The Family in Health and Disease

• What is Family Medicine?
• Who is a Family Physician?
• What are the Domains of Family Medicine?
• Why Family Medicine?

Family Medicine is the medical specialty that provides continuing and comprehensive health care for the individual, in a holistic manner within the context of his family and environment. It encompasses all ages, both sexes, and every disease entity, integrating biological, clinical, and behavioral science.

WONCA

Who is a Family Physician?

• One educated and trained in the discipline of family medicine.
• Has peculiar attributes and requisite competencies to provide continuing and comprehensive medical care, health maintenance, and preventive services to members of a family irrespective of gender, age, or disease (i.e., biological, behavioral, or social).
• He is a front line doctor/first contact doctor.
• Health system gatekeeper.
• Primary care physician.
• Provides continuing, comprehensive care to the undifferentiated patient from cradle to grave.
• He is the WHO five-star doctor (Care provider, Decision-maker, Communicator, Community leader & resource Manager).
• Up to 7 stars now - team player and researcher.

Society, community,culture,nation etc ↔ Family, communication (family is a biological system) ↔ Person ↔ Organ systems ↔ Tissues ↔ Cells Molecules

Why Family Medicine?

• Medical Specialization and overspecialization
• Fragmenting of health care
• High cost of health care out of reach of the poor
• Increasing interest in ‘outside hospital care
• Epidemiological transitions/changing diseases
• WHO recognition of the importance of Primary Care (1978 Alma-Ata conference)

• FM is best understood in terms of Systems Theory which posits that;
• All natural entities and phenomena can be organized into specific systems that share common properties.
• Systems theory holds that each level in the hierarchy of systems is semi-autonomous yet dependent on levels above (suprasystem) and below (sub-system), that is, levels are interdependent and influence each other both positively and negatively.
• The Supra-systems;
• Above the family is a biosphere that includes the society, community, culture, nation, etc.
• The sub-system;
• Includes the person/personality, organs/viscera, cells, molecules, genes, etc. that provoke a disturbance in the homeostatic process of the individual.
• Can also be explained as;
• Micro (internal) system (physiology/pathology/anatomy/biochem)
• Macro (external) system (family/society/occupation/culture/religion)
• Sys theory highlights non-reductionism

System vs Reductionist/Molecular Theory

• System viewpoint emphasizes that the whole, the combination, and inter-relationships of parts provide the greatest insight (Holistic/biopsychosocial approach).
• Whereas in the reductionist approach, the individual part is the level of analysis.
• In reductionism (molecular theory), everything is explained by molecular biology (Biomedical).
• To understand a phenomenon, we must recognize that 'the whole is greater than the sum of the parts.'

Comparison:

• A biomedical focus concentrates on pathological changes in cells, organs, and physiological systems while a holistic practice has a wider lens that includes the whole person and family.

Systems Theory:

• Systems theory holds that each level in the hierarchy of systems is semi-autonomous yet dependent on levels above and below, that is, levels are interdependent and influence each other both positively and negatively.
• Understanding the impact of these 'systems' on each individual patient's illness and disease experience and vice versa constitutes an important strength of family medical care when compared to other medical specialties.
• Family medical practice, therefore, adopts holistic care of the patient from cradle to the grave (HOLISTIC MEDICINE).
• BIO-PSYCHO-SOCIAL care as against BIO-MEDICAL care.

What is a Family?

• A family is defined in the context of the index patient.
• 'As a group of individuals connected to a patient biologically, legally, or by choice from whom the patient reasonably expects a measure of support in the form of food, shelter, clothing, finance, and emotional nurturing.'
• Family is the unit of care in family medicine.
• Family has both structure and functions.

Family Structure

1. Nuclear: a couple and their children residing in one home.
2. Extended: aka three-generation family consisting of grandparents, their children, and grandchildren.
3. Single parent: aka lone or open-parent family. Consists of a parent with one or more children in a home.
4. Reconstituted family: one or both parents have been married before and bring with them children from previous marriage(s).

Basic Functions of the Family

1. Physical maintenance and care of family members; provides shelter, clothing, food, and health care.
2. Addition of new members through adoption or procreation;
3. Socialization of children; guides development of mature and acceptable patterns of socially acceptable behavior (e.g., eating, elimination, sleeping, sexuality, aggression, and interaction with others).
4. Social control of its members;
5. Production, consumption, and distribution of goods and services.
6. Division of labor; decide who will assume what responsibilities, e.g., providing income, managing household tasks, maintaining the home, and caring for young, old, or incapacitated family members, and other designated tasks.
7. Affective nurturance (love).

Family Dynamics

• Family dynamics are the interactions between family members as well as the varying relationships that can exist within a family.
• Varies from family to family and changes from time to time as members grow - it is not static.
• Family has basic functions to her members and to the larger society.
• Could be Functional or Dysfunctional.
• A Functional family is a family where a balance between the family functions is achieved (not over- or under-emphasized).
• Well-functioning families are flexible and able to adapt to challenges utilizing their own resources.
• A Dysfunctional family is one with chronic inability to respond to the needs or cope with changes and stresses in the environment.
• Dysfunctional families have difficulty adapting and mobilizing resources and break down easily.
• It is characterized by conflict, misbehavior, and neglect or abuse on a regular basis that members may even accept as normal (especially children).
• Relationships are tense with yelling and screaming, and there is no freedom for self-expression.
• ‘That the family influences the causation of disease and has a great impact on the rehabilitation of chronic disease.
• And it determines;
• Therapeutic success or failure (including medication compliance), as well as,
• Degree of mental health and illness.

The family also plays a major role in preventive and wellness aspects of healthcare.

Relationship between family and health is vice versa; disease process impacts negatively on the family and the family impacts positively or negatively on the disease process.

Can disease impact positively on the family?

Effects of Family on Health

1. The family generates, prevents, tolerates, or corrects health problems within its members.
2. Members share risk factors of diseases; they also share the positive factors contributing toward good health.
3. Many factors causing health problems abound in the family, such as genetic, behavioral/lifestyle factors, prolonged emotional stress, etc.
4. Diseases can also be transmitted within the family, such as HIV from mother to child, among partners, etc.
5. The burden of nursing a member with a chronic illness may impact on the health of other members (e.g., stroke, SCD patient, etc.).
6. Health-seeking behavior of individual members depends on the family.

Conversely, the strong positive bond and support in a functional family lend emotional, physical, financial support to a suffering member and thus facilitate treatment and recovery.

Mechanisms of How Family Affects Health

1. Genetics and Disease Susceptibility: Family effects through genetics are particularly strong. Although they can be moderated by environment and behavior, the effects are for a lifetime. For example, Sickle Cell Disease (SCD) and hemophilia are directly inherited from parents; others, like hypertension (HT) and diabetes mellitus (DM), are strongly mediated by family factors.
2. Prenatal and Perinatal Transmission of Disease: Generations of families have experienced prenatal or perinatal transmission of diseases ranging from syphilis to HIV infection. In many areas of the world, this family influence has charted the destiny of countless children.
3. Child Rearing and Nurturing: Family belief systems on child rearing and nurturing affect their health, e.g., the number of children to have, how to raise them, etc.
4. Nutrition and Lifestyle: Family traditions and socioeconomics play an important role in access to adequate nutrition. Many lifestyle behaviors, such as smoking, diet, exercise, and alcohol consumption, are influenced by parents and extended family and by their habits and beliefs.
5. Health Seeking Behavior: Family determines health seeking behavior of members.
6. Spread of Infectious Disease: Family living conditions and contacts are major influences on the spread of many infectious diseases like PTB. Also, families are important vectors in times of epidemics.
7. Outcomes in Acute and Chronic Illness: Studies have shown a strong relationship between the degree of family social support and illness outcomes. Also, family dysfunction can contribute to illness as well as adverse health outcomes.
• Family factors that have protective influence on health and illness include;
• Closeness and connectedness;
• Well-developed problem-focused coping skills;
• Clear organization and decision-making; and
• Direct communication.
• Family Pathologies that Can Adversely Influence Health and Illness
• Intra-family hostility,
• Criticism, and blame;
• Perfectionism and rigidity;
• Lack of extra family support systems; and
• The presence of chronic psychopathology.

Think Family

• The family system changes over time as its members grow older.
• ‘Thinking family” implies:
• Being aware of the challenges the family faces in adapting to these changes because any change in one part of the family system has a profound effect on the entire family. Examples include birth, death, marriage, divorce, disability, job loss, etc.
• Being aware of a physician’s responsibility for providing good information and being vigilant for communication blocks within a family.
• Being sensitive to the unmentioned family stresses behind depression and somatic symptoms like headaches, dyspepsia, or recurrent abdominal pain.
• Being aware of the effects on the family system of the physician’s own actions, e.g., admitting somebody to the hospital, making a serious diagnosis.
• Being aware of some ‘traps,’ e.g., being enlisted by one side of a family conflict, ethical dilemmas of disclosure of confidential info to other family members, etc.

Four Levels of Involvement with the Family

1. Minimal involvement.
2. The provision of information and advice. Entails communicating medical findings and treatment options to family members, listening attentively to their questions and concerns. No special skill/knowledge of family development or reactions to stressful experiences is required.
3. Understanding of the Affective Aspect of Family Relationship plus 1 & 2 above:
• At this level, the physician is able to provide emotional support, thus helping the family deal with the emotional stress of having a member with a serious chronic disease like cancer, schizophrenia, physical disability, etc.
• Knowledge of family development and how families react to stressful experiences is required.
• Good listening skills and responsiveness to the expression of subtle cues of emotional needs are also required.
4. Fourth Level: A systematic assessment of family function is carried out with an intervention plan designed to help the family deal with its problems.
• This may include reframing the family’s definition of the problem and how to cope.
• Practicing at this level requires knowledge of ‘System theory’ and skill to convene and perform ‘Family conferencing.

• The use of a specific family model provides a focus for the understanding of the family.
• Categorized according to their basic focus as
1. Developmental: e.g., Duvall’s and Stevenson’s family models
2. Interactional: e.g., Satir’s Interactional model
3. Structural-Functional: e.g., Friedman’s and Calgary’s family model
4. Systems: Family model e.g., Calgary’s Family model
• These models emphasize differently the various tasks faced by families depending on their stage, thereby assisting the family physician understand and manage the family better.
• We shall consider only the Duvall’s developmental family model at this level.

• Studies of illness in the community have revealed that physicians see only a small fraction of the health problems experienced by the population at large.
• Occurrence of symptoms is the norm rather than the exception as most people have symptoms but have learned to cope with them or self-manage their symptoms.
• Therefore, it is not whether symptoms are present or not, but how serious or frequent they are, and how they are acted on (seek professional help or not).

Definitions of Terms

• Illness: A state in which the physical, social, developmental, intellectual, emotional, or spiritual functioning of the individual is diminished or impaired. (Could be active or chronic illness).
• Sick Role: A form of behavior deemed appropriate to those perceived as being encumbered by illness.
• Illness Behavior: “The ways in which given symptoms may be differentially perceived, evaluated, and acted (or not acted) upon by different kinds of persons.” It is the behavior of those who have entered the ‘sick role’.

STAGES OF ILLNESS BEHAVIOUR

1. Symptoms experience
2. Assumption of the sick role
3. Medical care contact
4. Dependent patient role
5. Recovery and rehabilitation

Concepts of Sick Role and Illness Behavior in Decision to Consult a Physician

• The concepts of sick role and illness behavior are helpful in analyzing the decision to consult a physician.
• Introduced by Parsons (1951) and it says: ‘When a person has consulted a physician and been defined as sick, he or she occupies a special role in the society’ - The Sick role.
• Entering the sick role has certain obligations and privileges.
• Privileges:
• The sick person is exempt from normal social roles.
• The sick person is not responsible for their condition.
• Obligations:
• The sick person should try to get well.
• The sick person should seek technically competent help and cooperate with the medical professional.

• Beware of Abuse of the Sick Role for Secondary Gains:

Whether a person decides to enter the sick role when he or she becomes ill is dependent on many individual and group factors that are independent of the severity of the illness.

• Whether or not an individual will enter the sick role and consult a physician is determined by the illness behavior exhibited by him/her.

• Studies have shown that the same symptoms are perceived differently by different sufferers, affecting their sick role and illness behavior irrespective of disease severity. This, in turn, will affect their health-seeking behavior.
• Illness behavior is related to ethnic origin, social class, age, sex, nature of illness, religious affiliation, personality, and environmental factors.
• An understanding of illness behavior redefines the perspective of the physician.
• The key question may be “why did the patient come?”
• The aim of therapy may not be to remove the symptoms but to help the patient to live with them, as many others in the population have learned to do.

• In Family Medicine, patients are managed holistically using the bio-psycho-social approach in the context of the family and the environment.
• The family is the unit of care in Family Medicine.
• "The good physician will treat the disease, but the great physician will treat the patient." - Sir William Osler, M.D.