Family functioning style

INTRODUCTIONChronic and mental health diseases, andtheir risk factors, are the leading causes ofdeath, disability, and health expenditureworldwide. In spite of the substantialprogress in biological interventions to treatthese illnesses, their control and theprevention of comorbidity are major healthchallenges. As the success of medicalinterventions depends on adherence todisease-management conduct, behaviouralinterventions are essential for effectiveclinical care. Multiple theories explain thecomplexity of health behaviour but, in recentyears, positive family dynamics have beenlinked to improved clinical outcomes forpatients,1,2 providing insights into newstrategies for health prevention.Family risk and protective factors have

been widely studied in mental healthdiseases, leading to conclusions that thefamily has an important role inpathogenesis, treatment, and recovery —particularly of patients with mood, anxiety,and substance abuse disorders, andattention deficit and hyperactivity disorder(ADHD).3–8 Research on the relationshipbetween family and health outcomes inbiomedical illness has concentrated oninsulin-dependent diabetes,9,10 children’sasthma,11,12 irritable bowel,13 anddementia,14 with less consideration given tochronic and highly prevalent conditions thatare commonly treated in primary care, butan association has been observed in type 2diabetes mellitus, hypertension, weight-related diseases, asthma, and chronic

obstructive pulmonary disease (COPD).15Findings link family variables to the clinicaloutcomes of patients, suggesting that theycould play an important unexplored role indisease management. These results are,however, inconclusive.Research assessing the importance of

the family in people’s health has beenconducted with small groups and mainly insecondary care clinics, thereby reducing theapplicability to patients in primary care.Consequently, the aim of this study was toevaluate the association between familyfunctioning style and prevalent healthproblems among families receiving primarycare in an underserved community ofSantiago, Chile. It was hypothesised thathealthy families have a better functioningstyle than families with health complaints,and that the health problems have acumulative effect, such that the familieswho face more health issues have a lowerfunctioning style.

METHODDesignA cross-sectional study was designed tocompare the family functioning style offamilies with common health problems —for example, asthma, overweight,depression — in primary care.

SettingThe electronic records of all familiesregistered at the JuanPablo II Primary CareClinic, in La Pintana — an underserveddistrict of the south-east metropolitan area

DGarcía-Huidobro,MD, assistant professor;KPuschel,MD, MPH, associate professor; GSoto,MS, clinical psychologist, Department of FamilyMedicine, Pontificia Universidad Católica de Chile,Santiago, Chile.Address for correspondenceD García-Huidobro, Pontificia Universidad Católicade Chile, School of Medicine, Department ofFamily Medicine, Vicuña Mackenna 4684, Macul,Santiago, Chile.

E-mail: [email protected]

Submitted: 20 July 2011; Editor’s response:30 August 2011; final acceptance:18 October 2011.

©British Journal ofGeneralPracticeThis is the full-length article (published online27 Feb 2012) of an abridged version published inprint. Cite this article as: BrJGenPract 2012;DOI: 10.3399/bjgp12X630098

Family functioning style and health:opportunities for health prevention in primary care

Diego García-Huidobro, Klaus Puschel and Gabriela Soto

Research

AbstractBackgroundThe relationship between family and health hasnot been studied in detail in primary care.

AimTo evaluate the association between familyfunctioning style and health problems amongfamilies receiving primary care.

DesignandsettingCross-sectional study in an underserved primarycare clinic in Santiago, Chile.

MethodFamilies registered at the Juan Pablo II PrimaryCare Clinic in Santiago, Chile from 2006 to 2010formed the study sample. Each family selectedan adult familymember to answer aquestionnaire to provide data on: familysociodemographics; health problems amongfamilymembers; and the family functioning style,as assessedwith the Family Functioning StyleScale (FFSS). The t-test was used to assessdifferences in family functioning styles betweenfamilies with andwithout health problems, andanalysis of variancewas used to study therelationship between the family functioning styleand the number of health problems present.

ResultsA total of 6202 families, comprising 25 037people, were assessed. The following diseasesand conditions were examined: in children—asthma or recurrent bronchitis, delayeddevelopment, enuresis or encopresis, behaviouralproblems, overweight; in adolescents and adults— teenage pregnancy, asthma or chronicobstructive pulmonary disease, smoking,hypertension, type 2 diabetes,major depression,alcohol or drug abuse, and frailty. Families withhealth problems had a significantly lower FFSSscore than families without health conditions.Mental health diseases had the strongestassociation with family functioning style. Aninverse relationship between the number ofhealth problems and the FFSS scorewas alsoobserved.

ConclusionA better family functioning style was associatedwith a lower prevalence of health problems infamilies. Bases for further research consideringthe family as a target for clinical interventionsare provided.

Keywordsfamily; family relations; primary health care.

e198 British Journal ofGeneral Practice, March 2012

of Santiago, Chile — were analysed. Thishealth centre is directed by the Departmentof Family Medicine at the PontificiaUniversidad Católica de Chile and servesapproximately 25 000 individuals. Peopleregistered at this clinic have a lowsocioeconomic status and low educationallevel, and there are high unemploymentrates among the adult population.16

ProceduresThe records of families who registered withthe health clinic from its opening inSeptember 2006 until March 2010 wereretrospectively analysed. When peopleregister at the clinic, they are asked to groupthemselves in families and elect a familymember to answer a three-sectionquestionnaire for the entire family group (67questions). A pre-specified definition offamily is not used, instead patients areasked to define their own family group. Thefirst part of the survey includessociodemographic information about allfamily members, the second sectionconsists of 30 items that assess thenumberof family members with health problemsaccording to their age, the third section is a22-item evaluation of the family functioningstyle. This evaluation is conducted using theFamily Functioning Style Scale (FFSS),17

validated in Chile.18 This instrumentappraises seven family factors on a 5-pointscale, and is used in Chilean primary care;19

scores range from 22 to 110 and the higherthe score, the better the family functioningstyle. This process is always undertakenwhen families register at this practice.

VariablesThe dependent variable was the FFSS. Theindependent variables were the healthproblems reported by the families. Thepresence of the following was assessed:

• in children (aged <15 years) — repetitivebronchitis or asthma, delayed child

development, enuresis or encopresis,behavioural problems, and overweight;and

• among adolescents and adults (aged≥15 years) — asthma or COPD,hypertension, type 2 diabetes mellitus,adolescent pregnancy, major depression,family violence, smoking, alcohol anddrug abuse, dementia, being bedbound,and frailty.

Other diseases that had been consideredin the survey but are treated in secondarycare— for example, type 1 diabetes, cancer,HIV/AIDS, and schizophrenia — wereexcluded from the analysis.

Statistical analysisData analysis was performed with SPSS(version 16.1). To assess the associationbetween the presence of health problems inthe family and the family functioning style,the independent t-test for univariateanalysis was used. Comparisons weremade between the FFSS score of families inwhom at least one member had one of thehealth problems studied and the FFSSscore of families that did not report any ofthe health problems assessed.Potential confounders were tested one at

a time to model the FFSS score. Thefollowing variables were examined withbackward linear regression:

• number of people per household;

• family income;

• education of family members;

• age; and

• sexof questionnaire responders. Only thefinal model included the family incomeand whether amember of the family wasilliterate. Estimated marginal meanswere analysed using Bonferroni multiplecomparison.

Analysis of variance and the Bonferronitestwere conducted to study theassociationbetween the family functioning style and:

• the number of family members with thesame health problem;

• the total number of different healthproblems in the family; and

• the total number of health problemsconsidering all members of the family.

Resulting two-tailed P-values of ≤0.05were considered statistically significant.

RESULTSA total of 6202 families were included in the

How this fits inThe relationship between family and healthis not questioned, but there have been noin-depth studies of it in primary care. Thisarticle describes the association betweenfamily functioning style andmultiple healthproblems in a large sample of familiesreceiving primary care. This relationshipprovides insight for further research insupport of the development of family-oriented clinical interventions for healthprevention and disease control.

British Journal ofGeneral Practice, March 2012 e199

study. They comprised 25 037 people,whichis the entire population that was registeredat the clinic up to March 2010; most ofthese individuals were aged <50 years andunderserved. Survey responders were, inthe main, female and aged 30–50 years.The sociodemographic description offamilies, family members, andquestionnaire responders are summarisedin Table 1.Overall, 724 (11.7%) survey responders

did not report any health problems among

familymembers. Their FFSS scorewas 92.5(standard deviation [SD] ±18.1), comparedwith a score of 87.1 (SD ±15.9) for thefamilies that reported at least one memberhaving one of the health problems studied(P<0.001). Lower FFSS scores were also inevidence for all of the families with healthproblems studied among children,adolescents, or adults using univariateanalysis, and for most diseases afteradjusting for potential confoundingvariables compared to healthy families(Table 2). Most of the largest differences inthe FFSS score between healthy familiesand thosewith familymemberswhowere illwere for mental and psychosocial healthproblems, such as child behaviouralproblems, major depression, smoking, andalcohol or drug abuse.Inverse associations between the FFSS

score and the number of health problemsper family (Figure 1), and the FFSS scoreand total number of health problems perfamily member (Figure 2) were also found.In effect, the higher the number of healthproblems affecting a family or familymember, the lower the FFSS score.The relationship between the FFSS score

and the number of family members withparticular illnesses was significant fordelayed child development (P<0.001),enuresis or encopresis (P = 0.002),behavioural problems (P<0.001), majordepression (P = 0.001), family violence(P<0.001), smoking (P<0.001), and alcoholand drug abuse (P<0.001 for both). For all of


Table 1. Sociodemographic characteristics of families, familymembers, and survey respondersCharacteristic n (%)a

Families 6202Family members per household, n ±SD 3.26 ±1.9Annual family income<US$3000 3430 (55.3)US$3000–6000 2177 (35.1)>US$6000 595 (9.6)Illiterate family member 526 (8.5)Family members 25 037Female 12 929 (51.6)Ages, years≤9 4685 (18.7)10–19 4846 (19.4)20–49 11 036 (44.1)50–64 3423 (13.7)≥65 1047 (4.2)Survey responders 6202Female 4630 (74.7)Age, years (SD) 43.3 (±14.6)aUnless otherwise specified. SD = standard deviation.

Table 2. Mean differences in the Family Functioning Style Scalescores of healthy families and thosewith a familymemberwho is ill

Univariateanalysis MultivariateanalysisMean Mean

Healthproblem n difference±SD P-value difference±SD P-valueChildrenRepetitive bronchitis or asthma 853 5.4 ±2.1 <0.001 9.7 ±2.8 <0.001Delayed child development 447 7.3 ±2.5 <0.001 3.8 ±1.1 <0.001Enuresis or encopresis 291 6.1 ±2.1 <0.001 7.4 ±1.9 <0.001Behavioural problems 1120 8.3 ±3.0 <0.001 11.0 ±2.7 <0.001Overweight 1057 6.0 ±1.8 <0.001 9.2 ±2.6 <0.001Adolescents or adultsAsthma or COPD 832 6.0 ±2.1 <0.001 8.1 ±2.7 <0.001Hypertension 1580 4.8 ±1.7 <0.001 4.0 ±1.4 <0.001Type 2 diabetesmellitus 667 5.2 ±1.7 <0.001 12.9 ±2.3 <0.001Adolescent pregnancy 380 8.2 ±2.7 <0.001 3.7 ±1.2 <0.001Major depression 905 6.7 ±2.0 <0.001 12.8 ±2.9 <0.001Family violence 579 13.0 ±3.8 <0.001 7.8 ±1.7 <0.001Smoking 3839 6.2 ±1.9 <0.001 12.2 ±1.9 <0.001Alcohol abuse 912 10.3 ±3.2 <0.001 15.9 ±2.9 <0.001Drug abuse 758 10.9 ±2.9 <0.001 17.4 ±3.2 <0.001Dementia 22 8.8 ±3.9 0.023 8.2 ±1.9 0.052Bedbound 74 6.8 ±2.8 <0.001 –0.2 ±2.0 0.723Frailty 168 7.2 ±2.6 <0.001 2.4 ±1.1 0.007COPD = chronic obstructive pulmonary disease. SD = standard deviation.

these health problems, the higher thenumber of family members who had them,the lower the FFSS score (data not shown).

DISCUSSIONSummaryFamily characteristics can increase the riskof adverse outcomes related to diseases orprovide protection from them. This studyfound a statistically and clinically significantassociation between the family functioningstyle and the presence of physical, mental,and psychosocial problems. Thisrelationship was particularly important formental health problems, such as alcoholand drug abuse, major depression, andbehavioural problems in children. Aninverse correlation between the number ofhealth problems and family members whoare affected by illnesses and conditions thatare highly prevalent in primary care wasobserved, and the FFSS score; thisconfirmed the study hypotheses.

Strengths and limitationsThis study has important limitations thatshould benoted. The cross-sectional naturelimits the temporal association betweenfamily functioning style and healthproblems. As discussed, this relationship

might be reciprocal, but longitudinal followup and analysis that considers the changesin the family functioning style across timecould contribute to a better understandingof this association; this shouldbeaddressedin further studies.The questionnaires were self-reported

surveys, and the health informationprovided by the chosen family member wasnot confirmed. It is possible, therefore, thatthehealth problems in the family could havebeen over- or underestimated by the surveyresponders. As self-reported surveys tendto underestimate the prevalence of mentalhealth and chronic diseases,20–22 moreresearch is needed to ascertain familymembers’ diagnostic abilities in assessinghealth problems among other relatives.However, similar results3–8,11,12,14,20,23–30 andpathophysiological pathways7,8,31–38 supportthe findings of this study.As underserved Chilean families were

assessed, it is possible that these resultscannot be transferred to other populations;additional research is needed to assess therelationship between family and health inprimary care. In spite of this limitation, giventhat the family is valuedworldwide,39 similarresults could be expected in differentcountries or cultures.

Comparison with existing literatureThe results are similar to those of previousstudies that have been conducted but that,for the most part, were undertaken inspecialist secondary care clinics. Familyfunctioning style has been related to thecontrol of multiple chronic and mentalhealth diseases — evidence supports thisassociation for: hypertension;20 diabetes;23asthma;11,12 obesity;24 delayed childdevelopment;25 ADHD;3 mood and anxietydisorders;4–6 sphincter-control disorders;26tobacco, alcohol, and drug abuse;7,8,27,28dementia;14 and health problems in olderpeople.29,30 However, this is the first study toassess the relationship of the family andmultiple diseases across the lifespan in alarge-scale community setting. The strongassociation between family functioning styleand health problems found in this studyreveals the importance of families in health.This supports theneed for primary care thatis family oriented, as well as theundertaking of further research in thissetting to assess its impact on clinical care.Multiple pathophysiological pathways

explain these findings. Families with betterlifestyle behaviours appear to have healthierfamilies: this study’s findings showed thatfamilies with fewer smokers and fewerindividuals who misuse drugs and alcohol


0 1 2 3 4 5 6 7 8 9 ≥10

Number of health problems per family

100

90

80

70

60Fam

ilyFu

ncti

oni

ngS

tyle

Sca

lesc

ore

172

100

844

19724

571

412

289

154

86 24

Figure 1. FFSS score (range 22–110) and the numberof health problems, by family.

0 1–3 ≥19

Number of health problems per individual family member

100

90

80

70

60Fam

ilyFu

ncti

oni

ngS

tyle

Sca

lesc

ore

4–6 7–9 10–12 13–15 16–18

786

852105

724

1580

357

167

67

Figure 2. FFSS score (range 22–110) and number ofhealth problems, by individual familymember.

Figures given on each bar of the chart indicate the number of families.

Figures given on each bar of the chart indicate the number of families.


have higher FFSS scores. Other studieshave resulted in similar findings,demonstrating that the family environmentand attachment reduce the incidence ofsmoking among adolescents,31,32 and thatmarital dissatisfaction and distress cancontribute to the development of alcoholand substance disorders.7,8Individuals in families experiencing stress

face activating the neuroendocrine system(hypothalamic-pituitary-adrenal axis),which modifies their metabolic andimmunological response.33,34 Higher levelsof cortisol and sympathetic nervous systemactivation could explain the elevated rates ofmental, respiratory, cardiovascular, andnutritional disorders found in familieswith alow FFSS score.35–38 In addition, mentalhealth disorders have a reciprocalrelationship with the family functioningstyle. Families, in which there arememberswith psychiatric conditions are susceptibleto experiencing relational problems.7 Thiscan also explain the lower FFSS score infamilies that have a member who hasbehavioural problems, sphincter-controldisorders, anxiety, mood disorders, isviolent towards the family, or misusessubstances.Multiple family characteristics have been

related to good or poor health. Familycloseness, caregiver coping skills, mutuallysupportive relationships, clear familyorganisation, and direct communicationabout the illness and its management havebeen linked to better clinical outcomes andhave been identified as family protectivefactors. However, other familycharacteristics, such as intrafamily conflict,criticism, blaming, lack of an external-family support system, rigidity, and the pre-illness psychopathology of patients andfamilymembers, are associatedwith poorerclinical outcomes; these are identified asfamily risk factors.15The FFSS scale assesses seven factors:

family agreement, cohesion, family support,problem-solving strategies, commitment,internal resources, and strengths. As theaim of this study was to evaluate therelationship of family functioning style withdifferent diseases in primary care, separateanalyses of how the different familydescriptors relate to the different healthconditions were not performed, but familyagreement and family support were higherin healthy families compared with those inwhom at least one family member had astudied condition. Research in this area isneeded to understand which familycharacteristics are associated withparticular diseases and their outcomes in

order to develop disease-specific familyinterventions to improve clinicalmanagement.

Implications for research and practiceBehavioural and preventive research iscurrently directed towards individuals andhas assessed outcomes only among thosewho are ill, ignoring the effects of clinicalinterventions on other family members. Inaddition, most interventions are directedtowards particular diseases, overlookingthe possible impacts on other similarconditions that affect the whole family. As aresult of this, family-oriented interventionscould be particularly useful in primary care,where health providers offer services inresponse to highly prevalent healthproblems and serve many family membersliving in the same household.Interventions directed at families can

affect several persons at the same time;they can also have an impact at differentstages of a disease (risk factor,asymptomatic or symptomatic illness, andrehabilitation), and when multiple illnessesaffect different family members.40Moreover, if transgenerational effects aretaken into account, the possible benefits ofthese interventions could be achieved in theshort, medium, or long term. Alongside allof these possible benefits is the fact thatfamily-focused interventions need not becostly, require advanced technology, orimply important adverse effects; inaddition, because most people praise theinstrumental, educational, and emotionalsupport of family members,38 this kind ofcare orientation could be easily accepted.As such, a family approach in preventiveand behavioural care has the potential to beculturally sensitive, economicallysustainable, and easy to practiseworldwide.Clinical trials and systematic reviews of

family-oriented clinical interventions haverevealed that, even though research in thisarea is limited, positive results can beachieved, thereby improving on theoutcomes of the care that is usuallyprovided to patients with multiple chronicdiseases.1,2,19In summary, this study showed that

family functioning style is significantlyrelated to physical, mental, andpsychosocial health problems, and thatclustering of health problems is related tolower levels of family support. This studyprovides the basis for further researchexamining the family as an eventual targetfor preventive and clinical careinterventions.

FundingThis studywas funded by theDepartment ofFamily Medicine, Pontificia UniversidadCatólica de Chile, Santiago, Chile.

Ethical approvalThe use of the registration records ofpatients was reviewed and approved by theEthics Review Board of the School ofMedicine of the Pontificia UniversidadCatólica de Chile (10-029, April 2010).

ProvenanceFreely submitted; externally peer reviewed.

Competing interestsThe authors have stated that there arenone.

Ethics committeeEthical approval was granted by the EthicsReview Board of the School of Medicine ofthe Pontificia Universidad Católica de Chile(approval number: 10–029, April 6, 2010).

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