Family Health Development: A Theoretical Framework

The authors of the current article propose an integrative framework of family health development. Our model serves as a heuristic framework for analyzing the dynamic interactions between individuals, family relationships, and environmental factors that influence health trajectories. In this article, we first describe the 3 time-related dimensions: individual development, intergenerational transmission, and population-level cohort change. These dimensions cut across each of 4 overlapping and interrelated domains of family functioning: structure, processes, cognitions, and behaviors, which we subsequently describe. We conceptualize family health development (FHD) based on Sen and Nussbaum’s capability approach that emphasizes interactions between individual and family capacities and extrafamilial opportunities and resources. This conceptualization contrasts with the idea that family health is determined exclusively via individual or family characteristics (eg, motivation, lifestyle behaviors).¹²  The current article provides a preliminary overview of the FHD model. In future work, we will describe the important ways that family culture and social determinants of health influence the architecture of opportunities and resources within which families operate. Finally, we describe potential applications of our model for the field.

Our model centers around 4 domains of family functioning. The influence of family functioning on health occurs in 2 broadly different ways. First, an overall sense of family cohesion provides emotional security that affects family members’ mental health, motivation to engage in health behaviors, and consequently physical health. Overall, family cohesion generally enhances the health of all family members. Second, family members provide specific, individually tailored supports to members, such as emotional and physical care, teaching and support for health behaviors, and facilitation of medical care and services. Providing these individual-targeted supports require resources, time, physical or emotional energy, and money. Consequently, families are frequently required to make choices about where to focus resources, which implies that families must make decisions at times to balance needs by limiting the extent of support to 1 member to provide support to others’ needs. This is most starkly revealed perhaps when 1 member has acute or chronic health conditions that require a high level of resources. For example, parents with a child with a developmental disability, such as autism, may need to decide whether to provide as many services and support to 1 member as possible, or to limit the extent of such support to maintain resources for other children as well as to maintain an overall level of family cohesion. Sibling competition for resources has been well studied among animals, and to a lesser extent among humans; but such processes can occur between all family members.

Our model considers change in individual and family level health¹³  along 3 dimensions of time.¹⁴  First, ontogenetic time marks how individuals and families develop over time and is often the focus of developmental research and life span studies. The LCHD theory focuses on early development as it unfolds through childhood, adolescence, and young adulthood. Second, generational time acknowledges that health develops intergenerationally within families.^15,16  Research shows that parents’ health behaviors, especially those valued and reinforced with the family, as well as patterns of health care utilization, are likely to be adopted by children.^17,18  Third, historic time informs our understanding of families as proximal contexts for change across cohorts.¹⁹  Family configurations shift over decades, affecting family organization and dynamics, and therefore health. Relevant historical trends include declining marriage rates and increasing rates of nonmarital births, smaller families, and working mothers.²⁰  Historic events, such as the COVID-19 pandemic or the drinking water crisis in Flint, Michigan, may have differential impacts on the health of cohorts within the same household. Government policies and broad social changes also shape family health across historic time. Civil rights programs to promote integrated education; mandatory seat belt laws; or the introduction of the Affordable Care Act differentially impact the health of individuals across birth cohorts.²¹  All 3 of these time dimensions are present in each of the 4 domains of family functioning, described below.

We view the 4 domains of structure, process, cognitions, and behaviors as useful and distinct conceptual categories, but recognize that in reality there are no sharp distinctions in the dynamic interplay of elements that constitute family health development. We also recognize that this model may be refined for different purposes, adapted for different cultures or family forms, and adjusted over time.

Family structure encompasses family composition, and roles and responsibilities. These structural factors, which themselves change over historical time, affect many family dynamics, such as decision making, and thus have important implications for family health development.

Family composition is a dynamic and fluid construct. Family can refer to a nuclear parent-child family, the set of family members living in a household, or family members across households (extended family). Family members are often, but not always, defined by shared genes or biology, shared households, long-term committed relationships, mutual obligations, exchanges of support and caregiving, and emotional ties. Practically speaking, membership in a family is self-defined, sometimes contentious.

Changes in family composition and family health are bidirectional.²²  Family composition shifts in response to illness, relationship dissolution, death, and health conditions within the family.²³  Research has examined the effects of single- versus dual-parent households, marital versus cohabiting relations, number of siblings, presence of grandparents, and other compositional elements on parent and children’s development and health.²⁴  The influence of family composition on well-being and health varies, depending on cultural, ethnic, and racial background.²⁵ 

Families are structured by the division and sharing of roles and responsibilities, such as caregiving, resource generation, and decision making, all of which have implications for family members’ health. These roles and responsibilities normatively shift over time as young children age into adolescence and adulthood, and not only take on more responsibilities for their own health, but may also assume caregiving, resource generation, or decision-making roles vis-a-vis older parents. Moreover, like all family elements, the articulation of roles and responsibilities are grounded in the transaction between cultural backgrounds as well as changing institutional and cultural contexts. The institutional and cultural context of healthcare settings influences families’ choices regarding children’s and parents’ roles. For example, adopting the role of “language broker” for older members of immigrant families has negative health implications for some children’s physical health development, depending on overall levels of stress or burden.^23,24  Families may also create and pass down roles for “health leaders” who manage health care for hereditary disorders across generations.

Common family caregiving relations consist of 1 or more caregivers caring for a child, spouses or partners exchanging mutual care, a child caring for a sibling, or an adult child caring for a parent. In the prototypical example of a parent caring for a child, parents provide affection and support critical for health development. They also model, direct, and teach children about healthy routines, preventive behaviors, and help-seeking. These caregiving roles change over time. Caregivers for family members, regardless of the age of the care-receiver (eg, child, adult, or older adult), may experience satisfaction and fulfillment in the role, as well as burden, role overload, and chronic stress which have consequences for mental and physical health.^26–28 

An important subset of family roles consists of interfacing with the outside world and filtering external influences on children. Here too there are bidirectional relationships between work and family members’ health. On the 1 hand, health conditions may limit employment (or necessitate continued employment to maintain health insurance). On the other hand, responsibilities within and outside the family may compete for time and energy, ie, work-family conflict, potentially leading to stress and health difficulties. For example, along with stress, individuals experiencing work-family conflict report less physical activity and more consumption of foods high in fat.^29,30  In addition to work, adult family members interface with the educational and medical systems on behalf of children and each other, which can also lead to higher levels of stress for individuals when demands are high (eg, managing complex health problems, addressing special education needs).

Family processes are ongoing and repeatedly deployed strategies that families use to achieve goals,³¹  such as family decision making, communication, and conflict, among others. We note that family processes consist of patterns of behaviors and can contribute to family structure. We distinguish between processes and behaviors by viewing processes as serving a general function for families, whereas behaviors are more discrete and more explicitly health related.

Families’ decision-making processes inform how a family manages healthcare decisions, including preventive care and treatment of disease or injury, and management of chronic conditions and health behaviors. Family systems clinicians and scholars have referred to the parental figures in the family as the “executive” subsystem, responsible for decision making, leading, and rule setting.^32,33  Tensions over the locus of decision making can emerge, such as when adolescents seek greater autonomy over personal choices and responsibilities. Family diversity in this area includes, at 1 end, authoritarian decision-making with potentially little regard for partner or child needs; and at the other, to unstructured decision making in which decisions may come about haphazardly or as the result of competition among family members.³⁴ 

High quality communication skills support expression of needs and desires without blame and criticism, facilitating productive problem solving and decision making. A review of existing studies related to adults’ chronic illnesses concluded that high-quality communication predicts better physiologic control of illness and improved patient survival. For example, open discussion of the illness, attentiveness, support for patient autonomy, and family cohesion predicted better disease management, quality of life, and survival; whereas criticism, high levels of structure and control, overprotection, and unresolved disease-related conflicts were related to worse health outcomes and mortality.³⁵ 

Poor communication skills and negative communication styles lead families from disagreement toward hostile conflict, including communication tactics such as blaming and criticism. The dynamics of family negativity, including hostile conflict and harsh, punitive treatment,³⁶  is an important area of active research. Negativity, both within an episode and over time, tends to spill over into other family “subsystems” (relationships or configurations) as stress and negative emotional arousal (anger, fear, resentment) overcome an individual’s self-regulatory capacity, triggering or exacerbating negativity toward other family members.³⁷  Recent innovative work to understand how incidents unfold within families may lay the basis for more effective interventions targeting different patterns of negativity and spillover.³⁷ 

Hostile conflict can lead to physical violence within the family, a substantially more widespread public health problem than typically acknowledged.^38,39  Family violence is particularly common in families with young children; roughly 90% of parents with a 3- to 8-year old child report past-year parent-child physical aggression and 50% report parent-parent physical aggression (13% and 24% of parents, respectively, report severe aggression).⁴⁰  These high rates are likely due to a range of factors, including the daily stress of caring for young children under conditions of time or resource scarcity. Physical violence tends to increase with levels of family-member stress, whether due to intrafamilial factors (eg, caregiving burden due to disabilities) or extrafamilial social-economic events⁴¹  and conditions (eg, poverty).

Children’s exposure to dysregulated, hostile, or repeated family conflict has particularly noxious implications for health, even in utero; among pregnant women, the stress and mood disruption that may accompany family conflict has negative consequences for fetal development, birth outcomes, and infant development.⁴²  During childhood, exposure to conflict threatens children’s emotional security and triggers children’s stress-related physiologic arousal,⁴³  as children often interpret hostile interparental conflict as signaling instability in the family structure and a lack of safety.⁴⁴  The combination of stress, insecurity, and maladaptive regulatory and behavior patterns may trigger or exacerbate physical, mental, and behavioral health problems. For example, for parents of children with autism, accessing and managing services and daily parenting tasks may be highly stressful, leading to increased interparental conflict. Such conflict, exacerbates stress and negative moods, which in turn undermines consistent, warm parenting and reduces parents’ abilities to access services for children.⁴⁵ 

Emotional warmth, support, and family cohesion promote family members’ positive mood, coping capacity, emotional and behavioral regulation. Such positive dimensions of family life are associated with better family member self-care, including lifestyle, preventive, and help-seeking behaviors. Individuals who are socially isolated or experience negative family relations may have reduced motivation or reinforcement for self-care behaviors.

A central family process is providing care for children, elderly parents, or other family members. An important aspect of caring for children is socialization, preparing children to live meaningful and healthy lives in their social context. The socialization of children includes modeling and teaching children health-promoting attitudes and behaviors. Parents socialize children through routines for sleep and meals, and in more conscious ways around preventative health behaviors (eg, nutrition, sunscreen, seatbelts, or dental care), as well as in attitudes, help-seeking, and treatment adherence. Caregiving may also include ill, disabled, or elderly family members; ongoing caregiving responsibilities can be experienced as burdensome and contribute to role overload and diminished mental and physical health.^26,28 

Family cognitions are integral components of family health. A large body of research describes and investigates constructs associated with how families think and feel regarding themselves in their family roles, identities, and relationships. Critical influences on family health development include family members’: (1) perceptions of self and others; (2) health knowledge, literacy, and attributions; and (3) health-related values, goals, and priorities.

Most of the previous research related to this domain has focused on parents and caregivers, specifically the ways in which parents think and feel regarding the parenting role, their child, and the parent-child relationship. Although parental cognitions are central to family health, they are linked with, and dynamically shaped by, those of other members in the family, including children.⁴⁶ 

Family members’ perceptions of themselves and those around them have important implications for family health. For example, perceived sense of competence and self-efficacy, the degree to which individuals see themselves as capable in general or on specific tasks,^47,48 are linked with health-promoting behaviors and important targets for prevention-focused interventions across the lifespan.^49,50  Perceived locus of control over health or illness is a critical predictor of psychological well-being and distress in families.⁵¹ 

Perceptions emerge in childhood and continue to play an important role across the life course. Children with higher levels of self-efficacy engage in more health-promoting behaviors.^52,53  Among young adults, self-efficacy significantly predicts level of engagement in a health-promoting lifestyle behaviors.²  In parenthood, sense of competence as a parent has been linked with supportive parenting behaviors, mental health, and overall parent-child relationship^49,54  and may buffer the effects of maternal depression on children’s outcomes.⁵⁵  Health-related perceptions are also intergenerationally transmitted within families, in part via supportive or critical parental feedback in childhood, adolescence, and adulthood.⁵⁶  For example, college students’ experiences of parental criticism related to eating, weight loss, and appearance, particularly for daughters, shape their own self-perceptions.⁵⁷  Such self-perceptions also appear to demonstrate patterns of change across cohorts. A review of research between 1960 and 2002 found that individual locus of control may be increasingly based on external, rather than internal, factors. This has important implications given linkages between locus of control and, for example, school achievement, feelings of helplessness, self-regulatory capacity, and depression.⁵⁸  Trauma at the family or community level may impact health-related perceptions of future generations.^59–61 

Heath knowledge (ie, accurately identifying factors that promote or detract from health) and literacy (ie, capacities that promote success in health settings, including selecting, understanding, and accessing appropriate treatments and services) have important implications for family health and quality of life. Parents with low health literacy enact behaviors that are less positive for their children's health, leading to worse child health outcomes, compared with parents with higher health literacy.⁶²  These findings are exemplified in research studies that find, for example, that parents’ estimations of children’s ideal portion sizes are more predictive of children’s health than children’s own estimations.^63,64 

Knowledge and literacy are linked with health-related attributions (ie, causal beliefs and explanations about health, development, and health care), with implications for FHD.⁶⁵  For example, parents’ concepts of development, beliefs regarding developmental timetables, the importance that parents attach to certain developmental milestones and ideas about child-rearing,⁶⁶  shape parenting practices and behaviors. Additional salient attributions include attributions about one’s responsibilities as patients in the health care system and causal beliefs about disorders and illnesses.^55,56 

Health literacy, knowledge, and beliefs are cultivated early in development. Children who accurately identify the relative health of foods and activities are more likely to be able to select foods and activities that promote their body's health.⁶⁷  Further, children as young as 5 are able to demonstrate implicit associations between stress and illness.²⁵  Bidirectional and longitudinal links exist between health-related attributions, coping, and health functioning among parents and their children.⁶⁸  Among parents of adolescents with chronic illnesses, parents who redefine stressors as potentially beneficial (eg, as opportunities for growth) are more likely to have adolescent children who make the same attributions.⁶⁹  Further, there appears to be reciprocal influence in attributions about health care providers, particularly trust or distrust in physicians, between parents and children.⁷⁰  Cohort effects in health literacy may stem from a range of factors, including experiences in both formal education and informal learning opportunities, social media, healthcare access, living environment, and health behaviors.⁷¹ 

Family health values, goals, and priorities are important components of family health cognitions⁷²  because they shape families’ health decisions, engagement, and willingness to invest resources in health treatments or services.⁷³  Generally speaking, a high value placed on health is associated with positive changes in health practices, even after controlling for socioeconomic and health status.⁷⁴  In addition to prioritizing health in general, a range of health-related values, including self-sufficiency, life enjoyment, connectedness and legacy, balancing quality and length of life, and engagement in care, are linked to positive health outcomes.⁷²  Although values are often passed down from 1 generation to the next, intergenerational transmission of health values can occur in both directions between parents and children.⁷⁵  Further, historical change leads to differences in health beliefs across age cohorts, which may correspond to differences in treatment adherence.

Behaviors are the most concrete, visible aspects of family functioning. Through behaviors, family structure, processes, and cognitions are expressed. We distinguish here between 3 main categories of health-related behaviors: lifestyle behaviors, specific preventive and promotive (ie, optimizing) health behaviors, and help-seeking.

Lifestyle behaviors are daily routines and periodic self-care behaviors addressing physical and emotional needs, including exercise, nutrition, sleep, and stress-management. Research indicates that parents’ health-related lifestyle behaviors are linked with those of their children.⁷⁶  There are a range of mechanisms underlying these linkages, including modeling and socialization practices; promoting health-seeking or treatment behaviors; and/or providing access, opportunities, and resources for a range of health behaviors.⁷⁷ 

As an example, in the past decade, the prominence of lifestyle behaviors within clinical practice and research has grown with the recognition of the link between obesity, diabetes, and mortality. Access issues are critical for healthy nutritious food, but within each household’s local context and limited by their resources (eg, money, time), 1 or more family members typically select, prepare, and serve food. In addition to the quality of nutrition, the social routines of family meals are important influences on the development of children’s eating habits, self-regulation, obesity, and general health.⁷⁸  Regular family meals give adults the opportunity to model self-regulation and healthy eating habits and provide a context for communication and the development of family cohesion. Although mealtimes may be marked by conflict or isolating behaviors (eg, TV watching, phone use), in general, family meal routines are linked with better health and emotional well-being.^79–81  Similarly, within the local context and limited by family resources, caregivers typically guide or organize family recreation and, in earlier childhood, physical activity. The organization of recreational time has changed over the past decades, especially among middle and/or upper-class households, where parent involvement and encouragement of organized activities and leagues have crowded out children’s free time that involved playing outside with peers.

The importance of family health behaviors further extends into other areas of health, including sleep. As with nutrition and physical activity, caregivers typically guide children’s early sleep behaviors, and across development stages provide an ongoing context of routines that shape sleep patterns. Emerging research has examined the organization and patterns of family sleep arrangements, beginning with parents’ decisions regarding where infants and children sleep; who puts children to bed and how; and who responds to night waking and how. Caregivers continue to influence children’s sleep through the provision of a calm household environment (see research on household chaos⁸² ) and the establishment of regular evening and bedtime routines. Inexpensive video entertainment, initially TVs in children’s rooms and presently addictive social media and games, has tended to disrupt parent control and guidance in this area and contributed to children’s poor sleep.

Substance use is also reciprocally linked with family dynamics and child health and development.^83,84  Despite large reductions in prevalence over the past decades, tobacco use continues to be the leading cause of preventable death in the United States.⁸⁵  Parents who smoke tend to have children who do, and both general parenting practices and smoking-specific discussion and punishment have been found to be related to adolescent smoking.⁸⁶  As with tobacco use, parent permissiveness around children’s drinking is associated with higher rates of use; and parent monitoring and establishing clear expectations minimizes adolescent drinking behaviors. Parental influence over substance use may even extend into late adolescence and early adulthood, as parent-focused intervention can reduce offspring alcohol use during college years. Siblings, especially older siblings, can also contribute to substance use onset by providing access to substances and opportunities for experimentation. The development and diffusion of substance use in early adolescent school-based cohorts begins with early starter youth who are often introduced to experimentation and provided substances by older siblings. These early-starting younger siblings then begin diffusion processes by transmitting substance use behaviors to close friends.⁸⁷ 

In addition to these lifestyle behaviors, families are also the most proximal context for children’s development of positive attitudes toward and adoption of preventive health behaviors, such as tooth brushing, using seatbelts, or wearing a bicycle helmet. Parents also model and influence children’s lifelong attitudes toward health providers, influencing choices across the life course around the adoption and implementation of preventative health recommendations.⁷⁷ 

Finally, parents influence children’s future behaviors around addressing injuries and illnesses. At home, parents model self-treatment behaviors, including the use of pain killers, response to illness, and self-treatment of minor cuts and sprains. Similarly, parents influence children’s help-seeking when health conditions arise, including whether parents seek out medical care, alternative health treatments (acupuncture, massage, herbal supplements), professional mental health care, or culturally based healers or religious leaders.

The usefulness of the FHD model lies in fostering a systematic way to think about the proximal environment, the family, which shapes much of the health opportunities and risks experienced over a lifetime. In Table 1, we have listed examples of family-related factors in the FHD affected by a recent public health crisis, the COVID-19 pandemic, and the related disruptions on family member health. We have first presented several factors related to the 3 “time clocks” discussed above. We then present a range of other factors by domain of family functioning. The result is a brief list of relevant risk and protective factors that are potential targets for preventive or clinical intervention. For example, divorced parents confronted challenges in managing pandemic health restrictions across households (structure); family conflict undermines sustained implementation of protective behaviors (process); family transmission of fatalistic attitudes leads to low expectations for and hence low levels of implementation of protective behaviors (cognitions); and increased substance use during the pandemic may have led to increased family violence (behaviors).

One can see from the list of factors in Table 1 that difficult decisions must be made about where to focus resources targeting risk and protective factors. Selection of targets is a complex subject, but briefly, the questions to consider in selecting an intervention target include: Is the target a strategic choice in that it is (or may be, awaiting experimental confirmation in a trial) a causal influence on other factors? How much harm or benefit can be realized due to this factor (across people, across health conditions, over time)? How malleable is this factor to change? What material and time resources are required to achieve what size change or impact? Could this be implemented at scale with sustained fidelity?

In Table 2, we present examples of factors relevant to the development of obesity risk in the family setting. By fleshing out the factors involved in a health condition with this framework, one can provide a cohesive approach to providing preventive, anticipatory, or treatment intervention. In the clinical practice setting, this framework can be used to help understand key aspects of a family’s functioning that are affecting the current or potential future health of a patient. One can use this model to facilitate discussions with patients about family health-related factors either explicitly or implicitly. In deciding where to focus, similar questions can be assessed such as the degree of risk associated with various factors in a particular family, malleability, and availability of resources to support and sustain change.

In this article, we described an integrative conceptual model of FHD within a LCHD lens. We provided an organizing, heuristic model for understanding the dynamic interactions between family structures, processes, cognitions, and behaviors across individual and population-level health trajectories. This framework can help disentangle and organize the proximal family dynamics reciprocally involved in LCHD, fostering greater understanding of how family dynamics get under the skin, in terms of health.⁸⁸  This framework can also prompt scholars and clinicians to consider family factors that might be neglected in the prevention or treatment of specific health conditions. Our hope is that this model facilitates the development of new, strategic health-promoting interventions targeting key family factors. In future work, we will describe how our family model intersects with cultural and social determinants of health via nested social and institutional environments, promoting deeper and broader understanding of life-course trajectories and expanding possibilities for promoting health and well-being of all family members across the life-course.

FHD

family health development