people into marriage. Although central to the overall assessment of the link between marriage and health, rigorous research evidence concerning the effect of marriage on specific physical health outcomes is limited, and few solid conclusions can be drawn.
The rigorous research currently available provides limited evidence of an effect of marriage on physical health. Recent research finds a significant positive effect of marriage on how men rate their overall physical health status; however, it finds no such effect for women. Researchers find a positive effect on women's physical health, as measured by the prevalence of specific health conditions and illnesses. However, no recent rigorous studies based on U.S. samples have examined whether a similar marriage effect on the frequency of health conditions or illnesses exists among men. Similarly, little evidence exists on the links between marriage and specific health conditions or diseases. One exception is a recent study that suggests a possible link between marriage and the risk of cardiovascular disease for women; however, the study finds no such effect for men. Overall, the existing research evidence on the links between marriage and physical health is limited to a narrow range of health measures and does not offer a complete picture of the influence of marriage on physical health.
Many studies have pointed to a strong relationship between marriage and longevity, but this research also has limitations. In particular, these studies are typically limited to simple descriptive comparisons of married and unmarried adults that do not adequately distinguish the effect of marriage from the possible effects of healthier people selecting into marriage. As noted, the most reliable studies of links between marriage and health examine measures directly before and after marital transitions. However, because longevity is determined only at the end of life, it is not possible to observe how a marital transition changes longevity.

Intergenerational Health Effects

An emerging literature on the possible intergenerational health effects of marriage suggests that marriage also has potential long-term consequences for the physical health of a couple's children. In particular, studies show that growing up with married parents is associated with better physical health in adulthood and increased longevity. Research suggests that such intergenerational health effects are especially strong for men and operate equally for African American and white men. There is less evidence examining possible differences in this relationship for African American and white women.
There are many possible reasons why parental marital status may have long-term health consequences for children. However, existing research provides limited evidence on the pathways by which childhood family structure affects adult physical health and longevity. Several studies suggest that the effects work mostly through the role of childhood family structure in shaping children's future socioeconomic attainment, and through adult health risk behaviors, such as smoking and heavy drinking. On average, children raised in two-parent families obtain more education and exhibit healthier adult behaviors than children from other types of families. These differences, in turn, have consequences for adult health and longevity.

Research on intergenerational health effects has focused on trends for people born in the late 19th and early 20th centuries, a period when patterns of marriage, divorce, and single parenthood were much different from today. It is possible that the apparent benefits of marriage for children's health have weakened as single parenthood and divorce have become more common and less stigmatizing. In addition, much of the research is limited to data for small nonrepresentative samples. The available nationally representative evidence is based on data sets that began tracking sample members as adults, which limits the ability to control for differences in the background characteristics of those who grew up in a two-parent family and those who did not.

Lesson 4: Loss

Source: Loss, NIH, National Cancer Institute,

Bereavement is the period of grief and mourning after a death. When you grieve, it’s part of the normal process of reacting to a loss. You may experience grief as a mental, physical, social or emotional reaction. Mental reactions can include anger, guilt, anxiety, sadness and despair. Physical reactions can include sleeping problems, changes in appetite, physical problems or illness.
How long bereavement lasts can depend on how close you were to the person who died, if the person’s death was expected and other factors. Friends, family and faith may be sources of support. Grief counseling or grief therapy is also helpful to some people.


Source: Grief, SAMHSA,

What is grief?

Grief is the normal response of sorrow, emotion, and confusion that comes from losing someone or something important to you. It is a natural part of life. Grief is a typical reaction to death, divorce, job loss, a move away from family and friends, or loss of good health due to illness.

How does grief feel?

Just after a death or loss, you may feel empty and numb, as if you are in shock. You may notice physical changes such as trembling, nausea, trouble breathing, muscle weakness, dry mouth, or trouble sleeping and eating.
You may become angry—at a situation, a particular person, or just angry in general. Almost everyone in grief also experiences guilt. Guilt is often expressed as “I could have, I should have, and I wish I would have” statements.
People in grief may have strange dreams or nightmares, be absent-minded, withdraw socially, or lack the desire to return to work. While these feelings and behaviors are normal during grief, they will pass.

How long does grief last?

Grief lasts as long as it takes you to accept and learn to live with your loss. For some people, grief lasts a few months. For others, grieving may take years.
The length of time spent grieving is different for each person. There are many reasons for the differences, including personality, health, coping style, culture, family background, and life experiences. The time spent grieving also depends on your relationship with the person lost and how prepared you were for the loss.

How will I know when I’m done grieving?

Every person who experiences a death or other loss must complete a four-step grieving process:
  1. Accept the loss.
  2. Work through and feel the physical and emotional pain of grief.
  3. Adjust to living in a world without the person or item lost.
  4. Move on with life. The grieving process is over only when a person completes the four steps.
People cope with the loss of a loved one in different ways. Most people who experience grief will cope well. Others will have severe grief and may need treatment. There are many things that can affect the grief process of someone who has lost a loved one. They include:
  • The personality of the person who is grieving.
  • The relationship with the person who died.
  • The loved one's cancer experience and the way the disease progressed.
  • The grieving person’s coping skills and mental health history.
  • The amount of support the grieving person has.
  • The grieving person’s cultural and religious background.
  • The grieving person’s social and financial position.
This summary defines grief and bereavement and describes the different types of grief reactions, treatments for grief, important issues for grieving children, and cultural responses to grief and loss.
Bereavement is the period of sadness after losing a loved one through death.
Grief and mourning occur during the period of bereavement. Grief and mourning are closely related. Mourning is the way we show grief in public. The way people mourn is affected by beliefs, religious practices, and cultural customs. People who are grieving are sometimes described as bereaved.
Grief is the normal process of reacting to the loss.
Grief is the emotional response to the loss of a loved one. Common grief reactions include the following:
  • Feeling emotionally numb.
  • Feeling unable to believe the loss occurred.
  • Feeling anxiety from the distress of being separated from the loved one.
  • Mourning along with depression.
  • A feeling of acceptance.

Normal Grief

Normal or common grief begins soon after a loss and symptoms go away over time.
During normal grief, the bereaved person moves toward accepting the loss and is able to continue normal day-to-day life even though it is hard to do. Common grief reactions include:
  • Anxiety over being separated from the loved one. The bereaved may wish to bring the person back and become lost in thoughts of the deceased. Images of death may occur often in the person’s everyday thoughts.
  • Distress that leads to crying; sighing; having dreams, illusions, and hallucinations of the deceased; and looking for places or things that were shared with the deceased.
  • Anger.
  • Periods of sadness, loss of sleep, loss of appetite, extreme tiredness, guilt, and loss of interest in life. Day-to-day living may be affected.
In normal grief, symptoms will occur less often and will feel less severe as time passes. Recovery does not happen in a set period of time. For most bereaved people having normal grief, symptoms lessen between 6 months and 2 years after the loss

Many bereaved people will have grief bursts or pangs.
Grief bursts or pangs are short periods (20-30 minutes) of very intense distress. Sometimes these bursts are caused by reminders of the deceased person. At other times they seem to happen for no reason.
Grief is sometimes described as a process that has stages.
There are several theories about how the normal grief process works. Experts have described different types and numbers of stages that people go through as they cope with loss. At this time, there is not enough information to prove that one of these theories is more correct than the others.
Although many bereaved people have similar responses as they cope with their losses, there is no typical grief response. The grief process is personal.

Complicated Grief

There is no right or wrong way to grieve, but studies have shown that there are patterns of grief that are different from the most common. This has been called complicated grief.
Complicated grief reactions that have been seen in studies include:
  • Minimal grief reaction: A grief pattern in which the person has no, or only a few, signs of distress or problems that occur with other types of grief.
  • Chronic grief: A grief pattern in which the symptoms of common grief last for a much longer time than usual. These symptoms are a lot like ones that occur with major depression, anxiety, or post-traumatic stress.

Cultures have different ways of coping with death

Grief felt for the loss of loved ones occurs in people of all ages and cultures. Different cultures, however, have different myths and mysteries about death that affect the attitudes, beliefs, and practices of the bereaved.
Individual, personal experiences of grief are similar in different cultures.
The ways in which people of all cultures feel grief personally are similar. This has been found to be true even though different cultures have different mourning ceremonies and traditions to express grief.
Cultural issues that affect people who are dealing with the loss of a loved one include rituals, beliefs, and roles.
Helping family members cope with the death of a loved one includes showing respect for the family’s culture and the ways they honor the death. The following questions may help caregivers learn what is needed by the person's culture:
  • What are the cultural rituals for coping with dying, the deceased person’s body, and honoring the death?
  • What are the family’s beliefs about what happens after death?
  • What does the family feel is a normal expression of grief and the acceptance of the loss?
  • What does the family consider to be the roles of each family member in handling the death?
  • Are certain types of death less acceptable (for example, suicide), or are certain types of death especially hard for that culture (for example, the death of a child)?
Death, grief, and mourning are normal life events. All cultures have practices that best meet their needs for dealing with death. Caregivers who understand the ways different cultures respond to death can help patients of these cultures work through their own normal grieving process.

Lesson 5: Parenting

Source: Parenting, Medline Plus,

If you're a parent, you get plenty of suggestions on how to raise your child. From experts to other parents, people are always ready to offer advice. Parenting tips, parents' survival guides, dos, don'ts, shoulds and shouldn'ts - new ones come out daily.
The truth is there is more than one "right" way to be a good parent. Good parenting includes
  • Keeping your child safe
  • Showing affection and listening to your child
  • Providing order and consistency
  • Setting and enforcing limits
  • Spending time with your child
  • Monitoring your child's friendships and activities
  • Leading by example

There are many different kinds of families. Some have two parents, while others have a single parent. Sometimes there is no parent and grandparents raise grandchildren. Some children live in foster families, adoptive families, or in stepfamilies.
Families are much more than groups of people who share the same genes or the same address. They should be a source of support and encouragement. This does not mean that everyone gets along all the time. Conflicts are a part of family life. Many issues can lead to conflict, such as illness, disability, addiction, job loss, school difficulties and marital problems. Listening to each other and working to resolve conflicts are important in strengthening the family.

Learning Activity 5.1: Immunization

Watch this video - Get the Picture: Childhood Immunizations (6.27 minutes)
After talking with parents across the country, CDC put together this short video to help answer the tough questions that real moms had about childhood immunizations. Understanding the importance of vaccines is crucial for you to protect your children’s health.
Source: //National Center for Immunization and Respiratory Diseases//

Learning Activity 5.2: Watch this video - Baby Steps: Learn the Signs. Act Early (4.32 minutes)

Early recognition of developmental disabilities such as autism is key for parents and providers. CDC realized the impact on families and invested in a campaign to help parents measure their children's progress by monitoring how they play, learn, speak and act.
Source: National Center on Birth Defects and Developmental Disabilities (NCBDDD) Release Date: 9/22/2008

Lesson 6: Family and Societal Violence

Violence Prevention

Source: Violence Prevention, CDC,

Violence is a serious public health problem in the United States. From infants to the elderly, it affects people in all stages of life. In the United States, violence accounts for approximately 51,000 deaths annually. In 2007, more than 18,000 people were victims of homicide and more than 34,000 took their own life.
Estimating the size of this economic burden is helpful in understanding the resources that could be saved if cost-effective violence prevention efforts were applied. The cost of these deaths totaled to $47.2 billion ($47 billion in work loss costs and $215 million in medical treatment).
The number of violent deaths tells only part of the story. Many more survive violence and are left with permanent physical and emotional scars. Violence also erodes communities by reducing productivity, decreasing property values, and disrupting social services.Violence is a serious public health problem in the United States. From infants to the elderly, it affects people in all stages of life. In 2007, more than 18,000 people were victims of homicide and more than 34,000 took their own life.

Understanding Violence

Source: Veto Violence,

Interpersonal violence is defined as the actual or threatened intentional use of force—physical, sexual, or emotional—against another person, group, or community. It may result in physical injury, psychological harm, or even death. Violence also includes suicide and nonfatal acts of self-harm.

Unfortunately, violence is a part of our daily life. It exists in all corners of our nation. It affects us all regardless of our age, gender, race, ethnicity, or socio-economic status. More than 50,000 violent deaths occur each year in the United States. The deaths only tell part of the story. Millions of others are left with debilitating physical and emotional injuries. These injuries negatively affect the health of victims for the rest of their lives.
Violence also erodes the fabric of our communities. It can threaten productivity in the workplace, decrease the value of our homes and businesses, and disrupt essential public and social services. The economic cost of violence is staggering. In 2000, the medical costs and productivity losses associated with nonfatal violence-related injuries and deaths were estimated at more than $70 billion each year. The total burden to society is far greater.

The good news is that violence is a problem with a solution. It can be prevented by using a thoughtful and systematic approach. While the field of violence prevention is still developing, our knowledge of “what works” increases every day.

Types of Violence

Learning Activity 6.1: Complete the Understanding Violence tutorial including each of the pop quizzes.

Sexual Violence

Sources: Violence Prevention, Centers for Disease Control and Prevention,

Sexual Violence (SV) refers to sexual activity where consent is not obtained or freely given. Anyone can experience SV, but most victims are female. The person responsible for the violence is typically male and is usually someone known to the victim. The person can be, but is not limited to, a friend, coworker, neighbor, or family member.
There are many types of SV. Not all include physical contact between the victim and the perpetrator (person who harms someone else) – for example, sexual harassment, threats, and peeping. Other SV, including unwanted touching and rape, includes physical contact.

SV can impact health in many ways. Some ways are serious and can lead to long-term health problems. These include chronic pain, headaches, stomach problems, and sexually transmitted diseases.
SV can have an emotional impact as well. Victims often are fearful and anxious. They may replay the attack over and over in their minds. They may have problems with trust and be wary of becoming involved with others. The anger and stress that victims feel may lead to eating disorders and depression. Some even think about or attempt suicide.
SV is also linked to negative health behaviors. For example, victims are more likely to smoke, abuse alcohol, use drugs, and engage in risky sexual activity.

Why is sexual violence a public health problem?

SV is a significant problem in the United States:
  • Among high school students surveyed nationwide, about 8% reported having been forced to have sex. The percentage of those having been forced to ever have sex was higher among female (11%) than male (5%) students.
  • An estimated 20% to 25% of college women in the United States have experienced an attempted or complete rape during their college career
  • Nearly 1 in 5 women and 1 in 71 men in the United States have been raped at some time in their lives.
These numbers underestimate the problem. Many cases are not reported because victims are afraid to tell the police, friends, or family about the abuse.Victims also think that their stories of abuse will not be believed and that police cannot help them.They may be ashamed or embarrassed. Victims may also keep quiet because they have been threatened with further harm if they tell anyone.
Certain factors can increase the risk for SV. However, the presence of these factors does not mean that SV will occur.
Risk factors for perpetration (harm to someone else):
  • Being male
  • Having friends that are sexually aggressive
  • Witnessing or experiencing violence as a child
  • Alcohol or drug use
  • Being exposed to social norms, or shared beliefs, that support sexual violence.


Source: Definitions, CDC,

It is important to understand what factors protect people or put them at risk for experiencing or perpetrating violence. Why are risk and protective factors useful? They help identify where prevention efforts need to be focused.

Risk factors do not cause violence. The presence of a risk factor does not mean that a person will always experience violence. Victims are never responsible for the harm inflicted upon them.
  • Risk Factor - Characteristic that increases the likelihood of a person becoming a victim or perpetrator of violence.
  • Protective Factor - Characteristic that decreases the likelihood of a person becoming a victim or perpetrator of violence because it provides a buffer against risk.

How can we prevent sexual violence?

Source: Understanding Sexual Violence, Centers for Disease Control and Prevention,

The ultimate goal is to stop SV before it begins. Efforts at many levels are needed to accomplish this. Some examples include:
  • Engaging high school students in mentoring programs or other skill-based activities that address healthy sexuality and dating relationships.
  • Helping parents identify and address violent attitudes and behaviors in their kids.
  • Creating policies at work, at school, and in other places that address sexual harassment.
  • Developing mass media (e.g., radio, TV, magazines, newspapers) messages that promote norms, or shared beliefs, about healthy sexual relationships.
For more examples, see Sexual Violence Prevention: Beginning the Dialogue.

Sexual Violence: Risk and Protective Factors

Source: Sexual Violence: Risk and Protective Factors, Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Violence Prevention,

Risk factors are associated with a greater likelihood of sexual violence (SV) perpetration. They are contributing factors and may or may not be direct causes. Not everyone who is identified as "at risk" becomes a perpetrator of violence.

A combination of individual, relational, community, and societal factors contribute to the risk of becoming a perpetrator of SV. Understanding these multilevel factors can help identify various opportunities for prevention.

Risk Factors for Perpetration

Individual Risk Factors

  • Alcohol and drug use
  • Coercive sexual fantasies
  • Impulsive and antisocial tendencies
  • Preference for impersonal sex
  • Hostility towards women
  • Hypermasculinity
  • Childhood history of sexual and physical abuse
  • Witnessed family violence as a child

Relationship Factors

  • Association with sexually aggressive and delinquent peers
  • Family environment characterized by physical violence and few resources
  • Strong patriarchal relationship or familial environment
  • Emotionally unsupportive familial environment

Community Factors

  • Lack of employment opportunities
  • Lack of institutional support from police and judicial system
  • General tolerance of sexual violence within the community
  • Weak community sanctions against sexual violence perpetrators

Societal Factors

  • Poverty
  • Societal norms that support sexual violence
  • Societal norms that support male superiority and sexual entitlement
  • Societal norms that maintain women's inferiority and sexual submissiveness
  • Weak laws and policies related to gender equity
  • High tolerance levels of crime and other forms of violence

Sexual Violence: Prevention Strategies

Source: Sexual Violence: Prevention Strategies, Centers for Disease Control and Prevention,

Sexual violence is a serious problem that can have lasting, harmful effects on victims and their family, friends, and communities. The goal of sexual violence prevention is simple-to stop it from happening in the first place. However, the solutions are just as complex as the problem.
Prevention efforts should ultimately decrease the number of individuals who perpetrate sexual violence and the number of individuals who are sexual violence victims. Many prevention approaches aim to reduce risk factors and promote protective factors for sexual violence. In addition, comprehensive prevention strategies should address factors at each of the levels that influence sexual violence -the individual, relationship, community, and society.
The most common prevention strategies currently focus on the victim, the perpetrator, or bystanders.

  • Strategies that aim to equip the victim with knowledge, awareness, or self-defense skills are referred to as risk reduction techniques.
  • Strategies targeting the perpetrator attempt to change risk and protective factors for sexual violence in order to reduce the likelihood that an individual will engage in sexually violent behavior.
  • The goal of bystander prevention strategies is to change social norms supporting sexual violence and empower men and women to intervene with peers to prevent an assault from occurring.
  • Other prevention strategies may target social norms, policies, or laws in communities to reduce the perpetration of sexual violence across the population.

Effective and Promising Programs

Unfortunately, little is known about what works to prevent sexual violence. To date, only one prevention program, Safe Dates, has been shown in a randomized controlled trial to prevent or interrupt sexual violence perpetration. Other programs are accumulating evidence for effectiveness and are moving towards or are currently conducting rigorous evaluations. Until more is known about what works and for whom, program planners can use prevention principles to strengthen their approach and evaluation to determine the effectiveness of new or existing programs.

Understanding Intimate Partner Violence

Intimate partner violence (IPV) occurs between two people in a close relationship. The term “intimate partner” includes current and former spouses and dating partners. IPV exists along a continuum from a single episode of violence to ongoing battering.IPV includes four types of behavior:
  • Physical violence is when a person hurts or tries to hurt a partner by hitting, kicking, or other type of physical force.
  • Sexual violence is forcing a partner to take part in a sex act when the partner does not consent.
  • Threats of physical or sexual violence include the use of words, gestures, weapons, or other means to communicate the intent to cause harm.
  • Emotional abuse is threatening a partner or his or her possessions or loved ones, or harming a partner’s sense of self-worth. Examples are stalking, name-calling, intimidation, or not letting a partner see friends and family.
Often, IPV starts with emotional abuse. This behavior can progress to physical or sexual assault. Several types of IPV may occur together.

Why is IPV a public health problem?

  • Nearly 3 in 10 women and 1 in 10 men in the US have experienced rape, physical violence, and/or stalking by a partner with IPV-related impact.
  • IPV resulted in 2,340 deaths in 2007. Of these deaths, 70% were females and 30% were males.
  • The medical care, mental health services, and lost productivity (e.g., time away from work) cost of IPV was an estimated $5.8 billion in 1995. Updated to 2003 dollars, that’s more than $8.3 billion.
These numbers underestimate the problem. Many victims do not report IPV to police, friends, or family. Victims may think others will not believe them or that the police cannot help.

How does IPV affect health?

IPV can affect health in many ways. The longer the violence goes on, the more serious the effects.
Many victims suffer physical injuries. Some are minor like cuts, scratches, bruises, and welts. Others are more serious and can cause death or disabilities. These include broken bones, internal bleeding, and head trauma.
Not all injuries are physical. IPV can also cause emotional harm. Victims may have trauma symptoms. This includes flashbacks, panic attacks, and trouble sleeping. Victims often have low self-esteem. They may have a hard time trusting others and being in relationships. The anger and stress that victims feel may lead to eating disorders and depression. Some victims even think about or commit suicide.

Who is at risk for IPV?

Several factors can increase the risk that someone will hurt his or her partner. However, having these risk factors does not always mean that IPV will occur.
  • Being violent or aggressive in the past
  • Seeing or being a victim of violence as a child
  • Using drugs or alcohol, especially drinking heavily
  • Not having a job or other life events that cause stress

Am I being abused?

Source: Am I Being Abused? CDC,

It can be hard to know if you're being abused. You may think that your husband is allowed to make you have sex. That's not true. Forced sex is rape, no matter who does it. You may think that cruel or threatening words are not abuse. They are. And sometimes emotional abuse is a sign that a person will become physically violent.
Below is a list of possible signs of abuse. Some of these are illegal. All of them are wrong. You may be abused if your partner:
  • Monitors what you're doing all the time
  • Unfairly accuses you of being unfaithful all the time
  • Prevents or discourages you from seeing friends or family
  • Prevents or discourages you from going to work or school
  • Gets very angry during and after drinking alcohol or using drugs
  • Controls how you spend your money
  • Controls your use of needed medicines
  • Decides things for you that you should be allowed to decide (like what to wear or eat)
  • Humiliates you in front of others
  • Destroys your property or things that you care about
  • Threatens to hurt you, the children, or pets
  • Hurts you (by hitting, beating, pushing, shoving, punching, slapping, kicking, or biting)
  • Uses (or threatens to use) a weapon against you
  • Forces you to have sex against your will
  • Controls your birth control or insists that you get pregnant
  • Blames you for his or her violent outbursts
  • Threatens to harm himself or herself when upset with you
  • Says things like, "If I can't have you then no one can."
If you think someone is abusing you, get help. Abuse can have serious physical and emotional effects. No one has the right to hurt you.

Healthy vs. unhealthy relationships

Sometimes a relationship might not be abusive, but it might have some serious problems that make it unhealthy. If you think you might be in an unhealthy relationship, you should be able to talk to your partner about your concerns. If you feel like you can't talk to your partner, try talking to a trusted friend, family member, or counselor. Consider calling a confidential hotline to get the support you need and to explore next steps. If you're afraid to end the relationship, call a hotline for help.
Signs of an unhealthy relationship include:
  • Focusing all your energy on your partner
  • Dropping friends and family or activities you enjoy
  • Feeling pressured or controlled a lot
  • Having more bad times in the relationship than good
  • Feeling sad or scared when with your partner
Signs of a healthy relationship include:
  • Having more good times in the relationship than bad
  • Having a life outside the relationship, with your own friends and activities
  • Making decisions together, with each partner compromising at times
  • Dealing with conflicts by talking honestly
  • Feeling comfortable and able to be yourself
  • Feeling able to take care of yourself
  • Feeling like your partner supports you
If you feel confused about your relationship, a mental health professional can help. Remember, you deserve to be treated with respect.

Learning Activity 6.2: Abusive Relationships

Watch this video titled Red Flags: Avoiding Abusive Relationships(21 minutes).

  • What are the red flags to avoid in relationships?

Learning Activity 6.3: Unhealthy Relationships

It can be hard to know what to do when someone you care about is in a controlling or violent relationship.
If this topic is unfamiliar to you and seems overwhelming, visit -
Help Someone in an Unhealthy Relationship: Quick tips

Learning Activity 6.4: Take Action

Visit this website then click on The Basics and Take Action -
Take Steps to Protect Yourself from Relationship Violence
What specific ways are you willing and able to help someone who is in an unhealthy relationship?

Contemporary Health Issues

Open Courseware

This compilation is openly licensed under Creative Commons Attribution-ShareAlike by Judy Baker, September 2012.
Feel free to use, reuse, customize, or share in accordance with the open license conditions of each source.
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