Michael D. Barnes, Professor of Public Health, Associate Dean, College of Life Sciences, Brigham Young University, 5011 Life Sciences Building, Deans Office, Provo, UT 84602-0002, USA. Email: ude.uyb@senrab_leahcim
Received 2019 Aug 24; Revised 2019 Dec 13; Accepted 2020 Apr 9. Copyright © The Author(s) 2020This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License (https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage).
Communities and populations are comprised of individuals and families who together affect the health of the community. The family unit is an unparalleled player for maintaining health and preventing disease for public health because members may support and nurture one another through life stages. Preliminary research confirms that family-oriented health promotion and disease prevention are promising strategies because the family unit is both a resource and a priority group needing preventative and curative services across the life course. Although there are growing numbers of successful efforts, family health systems are generally underutilized in health promotion practice. This lack of utilization in policy and practice have hampered the collection of robust evidence for family health. This paper purports that families are important actors in public health. Yet, since no one pattern for healthy families is known, public health practitioners can consider six principle-based approaches to legitimately and respectfully advance the families’ innate potential for health promotion and disease prevention. Each perspective aims to foster higher capacity for family health systems to function appropriately in public health practice. Health promotion practitioners and researchers can explore family health perspectives with the potential for systems policy and practice adjustments in public health.
Keywords: family health, settings of practice, family health system What do we already know about this topic?The family unit is an unparalleled player for maintaining health and preventing disease because members may support and nurture one another through life stages.
How does your research contribute to the field?This editorial asserts that families are important actors within public health and presents 6 specific perspectives aimed at fostering a higher capacity for family health systems to function appropriately in public health practice.
What are your research’s implications toward theory, practice, or policy? Public health can become trusted as a resource and partner with families or family members.Public health has been defined as “what we do together as a society to ensure the conditions in which everyone can be healthy.” 1 Families of all shapes and sizes form the basic societal units and are the foundational producers of individual and community health. 2 As such, health promotion has a responsibility to focus efforts on including families within strategic partnerships and public health programming. 3
Throughout the discipline of public health, we are seeing an increasing call to emphasize empowerment of the “public” in public health. 4,5 Public Health 3.0 supports this emphasis and suggests that “public health is what we do together as a society to ensure the conditions in which everyone can be healthy.” 1 These efforts call for greater public engagement in prevention and local decision-making designed to give individuals increased control over the conditions that determine health including those directly involving family relationships. Though not specifically prioritized in Public Health 3.0, the family is the foundational producer of individual and community health 2 and should be a focus for strategic partnerships and public health programming. 3
Some health promotion programming makes great efforts to consider families. However, because no clear US funding or policy structures prioritize families, it is difficult to maintain family-centered interests in health promotion interventions. 6 To legitimately and respectfully advance the innate potential for health promotion and disease prevention that may exist in most families, this paper presents 6 principle-based perspectives for health promotion practitioners to consider for engaging families. These perspectives are presented based on the notion that the family is an essential “actor” within the “public” of public health and, when approached as a partner, 1 families may facilitate better overall health outcomes for individuals and communities. 7 -9 These perspectives are based on consensus-built definitions of family (see Figure 1 ) 10 and family health (see Figure 2 ). 11 The perspectives are also rooted in family impact principles such as family engagement, family diversity, family stability, and family responsibility that are designed to facilitate consideration for how proposed and existing family policies and programs support or hinder families. 11,12
Family: a working definition.
Family health: a working definition.
The family unit is an unparalleled player for maintaining health and preventing disease for public health because members may support and nurture one another through life stages 13 and over time. 14 The family’s capacity to nurture, care, protect, teach, and influence throughout the life course makes it an effective entry point in the promotion and maintenance of individual and collective health and an important component for public health practice. 2,15 -17
Recent demographic shifts (e.g., a growing proportion of the population being older adults, an increasing number of multigenerational families, and more people living alone) necessitate a critical shift from a traditional public health focus on mothers and children to the larger context of the family. 18 -20 This shift is imperative because nearly all individuals are nested within families where each member is connected to and influenced by one another, as described by the family systems theory. This theory identifies families as cohesive units that functions as a system with its own set of rules and responsibilities. 21 Each member exerts a profound impact on the choices of another in the family, 21 the consequences of which can be carried through generations. 22,23 Such consequences are seen in social disparities, intergenerational poverty, even in the long-term physical and emotional impact of adverse childhood experiences also known as ACES. 24 Cheng 23 recommends preventing and breaking such intergenerational impact by focusing on the parents, children, and future offspring using the 3-generation approach. 23 Examples of health outcomes that would benefit from a family-based approach include genetic disorder testing for infants and children; suicide and substance misuse rates among adolescents and young adults; and noncommunicable diseases such as Alzheimer’s and dementia among adult men. Although great potential exists for utilizing the family in public health, an increasing variety of family configurations and an even wider variety of social determinants of health create challenges underscore the complexity and needs required by public health to embrace many unique family configurations with varying degrees of protective factors and risks. 20,25 -28
Framing family health for policy and funding decisions involves many factors. “Achieving the goal of Healthy People requires addressing the social determinants of health, which includes both social and physical environments where people are born, live, work and age.” 1 Framing the need for policy and funding action among decision makers often involves presenting the social benefits for improving family health by promoting proven policies such as (1) higher levels of educational attainment to grow family stability and strength or (2) increasing minimum wage so families can better flourish; (3) reinforcing healthy built environment and community safety for families to better thrive; (4) expanding Medicaid to better help provide economic relief or access to health services among poor families; (5) promoting family leave policies for employees with major life events such as child birth or caring for chronic family health needs; and (6) revisiting incarceration policies that foster family ties or favor a quicker reintegration into family responsibilities to reduce recidivism or enhance positive parental influence for family members back home. These examples illustrate that prevention efforts should consider the family at individual, social, and public levels. 29 In addition, presenting interdisciplinary findings from data with family implications is important. Such data are currently limited, but some sources exist. For example, the widely recognized research-driven Developmental Origins of Health and Disease (DOHaD) identifies a clear capacity to frame early life exposures on future health, and that health can be transmitted across generations. 30 Not only does DOHaD deserve additional funding and policy support, its results point to intergenerational and life-course implications and health promotion activities for family health. 30 Finally, framing should also consider experiences from other countries outside the United States who more readily embrace a commitment to family health. For example, local authorities within Ministry of Health systems in various countries regularly transfer best practices through United Nation’s No Family Left Behind initiative to support the 2030 Agenda for Sustainable Development. The most recent 2019 World Family Summit focused how family policy can be integrated across several sustainable development goals (SDGs). 31
Through these kinds of family-centered, social-determinant-based policies, health promotion may directly shape social and physical environments where family health outcomes can be enhanced. In an increasingly divisive political environment, incorporating family-centered ideals to key social policies may yield success to appeal to both liberal and conservative policy makers by promoting the value of family health.
Families may be unaware of the public health system and how it can help them reach their health and well-being goals. Once aware families may also be distrusting of public health services due to limited experience or other factors. 32 Gaining the confidence of a parent or any member of a family means (1) avoiding disparaging views of the family’s capacity, (2) resisting a conditional basis for partnering, (3) resisting a we-know-better approach, and (4) acknowledging the rights and privacy of families and their need for independence in carrying out their responsibilities. 11 This approach is important in the United States because many families highly value their independence and privacy, even among those with the greatest needs. 11 Public health practitioners must demonstrate their respect and value for each family’s capacities, human growth potential, and health decision-making. 33 Finally, unprecedented changes to family composition, structure, routines, and work prompt the need to be flexible for the health challenges families may face. 34,35 Demonstrating respect and optimism may also take the form of collaborative family health policies or supporting public health practices using a positive, resourceful, and relevant approach.
The self-determination theory explains the psychology behind the choices we make. It argues that intrinsic motivation plays a dominant role in personal choices. This means that when an individual’s basic psychological needs of competence, relatedness, and autonomy are met, deeper engagement and commitment are engendered, thus enhancing individual growth. 36 The public’s health is a product of individual and family choices, which in turn influence the health of the community. The application of the self-determination theory in public health entails nurturing the individual’s and the family’s capacity to make healthy choices while allowing them to retain control over their lives. Public health can help to facilitate family competence, autonomy, and resilience by helping trusted support persons mentor heads of households. 36 Families mentoring families is relevant because public health educators are rarely available or connected enough to be an ideal mentor for families, such as family health navigators. 37 Similar to success from community health workers and other peer mentoring programs (patient navigator, home visiting, positive deviants, and others), public health’s greatest capacity may be to help identify and support trusted mentors to have a positive impact where and when family members need them most. Trusted family mentors could be a trained family member, neighbor, coach/teacher, or known community gatekeepers. 38 They may offer basic skills and helpful resources to improve family health. For example, in one randomized controlled study of home visits by neighbor mentor mothers, the mentors were selected as “positive peer deviants” who were successfully trusted to navigate the family through a set of difficult odds based on their own family’s experience. 39 In this study, “mentor mothers” were trained to conduct home visits and to assist families through the barriers faced by the household. Child health outcomes improved because the highly trusted mentor bolstered the caregiver’s skills and capacities. These results illustrate that networks of trusted family mentors can be leveraged to authentically enhance important family-centered efforts while retaining control over their lives.
Children and young adults are most likely to model or carry forward their own family experiences or practices when they envision relationships and family choices for the future. 23 Throughout their development, children and young adults witness many types of households and from their observations they draw conclusions from which they may generalize for their own potential future family. We acknowledge that modeling one’s own family experience is not always a good thing. 40 Helping children, teens and young adults learn positive practices from their own families or others close to them is likely to be most valued, especially if such strengthening addresses one or more universally desired needs. Perhaps the first step is focusing on positive family practices. This notion may appear naïve; however, positive childhood experiences (counter-ACEs) were recently found to have a compensatory effect on early ACEs experienced in life. 12 Counter-ACEs, also known as positive childhood experiences, focus on building and modeling strengths to promote well-being such as fostering safe, stable, nurturing relationships that produce positive health impacts in later life. 41 One of the reasons positive experiences are important may be explained by its relationship to resilience. 12
Positive modeling of healthy practices may also include a family’s effort to replace poor food choices by making time to try new foods in various ways or promoting a gaming app for teens or children that involve interactions with family members (e.g., brushing teeth) to learn better attitudes about challenging behavior. 42 Although more community practice and research interventions need to be tested, there may be enough available that even most children can learn to recall and hold on to one or more positive family experiences so they are better prepared to make family decisions when they are older. The long-term public health impact for this perspective is important, particularly for their impact over the life course.
Family caregivers are not likely to see a list of best practices as being applicable to them. So called best practices are based on nonuniversal assumptions that are unlikely to generalize from one household to another based on family circumstances and context, needs, social consciousness, and interests. Rather, health promotion practitioners can regularly assess family members needs and involve them to solve their own problems using well-established community development models in public health (eg, community-based participatory research, etc). These efforts may yield identified needs that require public health to partner across disciplines and services not typically leveraged. Regardless, the preeminence of household leaders should be valued because they often have their family’s most significant interests at heart. They also know the problems that are most important to them. Working with family members through problem-solving, establishing assessments of need, and involvement in participatory-based efforts or models become clear opportunities for practitioners. For example, Harvard’s self-sufficiency intervention provides an outline of basic principles that are flexibly considered using parents who are supportively trained using a patient/health navigator-like model. 43 These trusted persons (i.e., parents, caregivers) seek to understand a given family’s barriers to poverty and self-sufficiency by learning the program’s key principles: family stability (housing/dependents), well-being (health and behavioral health), education and training (attainment), financial management (savings vs debt), and employment and career management (earning level). When public health both values the need for teaching family health while also flexibly supporting families through those teachings, success is more likely to occur. 42 Thus, health promotion practitioners should anticipate the transferal of family “teaching” but not in the form of universal best practices. Approached that way, practitioners will be in a position of greater respect and confidence due their recognition that key family members often have their family’s best interests at heart.
Communities and populations comprised of individuals and families together affect the health of the community. Families have major influence on health outcomes and are vital to the systems of every community. The family or household setting is the natural place where many health behaviors, good or bad, are developed, maintained, and changed. Preliminary research confirms that family-oriented health promotion and disease prevention are promising strategies because the family unit is both a resource and a priority group needing preventative and curative services across the life course. Although there are growing numbers of successful efforts, family health systems are generally underutilized in health promotion practice. This lack of utilization in policy and practice has hampered the collection of robust evidence for family health. This paper purports that families are important actors within health promotion practice and presents 6 specific perspectives aimed at fostering greater capacity for family health systems to function appropriately. These perspectives seek to increase public health effectiveness through positively framed family-oriented approaches. Each perspective supports health promotion practitioners and researchers to explore family health so that successful partnering and action can be meaningfully pursued while also bolstering family trust.
Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
ORCID iDs: Michael D. Barnes https://orcid.org/0000-0002-5734-4512
AliceAnn C. Crandall https://orcid.org/0000-0002-6547-1378
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