Cuban Medical Literature
Towards a New Conceptualization of Family-Group Health and its Conditioning Factors

Isabel Louro Bernal

ABSTRACT: Professional experiences in the teaching and research fields have produced important evidence regarding the need to clarify and set limits on the concept of family health. There are several definitions of family health which do not consider the family group as a unit of medical, psychological and social care in the community. This paper proposes a new theoretical conception of family-group health and its conditioning factors, which is useful for health professionals, including researchers, professors and administrators. The present paper outlines the theoretical foundations of the psycho-social approach underlying this conception. This proposal embodies the theoretical component of an evaluation model which has been designed to provide information for family health diagnosis in Primary Health Care. This paper is based on bibliographic review, debates with experts, and the results of research with Cuban families.

INTRODUCTION

The literature contains little theoretical description of family health. Nevertheless, it has frequently been addressed empirically by health and family welfare professionals.

For over a decade, international organizations have spoken in favor of strengthening and assisting family health, (1, 2, 3) acknowledging this social group’s influence upon health. Nevertheless, the concepts of family and family health are still not very clear.

The bibliographic review identified different meanings for the term “family health:” a public policy; a movement for developing health services; a field that groups people by age; or a specific intervention group.

The Pan American Health Organization defines family health as a prioritized programmatic field composed of: teenage and childhood health, healthy aging, reproductive and sexual health, safe pregnancy and maternal mortality reduction. (4)

Inherent in this vision of family health is a social understanding of health problems, recognizing the indivisibility of the mother-father-child group in the health intervention process. Health intervention with one member of this family unit requires contextualizing his or her living conditions to enable better understanding of biological effects.

When the family is the unit of analysis, the concept of individual health is often extended to that of the family, where a healthy family is distinguished from a sick family through clinical diagnosis. Family health, however, is a group concept.

WHO experts argued in 1978 that “the health of the family as a group determines and is determined by that family’s capacity to function effectively as a biosocial unit in a given culture and society.” (5)

Since then, the group dimension has been included in the concept of family health. This dimension depends on intra-family relationships and the conditions that favor effective functioning. It is also inferred that a “functional family” cannot be determined by adding up the states of health or illness of each one of the family members, as is sometimes erroneously concluded.

In 1985, Nina Horwitz published an article entitled Family and Family Health: An Approach to Primary Care, which laid important foundations regarding the concept of family health. In that paper, Horwitz considered family health as the adjustment or balance between internal and external elements in the family group, and not simply the sum of the members’ health. (6) Neither this definition, nor that given by the WHO, define effective functioning and its conditioning factors.

A 1996 research project on community diagnosis of family health in parts of Havana defined family health in terms of effective functioning and the ability to confront changes in the social environment and within the family group, facilitating individual growth and development in relation to the demands posed by each life stage. (7)

González Benitez argues that family health depends on the interaction between personal (psychological, biological, social) factors, factors operating within the family group (functionality, structure, family economy, stage in the life cycle, crisis handling), and sociological factors (community and society life styles). (8)

The methodological assessment group for family studies of the Ministry of Public Health in Cuba put forward a definition for the Family Health Intervention Manual which includes dynamic interaction in family functioning, material conditions in family life, as well as the health of all of its members. (9)

In his book Crisis, Family and Psychotherapy, Clavijo Portieles describes family health according to the concept of healthy family, arguing that a family is considered healthy when their members are both physically and mentally healthy, and the family is structurally, functionally, psycho-dynamically, semantically and ecologically integrated among themselves and with the surrounding environment. (10)

This is a “sum total” approach to family health, which does not go beyond the traditional limited concept of health as the absence of symptoms. Furthermore, it conceives health according to the Cartesian paradigm, splitting it into physical and mental health, and ignoring that family health is a clear expression of the indivisibility of biological, psychological and social factors.

METHOD

The theoretical conception of family group health is the result of bibliographic review, debate with experts, and research experiences in the field of family health with Cuban families. The work began with 28 focus group sessions with 11 experts in family matters. Subsequently, 25 family professionals in the fields of medical care, teaching and administration endorsed the proposed concepts and approaches.

RESULTS

Principles Underlying the Family-Group Health Conception Health’s Socio-Psychological Conditioning

The actions of different levels of social structure upon health permits an understanding of the role the family plays as an intermediary between society and the individual. That is, how the macrosocial structure’s influence is exerted upon the family; how the family itself is constructed as the basic unit of the mesosocial structure, and how it acts at the same time as a determinant and modulator of the influences of the individual. (11)

The historical-cultural theory of development laid out by L.S. Vygotsky offers a general theoretical conception which recognizes the decisive influence of social mediations and the role of the family as a development enhancer. (12,13) From generation to generation, the family transmits its history, experience, values, and customs, which are all very closely linked with a healthy home.

Health-Regulating Function of the Family

The family plays an essential, transcendental role in health conservation and protection, as it fulfills functions which are inherent to satisfying basic needs and caring for its members. This also includes obtaining and administering economic resources at home, and organizing household services.

It is within the family that the motives and habits connected with health-related behavior are formed. Health-protecting or disease-causing processes are initiated therein, while highly meaningful and effective support resources are also developed.

How a family functions is a predisposing or coadjuvant factor in the production and development of diverse diseases and health problems of its members. (14, 15)

Psychological Regularities in Family Life

The understanding of family psychology is based on the character of intra-family relationships, the group’s systemic functioning, the regularities of each life stage, and family stress.

The general theory of systems offers the conceptual framework for the understanding of family functioning. (16,17) The systemic approach and the dialectic of society-group-individual relationships are the essential principles underlying family research.

Summing up, different theoretical approaches contribute to creating an integrated framework consistent with the most general principles of production of psychological phenomenon. This framework also describes necessary processes in social formation including socialization, begun on the family level, social conditioning of human behavior as reflected in the family where it exerts powerful influences, the particularities of group functioning in the family, and the relevant links among its members.

The theories which allow for understanding family life from the psycho-social point of view are based on socio-historical and cultural determinism, systemic family functioning, the concepts of family evolutionary development according to age, and the effects of stress on the family.

A Family-Group Health Conception

Family-group health is a complex web of socioeconomic, cultural, environmental, biological, genetic, psychological and relationship conditions which are defined on a micro-social scale in the context of the family home.

It is defined as the family’s capacity to fulfill its functions, enhance its members’ harmonic development, and constructively face crises in a given social, cultural and economic context.

At a certain development stage, the capacity to fulfill functions can be seen as the product of reciprocal multi-causality between the material conditions of existence, and evolutionary, functional and structural processes of family life, to which individual and group health is intrinsic.

It is particularly expressed in the health-enhancing experiences provided by the family, addressing in a constructive and creative way the demands coming from each stage of biopsychosocial development of all of its members and of their way of life.

A development-enhancing family creates a home atmosphere in which there is harmony, communication, affection, unity, respect and solidarity that is translated into well-being and satisfaction for its members. This type of family faces problems and makes decisions without using destructive mechanisms and adopting rule, role and hierarchy changes to adapt to critical processes in a transforming manner. This family is able to resort to external resources and assimilate new experiences whenever necessary.

The development-enhancing family is considered to be strong enough to meet the bio-psycho-social needs of its members, face the regularities of the life cycle and manifest motivations and behaviors that favor good health.

Family health synthesizes its genetic, psychological, socio-historical and cultural heritage with how it confronts the health status and illness of its members.

It does not refer to the health of each of the family members, nor is it a condition that is reached by the addition of individual conditions or the absence of diseases and health problems in the members of a family.

As a dynamic condition, family health is subject to variations resulting from the changing influences on its members, produced by experiences and family conflicts related to family life cycle stages, the individual life cycle stages of its members (each with its characteristic health events), and by daily life experiences and the very characteristics of family interpersonal relationships.

As a field of knowledge, family health is directly connected with several social and psychological disciplines that underlie the essence, function and development of this special social group, as well as its decisive influence in the formation of new generations and its repercussion on the health-disease situation of all of its members.

It is this author’s opinion that the conceptual limitation between familial health and the health of the family is irrelevant, as in both cases it is the health of the whole, rather than that of its individual members, that is under consideration. Either term can be used depending on grammatical conveniences.

The integration of linked, complex knowledge of social phenomena defined in the family, the dialectical materialist conception, the contribution of epidemiological thought and family-group relational psychology, have permitted the development of a holistic and integrative conception of biological, social, environmental and psychological factors influencing the health of the family.

Family Health Conditioning Aspects

Conditional factors in family health are found in six dimensions: socio-economic and cultural context, home structure, critical family life processes, intra-family relationships, family problem-solving capacity, and social support. (18)

Socio-Economic and Cultural Context

Taking into account the importance of the social, economic and cultural context for family life as an essential health substratum, and reviewing research results and the opinion of consulted experts, we proposed including within this dimension the categories of family socio-labor insertion, economic situation, and material living conditions at home in conjunction with the family’s cultural expressions, such as religious beliefs and practice and ethical-moral values. (19, 20, 21, 22)

Home Structure

This dimension refers to the characteristics of the family core, including number of members living together, relation between them and the head of the family, age and sex.

Home is the residential unit that brings together the family group living under the same roof, even if they do not share blood links or family bonds. It excludes those family members who do not live together and who do not share everyday relationships. It is the human habitat, the place where material and spiritual needs are met. It is vital space for the family, where vital processes for the human being take place.

Family-Life Critical Processes

A critical process occurs when a family lives through events of various natures which can potentially affect health for a certain period of time. Critical processes spark evaluations and repercussions in family relationships and feelings, and produce high demands and changes to the family’s internal functioning.

Any family can face the critical processes that occur throughout the life cycle. These processes are related to the large number of influences emerging from social life, problems related to the growth, development and health condition of its members, as well as those problems related to a lack of medical and social services, which are not relevant to Cuba.

While these processes vary in magnitude in the meaning and effects they have on family life, they pose new challenges and place the family in a crisis situation.

Intra-Family Relationships

In relating among themselves, a family develops certain patterns and manners among its members. This set of interpersonal and intra-family relationships, also called intra-family functioning, will be the basis for the physical, intellectual, psychological and spiritual development of each of its members. It will be the appropriate atmosphere for psychic balance, love expression, trust and stability. It will be a reference for moral conduct and relationships to be imitated by the children, who will eventually take them up as relationship principles.

Family Problem-Solving Capacity

Problem-solving is the family’s capacity to mobilize, make decisions to act upon problems, and the way the family behaves when confronted with critical processes.

This capacity tends to shape a relatively stable style of facing critical processes as a group.

Family problem-solving capacity can be considered either in a constructive or destructive way. The former is present in families who assume attitudes of change and behave in a manner favorable to health, such as role adjustment, are flexible with established norms and seek community or professional support. Negative and rejection behaviors are families that refuse to take professional guidance, overlook hygienic-sanitary measures at home and its surroundings, and do not take care of sick or handicapped family members. In other families, no reconstruction of the problem is made, and problem solving is evaded.

Social Support

Social support is the different type of resources that the family can employ for its daily life, and especially in situations which exceed its resources and potentials. Types of support include instrumental, material or tangible, and psychological, which includes trust, acceptance and understanding, both of which are necessary to meet the demands of life.

The relation between factors conditioning above-mentioned family-group health is conceived of as a dynamic of systemic, multidirectional and complex interaction.

Graphic 1: Family Health

These factors can be interpreted in two levels. The socio-economic and cultural context, home structure, and social support form the level which represents the primary substratum wherein family-group health is produced. It is from this substratum that the critical processes inherent to family life emerge, as well as the problem-solving capacities that respond to such processes and the set of intra-family relationships that produce family functioning. All of these processes modulate the influences of socio-family life changes.

The interrelation between the two levels can be analyzed in terms of how the family forms and inherits the basic economic, social, cultural and educational substratum that is indispensable for its development; how it systematically exposes itself to new demands, challenges and urges of life’s critical processes; and how it creates a system of internal relationships, undertakes changes in its structure and functioning, and habitually faces such demands.

It is likewise understood that socioeconomic and cultural context and intra-family relationships are more relevant in configuring family health. These results have been confirmed by several research projects. (23, 24, 25, 26, 27, 28)

CONCLUSIONS

A new concept of family-group health is established. This concept provides an integrated vision of the biological, social and psychological processes, that condition and favor the understanding of the family-health relationship. At the same time, it consolidates the practical expression of the bio-psycho-social paradigm that substantiates Cuba’s health practice.

This concept contributes to the application of the family approach to actions in the fields of medical care, research, teaching and administration.

REFERENCES

1. Naciones Unidas. Declaración de Cartagena de Indias. En: Familia y Futuro. Un Programa Regional en América Latina y el Caribe. Anexo 1 y 2 Bogotá: CEPAL. 1994.
2. Organización Panamericana de la Salud. Familia y Salud. Informe de la 37ª Sesión del Subcomité de Planificación y Programación del Comité Ejecutivo WDC: OPS; 2003: http://www.who.int/gb/ebwpo/pdf/eb113/seb113r12.pdf.
3. Naciones Unidas (ONU). La Familia y la Salud en el Contexto del Décimo Aniversario del Año Internacional de la Familia. Informe 113ª reunión de la ONU. WDC:ONU; 2004: http://www.who.int/gb/pdf .
4. Organización Panamericana de la Salud. Orientaciones Estratégicas y Programáticas para el Período 1999 - 2002. WDC: OPS; 1999: http://www.ops,org.htm .
5. Organización Mundial de la Salud. Índices Estadísticos de la Salud de la Familia. Informe de un Comité de Expertos. Ginebra, 1976:30-3. Serie de Informes Técnicos; No. 587.
6. Horwitz N, Florenzano R, Rigeling PI. Familia y Salud Familiar. Un Enfoque para la Atención Primaria. Bol OPS 1985; 98 (2): 144 – 53.
7. Ortiz MT, Louro I, Jiménez L, Silva LC. Salud familiar. Caracterización en un Área de Salud. Rev Med Gen Integr 1999; 15 (3): 303 – 9.
8. González B I. Reflexiones Acerca de la Salud Familiar. Rev Cubana Med Gen Integr 2000; 16 (5): 508-12.
9. Louro I, Infante O, De la Cuesta D. Pérez E, González I, Pérez C, Pérez C. et al. Manual de Intervención en Salud Familiar [en línea] 2001: http://bvs.sld.cu/libros/manual/indice.html.
10. Clavijo PA. Crisis, Familia y Psicoterapia. La Habana: Ecimed; 2002.
11. Louro B I. La Familia en la Determinación de la Salud. Revista Cubana de Salud Pública. 2003; 29(1): p 48 –51.
12. Arias B G. Acerca del Valor Teórico y Metodológico de la Obra de L.S. Vygotsky. Revista Cubana de Psicología. 1999; 16(3): 171.
13. Arias B G. El Papel de los Otros y sus Características en el Proceso de Potenciación del Desarrollo Humano. Revista Cubana de Psicología.1999; 16(3) p 194 –199.
14. Moya F J. Terapia Familiar Sistémica. Córdoba: Triunfar; 2000. p 24 – 40.
15. Louro B I. Atención Familiar. En: Alvarez Sintes. Temas de Medicina General Integral. Vol 1 Salud y Medicina. La Habana: Ciencias Médicas; 2000 p 211-212.
16. Capra F. La Trama de la Vida. 1ra. ed. Barcelona: Anagrama; 1997.
17. op cit en 14.
18. Louro B I. Modelo teórico de salud del grupo familiar. Rev Cubana de Salud Pub. 2004 ( En prensa).
19. Espina P M, Martín P L, Núñez M L. Reajuste Económico y Cambios Socio Estructurales. En: Los Cambios en las Estructuras Socioclasistas. La Habana: Ciencias Sociales; 2003. p. 13 – 16.
20. Donate A M, Nabut H JL Condiciones Materiales de Vida del Entorno Familiar. Ciudad Habana: Ciencias Sociales; 1991.
21. Ramírez C J. Religión y Relaciones Sociales. La Habana: Academia; 2000. p. XVI.
22. Gutiérrez M JM, Arias B G, López H J, Rubens M. Estudio Longitudinal del Niño Cubano. Informe de investigación. La Habana: MINED; 2003.
23. Carriera E. Estudio Psico-Social de Familias de un Consultorio Médico en la Comunidad. [Trabajo para optar por el título de Especialista en Medicina General Integral] 1991, Facultad Finlay – Albarrán, Ciudad de La Habana.
24. Bonet M, Louro B I, Ochoa R. Diagnóstico Inicial de las Familias en Yaguajay con el uso de Indicadores Positivos. Informe de investigación. Proyecto Yaguajay. 1995.
25. González G J. Factores de Riesgo Familiar en el Intento Suicida. Municipio Playa. [Tesis en opción al grado de Master en Psicología de la Salud]. 1996 Facultad de Salud Pública, Ciudad de La Habana.
26. Almenares A M. Louro B I, Ortiz G MT. Comportamiento de la Violencia Intrafamiliar. Rev Cubana Med Gen Integr 1999; 15(3):285.
27. Ortiz G MT. Violencia Intrafamiliar desde la Perspectiva de la Mujer. [Tesis de Especialista en Psicología de la Salud] 2000. Facultad Calixto García. Ciudad Habana.
28. Gutiérrez M JM, Arias B G, López H J, Rubens M. Estudio Longitudinal del Niño Cubano. Informe de investigación. La Habana: MINED; 2003.

THE AUTHOR

MS, Health Psychology. Associate Professor and Researcher, National School of Public Health; ilb@infomed.sld.cu