FAMILIES AND COMMUNITIES

AS UNITS OF CARE
Role of Biopsychosocial Factors on Disease Causation
The biopsychosocial model was proposed as a scientific paradigm of George Engel.
Engel encouraged health care providers to observe biochemical and morphologic changes in
relation to a patient’s emotional patterns, life goals, attitudes towards illness, and social
environment. The biopsychosocial model is built on the conviction that the brain and peripheral
organs are linked in complex, mutually adjusting relationships, atuned to changes in social as
well as physical stimuli. This model regards environmental stress or intra-psychic conflict as
having pathologic potential for the individual. The emotions may serve as the patient’s bridge
between the significance of stressful events and the changes in physiologic function. Engel
urged primary care physicians to evaluate their patients in terms of biological, psychological,
and social data to effectively assess and manage clinical problems.

By employing the biopsychosocial approach, we become cognizant of the interplay

between the biomedical and psychosocial determinants of health in bringing about a state of
illness or wellness. Thus, we become holistic in the management of our patient’s case.

I. Biological Factors
 demographic characteristics: age, sex, race, marital status, area of residence, social
class, educational background, occupation
 genetic characteristics: familial / hereditary diseases
 environmental characteristics: living environmental, occupational hazards
 lifestyle characteristics: exercise, diet, vices (i.e., smoking, alcoholism, illicit drug
use)

II. Psychological Factors

 affective, cognitive, behavioral dimensions, feelings, beliefs, expectations
 personality
 coping styles / mechanisms

III. Social Factors

 social systems such as family, school, work, church, government and social values,
customs, and social support
 family life cycle
 impact of illness / illness trajectory
 family assessment tools
 access to health care
 quality of the patient’s health care

Engel’s biopsychosocial approach recognizes that health and wellness are shaped by a
complex interaction of biological, psychological, social variables that cannot be neatly
compartmentalized in any one domain. Consequently, these components each have a
significant contribution to the health outcomes of individuals.
Important Times for Psychosocial Intervention
1. natural transition in the family life cycle
2. when patient compliance or lifestyle issues impinge on health
3. dramatic change in patient symptoms
4. significant medical diagnosis precipitating psychosocial crisis
5. patients living with chronic illness require sensitive psychosocial care

FAMILY STRUCTURE
1. Nuclear Family
 members consist of parents and their still dependent children, occupying a
separate dwelling not shared with members of the family of origin / orientation
of either spouse
 financially independent

2. Extended Family
 unilaterally or bilaterally extended
 includes three generations; family centered; lives together as a group

3. Single Parent Family

 children less than 17 years of age living with a single parent, another relative or
non-relative
 results from loss of spouse by death, divorce, separation, desertion and out of
wedlock birth of a child
 adoption
 one parent working outside the Philippines (i.e., overseas Filipino workers /
OFW families)

4. Blended Family
 includes step-parents and step-children
 caused by separation/divorce/annulment or death of a spouse with subsequent
cohabitation or remarriage with a partner of similar spousal situation

5. Communal / Corporate Family

 group of individuals which is formed for specific ideological or societal
purposes, sharing common goals, beliefs, values, norms and practices
o e.g., Amish community in Lancaster county in Pennsylvania
 FAMILY LIFE CYCLE
▪ represents composite of the individual developmental changes of family members
▪ presents cyclic development of the evolving family unit
▪ shows the evolution of the marital relationship

Why do we study the family life cycle?

1. provides a predictable, chronologically oriented sequence of events in family life with
which family physicians and other health professionals are already familiar with
2. involves a sequence of stressful changes that require compensating or reciprocal
readjustments by the family to maintain viability
3. events of the family life cycle can be related to clinical events and to health
maintenance of the family

Stages of the Family Life Cycle

1. UNATTACHED YOUNG ADULT

▪ start of the family life cycle
▪ “between families”
▪ young adult has come to terms with family of origin and is formulating personal
goals in developing as an individual including forming a new family
▪ emotional process of transition / key principle: accepting parent-offspring
separation; accepting financial and emotional responsibility for oneself

2. THE NEWLY MARRIED COUPLE

▪ transition stage of the couple from individual to couple living
▪ emotional process of transition / key principle: commitment to the new system

Stages of Marriage
STAGES EMOTIONAL ISSUES CRITICAL TASKS
Honeymoon  differentiation from
family origin
Stage (less than  commitment to the marriage
2 years)  making room for spouse
with family and friends
 keeping romance in
Early Marriage the marriage
Stage (2-10 years)  maturation of the relationship
 balancing “separateness”
and “togetherness”
Middle Marriage  adjusting to midlife changes
Stage (10-25 years)  post-care review  re-negotiating marriage
 maintaining
couple
Long Term Marriage functioning
Stage (more than 25  “farewells” and planning  closing of adapting
years) family home
 coping with death of
the spouse
 3. THE FAMILY WITH YOUNG CHILDREN
▪ starts with the pregnancy for the first child to emergence of adolescents
▪ defines new family status: wife to mother, husband to father
▪ conflict with home and school regulations
▪ emotional process of transition / key principle: accepting new members in to the
system

4. THE FAMILY WITH ADOLESCENTS

▪ adolescents to teenagers (i.e., identity crisis stage)
▪ parents to middle age (i.e., mid-life crisis stage)
▪ grandparents to later years (i.e., generation gap crisis stage)
▪ emotional process of transition / key principle: increasing flexibility of
boundaries to include children’s independence and grandparents’ frailties

5. LAUNCHING FAMILY / LAUNCHING OF ADULT CHILDREN

▪ begins when first child leaves home and ends when last child leaves home
▪ launched children start their own families
▪ emotional process of transition / key principle: accepting a multitude of entries
intro and exits from the family system

6. FAMILY IN LATER YEARS

▪ begins with departure of last child, continues through retirement of one or both of
the couple, ends when both are dead
▪ emotional process of transition / key principle: accepting the shifting of
generational goals

Two Levels of Orders of Magnitude of Change

1. FIRST ORDER CHANGES
 involves increments of mastery and adaptation
 a “need to do” something new
 no change in the main structure of the family
 no change in the family’s identity and self image
 e.g., change of residence, employment (i.e., young adults), establishing a place to
call their own (i.e., newly married couple), working out money matters (i.e., family
with young children)

2. SECOND ORDER CHANGES

 involves transformation of an individual’s status and meaning
 a “need to be” something new
 there is change in the role and identity of family members
 change occurs between stages of the family life cycle
 e.g., change when a family moves from newly married to family with young
children, husband becomes father and wife becomes mother
IMPACT OF ILLNESS ON THE FAMILY
▪ discover the meaning of illness for the family
▪ investigate disease: examine clinical and laboratory evidence of biologic and psycho-
physiologic dysfunction
▪ investigate illness: exploring the meaning of disease to the patient and the patient’s
family

Major illnesses involve loss of:

▪ body parts
▪ ability to carry out normal and treasured activities
▪ sense of self-esteem
▪ dreams and plans for the future
▪ sense of invulnerability of one’s self and loved ones that keeps fears of
impending death and separation at bay

The Family Illness Trajectory

▪ normal course of the psychosocial aspects of disease for the patient and the family
▪ knowledge of trajectory allows the physician to predict, anticipate, and deal with a
family’s response to illness
▪ indicates normal and pathologic responses thus enabling family physician to
formulate special therapeutic plan

Stages of the Family Illness Trajectory

1 Stage I Onset of Illness to Diagnosis
2 Stage II Impact Phase --- Reaction to Diagnosis
3 Stage III Major Therapeutic Efforts
4 Stage IV Recovery Phase --- Early Adjustment to Outcome
5 Stage V Adjustment to Permanency of Outcome

Stage I: Onset of Illness to Diagnosis

 warning sign --- malaise is the preliminary stage of the illness trajectory
 stage experienced prior to contact to medical care providers
 medical beliefs and previous experiences influence meaning of illness
 nature of onset may play an important role on impact of illness on a family

Characteristics Impact on
Nature of Illness Onset of Illness of the
Experience Family
acute, rapid rapid, clear  little time  caught up in
for physical suddenness
 deals with
and
immediate
psychologic decisions
al  often with little
adjustment support within
 short period and outside of the
between stages, family unit
little time to  if less threatening,
remain in state of may be dramatic
uncertainty but less crisis
oriented problem
for the family
 chronic, debilitating gradual  suffer from state  vague
of uncertainty apprehension
regarding and uncertainty
meaning of  fearful
symptoms fantasies and
anxiety over
the denial of
seriousness of
symptoms and
possible
implications

Stage II: Impact Phase --- Reaction to Diagnosis

EMOTIONAL PLANE COGNTIVE PLANE
 during onset of illness, there may be  Phase I: initially tension confusion
initially denial, disbelief, and anxiety with probably lack of capacity for
 this is followed by emotional upheaval problem solving
(i.e. anger, anxiety, depression)  Phase II: repeated failure in deriving diagnosis
 last phase is accommodation and acceptance may lead to exacerbation of tension and
of diagnosis increase distress
 Phase III: increasing assessment and
receptivity of family to new approach
for relief of distress
 Phase IV: acceptance of the diagnosis
enables the family to mobilize resources

Stage III: Major Therapeutic Efforts

CRITICAL ISSUES IN CHOOSING THERAPEUTIC PLAN
1. psychological preparedness state of the patient and his/her family
2. assumption of responsibility for care, responsibilities of each party
3. economy of the therapeutic plan
4. lifestyle and cultural characteristics of a family
5. hospitalization gives rise to stressful logistic problem

Stage IV: Recovery Phase --- Early Adjustment to Outcome

Experience of recovery of adjustment to the illness outcome varies according to type of
outcome anticipated

1. return to full health

 simplest, gains from illness experience
 e.g., regaining health after community-acquired pneumonia

2. partial recovery
 followed by period of waiting to learn if disease will return or fear of death,
maintain constant sense of vulnerability
 e.g., cancer in remission; completing six-month regimen of anti-Koch’s infection

3. permanent disability
 e.g., S/P below the knee amputation (BKA) for a neuroischemic foot ulcer
Stage V: Adjustment to Permanency of the Outcome
 second crisis occurs as the family realizes that they must accept and adjust to
the permanent disability
 family must accept that life goes on
 continued unwillingness to incorporate reality of permanency may be a sign of
pathology

1. For Acute Illness

 potential for crises when family routine is suspended
 emotions are high and can lead to anger especially if medical care is perceived to be
inadequate

2. For Chronic Illness

 prolonged fear and anxiety can cause higher incidence of illness in other
members of the family
 brings about additional burden, feelings of guilt specially if patient was
previously neglected
 over indulgence towards sick member’s feelings of overwork, anger, resentment, and
guilt

3. For Terminal Illness

 initial response is of shock and overwhelming anxiety
 highly emotional and devastating
 grief reaction:
o if functional = family members become drawn closer and unify
o if dysfunctional = seed for family discord and breakdown and possible
disintegration of the familial system
 aid in efficient and functional readjustment
 provide quality care: home care is best

STEPS IN FAMILY SYSTEMS APPROACH

1. Recognize the family structure.
 graphic representation of the members of the family

2. Understand the normal family function.

 dynamic image of relationships in the family

3. Learn to assess family structure and function in clinical practice.

 family physician should listen more and talk less

FAMILY ASSESSMENT TOOLS / INSTRUMENTS

1. Family Genogram
 The family genogram is a graphic representation of both the genetic pedigree of
the family and key psychosocial and interactional data using standardized
symbols.
 It represents three components of the family:
A. Family Tree
 It consists of three or more generations, and each generation is identified by
Roman numerals.
 The first born of each generation is farthest to the left, with siblings following
to the right in order of birth.
 The family name is placed above each major family unit; given names and
respective ages are placed below each symbol.
 One member of the family is of greater medical significance because of an
illness and he is known as the index patient and is identified with an arrow.
 Date is indicated when the chart was developed so that ages could be adjusted
over time.

Figure 1. Some common international symbols used in making the family genogram.

B. Functional Chart
 This gives a more dynamic image of the family, especially of relationship of
members. It allows one to judge the totality of the family unit, its strengths and
weaknesses, its ability to withstand stressful situations.
 Figure 2. Some international symbols used in denoting family relationships /
dynamics in a family genogram / map.

C. Family Illness / History

 This denotes the presence of inherited diseases or familial tendencies
indicating potential problems in the family.

 The genogram is a very excellent tool that can be used to learn about family
structure. However, it has a limited role in assessing family function. It normally
takes 10-15 minutes to construct a family genogram, thus making it impractical in
routine clinic visit. Nevertheless, it has been suggested to place the basic structure
of the genogram initially in the chart to shorten time consumption, then complete it
on succeeding visits / consults.
 Advantage/s:
 records names and roles of each member of the family
 separates extended family into several household
 documents medical problems of each member
 documents significant dates in the family history
 Disadvantage/s:
 limited value in assessing family function
 2. Family A.P.G.A.R. (of Smilkstein)
 Advantage/s:
 rapid screening for family dysfunction
 good reliability and validity to measure individual satisfaction with family
relationship
 allows evaluation of the functional status of the family and its effect on the
care of the sick member
 Disadvantage/s:
 needs little time to complete
 Filipinos, because of their closely-knit ties and protectiveness of the family,
may not be too comfortable revealing matters / issues about their families.

Components of the APGAR

A = Adaptation:
 It is the family’s utilization of the resources available, within and outside of the
familial system, when significant life events pose a crisis.
P = Partnership:
 It is the sharing of the family members in decision-making and responsibilities
through communication.
G = Growth:
 It is the physical and emotional growth attained by each family member from
the family’s ability to support and guide its members for the choices and
directions they wish to take.
A = Affection:
 It is the loving and caring relationship of the family. It reflects the satisfaction
with emotional relationships and shared intimacy within the family.
R = Resolve:
 It is the commitment of family members to devote time to support each other’s
physical and emotional growth. It also pertains to the sharing of wealth and
space.
 FAMILY APGAR
Part I: helps define degree of patient’s satisfaction or dissatisfaction with family
function

ALM SOM HARD

O ST E OF LY
ALW THE EVER
A YS TIM
E (0 pt)
(2 pts) (1 pt)
A I am satisfied that I can turn to my family for
help when something is troubling me.

P I am satisfied with the way my family talks

on things with me and shares problems with
me.
G I am satisfied that my family accepts and
supports my wishes to take on new activities or
directions.
A I am satisfied with the way my family expresses
affection and responds to my emotions, such as
anger, sorrow, and love.
R I am satisfied with the way my family and I share
time together.

Part II: delineates relationships with other members; it also identifies person/s who can
give assistance to the patient; and, it also indicates conflict not revealed in Part I

Who lives in your home? How do you get along?

Relationshi Age Sex Well Fairly Poor
p
1.
2.
3.

If you do not live with your own family, list the How do you get along?
person/s to whom you turn to for help.
Relationsh Age Sex Well Fairly Poor
ip
1.
2.
3.

SCORING SYSTEM:
• 2 points = almost always
• 1 point = some of the time
• 0 point = hardly ever
INTERPRETATION OF SCORES (i.e., average score of the index patient and at least one other family
member):
• 8-10 points: highly functional family
• 4-7 points: moderately dysfunctional family
• 0-3 points: severely dysfunctional family
 FILIPINO FAMILY APGAR
Part I: helps define degree of patient’s satisfaction or dissatisfaction with family
function
PALAGI PAMINSAN HINDI
- MINSAN HALOS
(2 pts) (1 pt) (0 pt)
A Ako ay nasisiyahan dahil nakakaasa ako ng
tulong sa aking pamilya sa oras o panahon ng
problema.

P Ako ay nasisiyahan sa paraang nakikipag-

talakayan sa akin ang aking pamilya tungkol
sa aking problema.

G Ako ay nasisiyahan at ang aking pamilya ay

tintatanggap at sinusuportahan ang aking mga
nais na gawin patungo sa mga bagong landas
para sa aking ikauunlad
A Ako ay nasisiyahan sa paraang ipinadadama ng
aking pamilya ang kanilang pagmamahal at
nauunawaan ang aking damdamin katulad ng
galit, lungkot, at pag-ibig.
R Ako ay nasisiyahan na ang aking pamilya at
ako ay nagkakaroon ng panahon sa isa’t isa.

Part II: delineates relationships with other members; it also identifies person/s who can
give assistance to the patient; and, it also indicates conflict not revealed in Part I

Sino ang nakatira sa inyong tahanan? Paano ang iyong relasyon?

HINDI HIN
GAANO DI
RELASYO EDAD KASARIA MABUTI
NG MAB
N N
MABU UTI
T
I
1.
2.
3.

Kung hindi ka nakakahingi ng tulong sa iyong Paano ang iyong relasyon?

sarili pamilya, kani-kanino ka humihingi ng
tulong?
HINDI HINDI
RELASY EDAD KASARIAN MABUTI GAANO MABUTI
ON N
G
MABUT
I
1.
2.
3.

Adapted from: “Family APGAR: Its Validation Among Filipino Families in the Emergency Room and Out
Patient Department, Sto. Tomas University Hospital, January-April 1992” by L. Cabahug, M.D. and A.
Pineda, Jr., M.D.
3. Family Map
 The family map is a tool designed to reflect family relationships and interaction
patterns.
 This tool utilizes common symbols, which suggest family dynamics.
 It is very important for primary care physicians in obtaining a therapeutic ally for
the delivery of care in the family. The family map enables identification of family
members who can be partners in the decision-making and medical care for the
patient.

Figure 3. Symbols of Family Structures and Dynamics

4. Family S.C.R.E.E.M. (social, cultural, religious, economic, educational and

medical)
 The SCREEM is an acronym that represents the family resources. It is a tool where
the primary care physician helps family members identify and assess their
resources to meet a crisis. However, the lack of resources can also serve as a kind
of pathology in certain situations.
 The SCREEM is commonly used when the need for care is long or lasts a lifetime,
such as in the case of chronically / terminally ill, and hospice care patients. It can
also be used to assess the resources of difficult and non-compliant patients.

RESOURCE PATHOLOGY
Social Social interaction is evident among Family members are isolated from
family members. Family members extra- familial social groups.
have well-balanced lines of Problem of
communication with extra-familial over-commitment may be evident.
social groups, such as friends, sports,
clubs, and other community groups.
Cultural Cultural pride or satisfaction can Family members experience
be identified, especially in distinct ethnic / cultural inferiority.
ethnic groups.
 Religious Religion offers satisfying spiritual Family members may observe very
experiences as well as contacts with rigid dogmas / religious rituals.
an extra-familial support group.

Economic Economic stability is sufficient to Family members experience

provide both reasonable economic deficiency with
satisfaction with financial status inappropriate economic planning.
and an ability to meet economic
demands of normative life events.
Educational Education of family members is Family members are handicapped
adequate to allow members to solve to comprehend important issues /
or comprehend most of the details.
problems that arise within the
format of the lifestyle established
by the family.
Medical Health care is available through Family members fail to utilize
channels that are easily established available health care facilities and
and have previously experienced in resources.
a satisfactory manner.

5. SCREEM Family Resource Survey

 This is a 12-item self-administered family resources questionnaire in Filipino
based on the family SCREEM. It is appropriate in assessing the family’s capacity
to participate in the provision of health care or to cope with crises.

Strongly
Strongly
Disagree / Disagree /
Agree /
Agree / Hindi Lubos na
Lubos na
Sumasang-Ayon Sumasang- Hindi
Sumasang-
Ayon Sumasang-
Ayon Ayong
SOCIAL
 We help each other in our family.
 Ang bawat isa ay nagtutulungan sa
aming pamilya.
 We are helped by friends and other
members of the community.
 Natutulungan kami ng aming mga
kaibigan at kasamahan sa komunidad.
CULTURAL
 Our culture gives our family strength.
 Ang aming kultura ay nagpapatatag ng
loob ng aming pamilya.
 A culture of helping and cooperation
in our community helps our family.
 Ang kultura ng pagtutulungan at
pagmamalasakit sa aming
komunidad ay nakakatulong sa
aming pamilya.
RELIGIOUS
 Our faith and religion help our family.
 Ang aming pananampalataya at
relihiyon ay nakakatulong sa aming
pamilya.
  We are helped by members of our
church or other religious groups.
 Natutulungan kami ng aming mga
kasamahan sa simbahan o mga
grupong relihiyoso.
ECONOMIC
 Our family’s savings is adequate
for our needs.
 Sapat ang naipong pera ng aming
pamilya para sa aming mga
pangangailangan.
 Our family’s income is adequate
for our needs.
 Sapat ang kinikita ng aming pamilya
para sa aming mga pangangailangan.

EDUCATIONAL
 Our education / knowledge is
adequate to understand
information about the illness.
 Sapat ang aming edukasyon /
kaalaman upang maintindihan ang
mga impormasyon tungkol sa sakit.
 Our education / knowledge is
adequate to care for the sick.
 Sapat an gaming edukasyon /
kaalaman upang maalagaan ang
may sakit.
MEDICAL
 It is easy to access medical
help in our community.
 Madaling makakuha ng tulong
medikal sa aming komunidad.
 We are helped by doctors, nurses, and
health workers.
 Natutulungan kami ng mga doctor,
nars, at “health workers”.

Scoring for SCREEM Family Resource Survey:

 strongly agree: 3 points
 agree: 2 points
 disagree: 1 point
 strongly disagree: 0 point

o Note: The interpretation of the SCREEM family resource survey is similar to the
family APGAR, where the sum of the scores of each category is obtained, and the
total score is interpreted.
▪ 0-6 points: The family has severely inadequate family resources.
▪ 7-12 points: The family has moderately inadequate family resources.
▪ 13-18 points: The family has adequate family resources.

6. Family Lifeline
 This tool summarizes the history of the family, particularly the individual or the
family’s significant experiences over a period of time in a chronologically
sequenced manner. It also includes how the family has coped with these stressful
life events.
 This tool may identify factors that may have directly or indirectly affected the
health of the entire family.
 The interpretation of the family lifeline is based on the most significant event that
probably affected the health of each member or influenced the health-seeking
behavior or perception on health of the individual or the family.

References
 Leopando ZE, Alip AJB, La Rosa-Fernandez T, Lazaro-Hipol C, Yu-Maglonzo, EI, Olazo RA,
Samaniego IA, and Serrano-Tinio C. Textbook of Family Medicine, Volume 1 --- Principles,
Concepts, Practice and Context. Philippine Academy of Family Physicians. Philippines, 2014.
 Department of Preventive and Community Medicine. Review Notes and Manual in Disease
Prevention and Control. College of Medicine, UERMMMCI, 2017.
 Rakel RE and Rakel DP. Textbook of Family Medicine, 9th Edition. China, 2015.
 Proceedings of the Orientation Course in Family Medicine, Philippine Academy of Family
Physicians