Health as a Function of the Family

Findings across the decades of research and scholarship support the significant relationship and importance of the family to the health of the family, individual family members, and communities. The family is described as the primary unit for health and as the most important social context in which health and illness occur and illness is resolved. Some report that one of the primary purposes, if not the primary purpose of family, is to ensure the health and well-being of its members (Friedman, Bowden, & Jones, 2003) and that health is a criterion for family life (Grzywacz & Ganong, 2009). The family is seen as a dynamic system that helps to maintain health, offers support to family members, affects health decisions, and attaches meaning to illness (Pardeck & Yuen, 2001; Rolland, 1987; Wright & Bell, 2009). The health of the family and family members is considered a function of the family the same as other functions such as biological reproduction, emotional development, and socialization (Friedman et al., 2003; Litman, 1974). The ability of families to meet their primary functions rests, at least in part, on the health of individual family members (Doherty & Campbell, 1988). For example, the state of family members' physical and mental health determines if and how family functions are met. These functions include the ability for employment, consistent monitoring of the behavior of children, and providing a safe environment for family members. Health is also reported as essential to effective family interactions and relationships. In 1976, the World Health Organization (WHO) reported that family is not only the basic unit of human social organization, but it is one of the most accessible for preventive and therapeutic intervention. WHO also noted that the health of the family is more than the sum of the health of individual family members.

A distinction has been made between the health of individual family members and the health of the family. In 1976, WHO reported that the health of a family goes beyond the physical and mental conditions of its members to the extent that it provides a social environment for the natural development and fulfillment of all who live within it. Importantly, WHO recognized that health is the interaction between social variables and family health; these social variables include ethnicity, socioeconomic status, employment, migration, and social and cultural norms and mores. This distinction between health and family health is considered a landmark in the recognition that multiple factors interact to affect health and that the health of family members is different from the health of the family.

Definitions of Health, Family Health, and Familial Health

How health, family health, and familial health are defined directs the actions and relationship of health professionals and families. The 1948 World Health Organization definition of health as “a state of complete physical, mental and social well being and not merely the absence of disease or infirmity” remains a global standard. It was a major conceptual advance in that it expanded the definition of health to psychological and social dimensions. A dilemma in these ensuing years has been a need for an operational definition of health and that the lack of such a definition continues to limit our understanding of the relationship of family to the health of its members and to the family system (Grzywacz & Ganong, 2009; Saracci, 1997). One effort to attempt to address this gap in the understanding of the relationship of the family to health was led by WHO in 1976. WHO established a workgroup, the WHO Consultation Family Unit and Health, to better describe the role of the family and health (WHO, 1976). The goal of the workgroup was to identify statistical indices of family and health by examining the family research and policy across four approaches: demographic, epidemiological (medical), social, and economic. The 1976 report resulted in recommendations and priorities for research, but the workgroup members were not able to identify specific indices of family health because of the complexity of measurement and because “family health is more than the sum of the health of individual family members” (p. 13). Through their work, they differentiated family health from familial health. The report recommended that family health, as an established concept, should apply to the sum of the states of health of the individual family members. Family health is measured by the ability of the family to meet its functions and not by the health of individual family members. Mauksch (1974) and Pardeck and Yuen (2001) further reported that family health is demonstrated by the development of, and continuous interaction among, the physical, mental, emotional, social, economic, cultural, and spiritual dimensions of the family, which results in the holistic well-being of the family and its members.

In contrast, familial health was proposed to indicate the functioning of the family for the promotion of the health and well-being of individual family members and the family system. To measure familial health requires the recognition that the level of health may be different across family members, ranging from demonstrated illnesses and conditions to the absence of observable illness to the actual positive health measured by development, function, and physiological measures (WHO, 1976). These are distinctions that can guide the research and scholarship on families.

Historical Evolution of Science of Family and Health

From the time of Nightingale, nurses have been encouraged to consider family members as important for nursing care (Whall & Fawcett, 1991). In a detailed case study in 1945, physician Henry Richardson acknowledged the importance of the family and emphasized the need to connect activities within the home and across family members to the care of individual patients. From the 1950s to the present, sociologists have been major contributors to our understanding of families and health, with their systematic focus on the role of the family with ill individual family members and their beginning study of the impact of illness on family (Litman, 1974; Vincent, 1963). Researchers examined intergenerational health care and the family, including patterns of decision making and the role of the family in health and illness behavior (Hill, 1958). Similar to current research, sociologists reported that families were unable and unwilling to care for sick family members in the home (Parsons & Fox, 1952). During this time, Sussman (1953) reported that existing techniques for measuring the interrelationship of family behavior to the etiology of disability and chronic illness were too limited to clearly advance our understanding of the important relationship between family and health. Litman and Venters (1979) noted that although much was known about health and health care of the populations, far less was known about the family as the unit of health. Importantly, this research began to examine the reciprocal nature of illness on the family and the effect of the family on health and illness of family members. It was also noted that mothers were the primary source of family data, resulting in the research being the mothers' perceptions of the family and its members. Wakefield and colleagues, [Page xxxiii]in a state of the science review, further delineated the conceptual and methodological issues in research of families (Wakefield, Allen, & Washchuck, 1979). They noted that the research focused on the internal family processes and gave limited attention to the interdependence of individual family members and the family to the larger social and physical environment. They reported that such a focus inferred the cause-and-effect relationship of family and health was internal to the family.

Beginning in the 1980s, more clinician family scholars such as Campbell (1986), Doherty (1993), Doherty and Campbell (1988), Feetham (1984, 1999), Feetham and Thomson (2006), Friedman (1981, 1998), Friedman et al. (2003), Gilliss and Knafl (1999), Grzywacz and Ganong (2009), McCubbin (1999), McDaniel, Campbell, Hepworth, and Lorenz (2003), Ransom (1986), Ross and Mirowsky (2002), and Wright and Bell (2009) advanced our understanding of the relationship of family to health through review articles synthesizing the state of the science. The reviews focused on two primary areas: family roles in health and illness and the effects of health and illness on individual family members and the family as an interdependent, interactive system. The outcomes of this research further demonstrate the importance of the family to the health of the individual family members and to the family system.

Roles of Family in Health of Family Members

One family role is in the health promotion and risk reduction for the family and its members (Roth & Simanello, 2004). The WHO (1976) cites the family as the primary social agent in the promotion of health and well-being. Families are known to have a significant effect on behaviors that influence individual health; these include exercise, diet, and substance use (alcohol, cigarette smoking, and drugs; McDaniel et al., 2003). The family creates the environment in which the family members develop their behavioral patterns that promote health or result in risk for illness and injury. During the past decades, genomics has contributed to our knowledge of the mechanisms of and prevention of disease (Feetham & Thomson, 2006). This research has also strengthened our understanding of the relationship of the biological family to the health of individual family members and the intergenerational family (Rolland & Williams, 2005). Family is the convergence of sociocultural and genetic influences. The intergenerational family influences how individual family members and the family respond to genetic information and the risk of disease, including behaviors to reduce their risk (Feetham & Thomson, 2006; Rolland & Williams, 2005).

The family is known to have a role in psychosocial factors and disease risk. Building from the knowledge that psychosocial factors can affect an individual's susceptibility to disease, research has shown that the family is an important source of support of family members and also a source of stress (Fisher, 2006). For decades, researchers have demonstrated that the family can be related to the onset of illness and affect the trajectory of illness (Coyne et al., 2001). The family is also reported as an important influence or buffer between the family member with an illness and the larger system, including the health care system (Weihs, Enright, & Simmens, 2008). Some researchers have reported a relationship to depression or stress and a decrease in cellular immunity. For example, Meyer and Haggerty (1962) demonstrated that chronic stress in families was related to the incidence of strep infections and days of school missed in children. Similarly, in a study of 500 families, a relationship between family stress and the increased utilization of health care was shown (Roghmann & Haggerty, 1973).

Families are also known to play a critical role in appraising both physical and mental health. While mothers are recognized as the gatekeeper of family members' access to the health care system, the mother's health care use is more of a predictor of the child's access to care than the child's health status. In addition to the role of the family as health appraiser, patterns of health service utilization are related to family structure and health beliefs.

Family Responses to Health and Illness in Family Members

Family responses to illness in family members and the role of the family in adaptation to illness and recovery provide further evidence of the importance of family and the health of family members (Deatrick, Alderfer, Knafl, & Knafl, 2006). Research [Page xxxiv]focused on family responses to specific illnesses has resulted in a body of literature reporting that the interactions within the family system affect the health outcomes of family members (Fisher, 2006; Svavarsdottir, McCubbin, & Kane, 2000). The progression of disease and disability can be linked to relationship of family members (Coyne et al., 2001; Holder, 1997; Reiss, 1990). Grzywacz and Ganong (2009) note that we determine the health of the family by how they respond to changes in the physical and mental health status of family members and how they function to prevent health problems. Because of the research design and measures, we know more about the negative outcomes of acute and chronic illness on the family than the strengths and resources demonstrated by families. The family as caregiver has been examined from childhood to family members with acute and chronic illness across the age continuum (Gilliss & Knafl, 1999).

Summary: What Do We Know about Family and Health?

The interdependence and importance of health and the family are accepted in theory and supported by research. Although our knowledge of this relationship has increased, it has also been limited in that research continues to focus more on measures of the negative outcomes (e.g., depression) of illness and injury on the family and family members. The research also continues to focus more on the responses of individual family members than on the responses of the family as a unit. Because the focus has been on the individual as the unit of measure and on conducting research of families with physical and/or mental pathology, less knowledge has been generated about health and how the family functions. A classic exception is the synthesis by McCubbin (1999) of research of normative family transitions and health outcomes. If research of families would build on the premise that health is a criterion of family, Grzywacz and Ganong (2009) suggest that such research should result in knowledge and strategies for protecting and promoting health across the life span while distinguishing the interdependence of activities of family to health of the family and individual family members. A limitation of this science is the lack of translation into the education of health professionals and practice in health care systems. As important is that the knowledge of the significance of family to the health of the family and family members has not translated into policy. This limitation is due in part to the conceptual and methodological limitations of the research but more importantly because there is not sufficient recognition of the need to build the process of informing policy into programs of research and scholarship (Feetham, 1999; Feetham & Meister, 1999; Healthy People 2010, n.d.). As a result, the family is not seen as the context of care, and the health care system continues to focus on the health and illness of individuals and not the health of families as a system (Feetham, 1999; Feetham & Meister, 1999; Par deck & Yuen, 2001).

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