The Familys Influence on Health

David E. Newton, MD, MS, DABFP PSPD/UNEJ 2004

I. Introduction A. Definition of a Family 1. any group of people related either biologically, emotionally, or legally. (Pequegnat & Bray, 1997) B. Why Study about the Family? 1. It is the most basic relational unit and the most intimate social environment in society. 2. It is the primary source of health beliefs, health-related behaviors, stress, and emotional support. 3. The family has a major influence on the physical and mental health of its members (Doherty & Campbell, 1988) 3. Understanding how families can influence health will assist the physician in working more effectively with patients and families. 4.The specialty of Family Medicine is unique in its emphasis on the health care of families over the life cycle. II. Family Relationships, Dynamics, and Health A. Association of the Family with Health and Disease 1.Family relationships and dynamics are strongly associated with both health and disease 2. Medicines emphasis on pathology leads physicians to focus on the negative aspects of the family and ignore the beneficial aspects 3. Family is the primary social agent in the promotion of health and well being. (World Health Organization, 1976) 3. How family relationships, and especially social support, promote health and buffer the effects of stress can help the Family Medicine physician to utilize these resources in patient care (Bray, 1995). B. Relationship between social relationships and morbidity and mortality 1. The age-adjusted relative risk ratios for those with poor social support are stronger than the relative risks for all cause mortality reported for cigarette smoking. 2. Family members, particularly a spouse, appear to be the most important source of social support and account for most of the association between social support and health. 3. The structural components of social support (i.e. marital status, number of children) have a direct effect on health 4. functional or perceived social support (i.e. quality of relationships) indirectly affects health by buffering stress (Blake, 1988) 5. Berkman and Syme Study (1979) a. 6000 adults

b. social networks are major predictor of mortality over a 9 year period, independent of socioeconomic status, previous health status, or health practices. c. marital status and contacts with relatives and friends were the most powerful predictors of health. 6. Studies in elderly (e.g., Blazer, 1982) a. older persons with impaired social supports have two to three times the death rate of those with good supports b. presence and number of living children were the most powerful predictors of survival. Adult children are most important source of social support in the elderly. III. Health Promotion and Disease Prevention A family-oriented approach is the most effective and efficient way to prevent disease and promote health (Doherty & Campbell, 1988). Most chronic illnesses result in part from unhealthy behaviors or risk factors that are difficult to change. A. Cardiovascular Risk Factors 1. Mate selection a. assortive matingthe tendency to marry someone with similar traits or behaviorsis common. b. smoking couples who quit at the same time are more likely to be successful. c. men with cardiac disease are more likely to comply with exercise programs if their wives have a positive attitude about the program. d. critical behaviors (nagging) by the spouse have a negative effect 2. Cholesterol a. a wifes interest in a cholesterol reduction drug program for a man correlates with compliance 3. Eating Habits And Obesity a. Most cardiac risk behaviors, including diet, smoking, and exercise are strongly influenced by the family (Sallis & Nadir, 1988). b. Studies of adopted children show that childhood obesity is influenced by both genetics and family environment. c. In 1958, 25 % of American mothers use food as a reward for their children, 10% for punishment (Bryan & Lowenberg, 1958) 4. Hypertension a. only of hypertensive individuals are under treatment and only of those have their BP under control b. Family involvement can have a dramatic effect on compliance and mortality in hypertensives (Morisky, et al., 1983) IV. Families and Chronic Illness

A. Families are the primary caregivers for patients with chronic illness. B. Randomized, controlled studies on schizophrenics show that the emotional climate and patterns of communication in the family powerfully affect relapse and the course of the disease and other chronic diseases. V. The Psychosomatic Family A. High cohesion vs. Low cohesion families 1. High cohesion=enmeshment=overprotectiveness, rigidity, conflict avoidance 2. Low cohesion= disengagement=parental indifference, absent father, poor living conditions, chronic family conflict A. Diabetes Mellitus 1. both low and high cohesion families associated with poor diabetic control in children (Anerson, et al., 1981) 2. optimal control requires family support and supervision with respect for individuality and age-appropriate autonomy. VI. Clinical Implications A. determine the amount of stress the family is experiencing, including any recent deaths, divorces, or separations, and any current illnesses, marital difficulties, or sexual dysfunctions. B. assess coping mechanisms past and current C. if unhealthy behavior (smoking, excess alcohol ingestion, obesity, etc.) is detected in one member of the family, screen the remaining members D. Enhance support from family members 1. identify and involve one influential person to support the patient 2. support the patients autonomy as well 3. for enmeshed families, help the patient and family negotiate boundaries 4. refer severely dysfunctional families for counseling a. presented to the family as a way to help the family cope with the chronic illness VII. Family Stress and Health A. Life Event Scale (Holmes & Rahe, 1967) 1. 10 of the 15 most stressful events are family events 2. prospective and retrospective studies using this scale have shown that in increase in stressful life events precedes the development of a wide range of different diseases. 3. Research in psychoimmunology has shown that stress can decrease immunity and make individuals more susceptible to a many different diseases, including infections. A. Impact of Divorce on the Family 1. Process of Separation and Divorce a. major impact on the health and well-being of all family members b. affect parent-child relationships, parenting practices and effectiveness, family conflict, family income and residence, extended family relationships, and peer and social relationships.

c. most research indicates that being married is associated with better outcomes, overall, and fewer health problems than being divorced or single (Somers, 1979) c. however, children may adjust better in a stable, divorced home better than in an unhappy, highly conflictual, intact home (Hetherington, et al., 1978) d. during the deliberation period before the separation, the physician can promote healthy methods of coping with stress, teach parents ways of relating to their children that maximize coping, and make appropriate referrals for counseling if needed. e. early assessment, intervention, and, if necessary, referral for counseling can prevent the difficulty of a marriage separation and divorce. 2. Post-Divorce Families a. family enters a stage of attempting to reach a new equilibrium and stability. b. child visitation creates stress but is important. 3. Adults Reactions to Divorce a. the first year after divorce is highly stressful. b. men and women often report a decrease in self esteem, loss of control, loneliness, and isolation. c. visits to the doctor frequently are due to complaints of fatigue, other somatic symptoms and depressive symptoms. d. marital disruption is the single most powerful sociodemographic predictor of stress-related physical illness. 1) separated individuals have 30% more acute illnesses 2) divorced men have increased rates of suicide and being victims of violence 3) immune function is reduced (Kiecolt-Glaser, et al., 1987) e. in most individuals, the recovery process takes 2 years. 1) many patients expect to recover much more quickly than is realistic (Musty, 1983). 4. Effects of Divorce on Children a. effects vary depending on a number of factors including: 1) sex of the child, age of the child, length of time since the divorce, post-divorce family relationships, and socioeconomic factors (Bray, et al., 1999) 2) usually more difficult for boys than girls which can persist for 4-7 years post divorce, particularly if the custodial mother remains single. 3) children under 3 yo regress in behavior (e.g. bedwetting), age 4-6 yo regress, become whiny and clinging, age 6-11yo sadness and upset and may feel responsible for the divorce and have reconciliation fantasies, age 12-18 react with anger, resentment, and

hostility and usually do not blame themselves for the divorce. 4) takes 2 years for adjustment and stability to return

Insert Table 3-1.

5. Role of the Family Physician in Divorce a. support and concern 1) ask open questions, e.g. How are things going at home? 2) educate them about the effects of stress and ways to cope 3) Most patients prefer that the physician listen empathetically rather than give advice concerning the problems of single parenthood (Anstett & Lewis, 1986)

4) reassure patients that their feelings are normal and will improve over time 5) be the childs advocate. Ask the child how he/she feels. Less than 10% of children have any adult talk to them about the divorce (Wallerstein & Kelly, 1980). Encourage each parent to talk to the child about the divorce and have them reassure the child that they are divorcing each other, not the children and that the child was not the cause of the divorce. 6) Suggest to parents to use consistent parenting, maintaining discipline, and allowing children to express their feelings, avoid blurring boundaries between parents and children, avoid actions that force the child to take sides or require the child to be the message-bearer between parents. 7) physicians can be alert to signs of poor coping in the child: depression, anxiety, somatic complaints, fatigue, boredom, drop in school performance, irritability, withdrawal from friends and usual social activities, running away, promiscuity, alcohol and drug abuse (Price, et al., 1983) B. Remarriage and Stepfamilies 1. Effects of Remarriage on Adults and Children a. brings a series of changes, both positive and negative b. often takes 2 years for adjustment c. girls have more difficulty than boys (opposite of adjustment to divorce) 2. Role of the Family Physician in Remarriage and Stepfamilies a. anticipate problems and provide preventive guidance and counseling. b. debunk myths about remarriage (such as fast adjustment) c. validate conflictual feelings in the family members d. encourage open communication within the family e. encourage the new married couple to take time for themselves without the children VIII. Conclusion A. The family has a powerful influence on our health beliefs and behaviors, as well as on our overall mental and physical health. B. When there is serious illness within a family, the Family physician can mobilize family strengths and resources C. Understanding how family stress and support influence health helps the family physician to be more effective in caring for families and preventing and treating illness. A family-oriented approach provides an enormously satisfying way to practice medicine (McDaniel, et al., 1990)

Reference: Rakel, Robert E., MD, Textbook of Family Practice, 6th Edition, W.B. Saunders Company, 2002, pp31-41