Estrategias de afrontamiento familiar y repercusiones en la salud familiar: Una revisión de la literatura

Enfermería Global Nº 47 Julio 2017 Página 592 REVISIONES Family coping strategies and impacts on family health: A literature review Estrategias de afrontamiento familiar y repercusiones en la salud familiar: Una revisión de la literatura José Manuel Martínez-Montilla1 Bárbara Amador-Marín1 Maria Dolores Guerra-Martín2 1Graduated in Nursing. Faculty of Nursing, Physical Therapy and Podiatry. Sevilla University. 2Doctora in Nursing. Faculty of Nursing, Physiotherapy and Podiatry. Sevilla University. E-mail: [email protected] http://dx.doi.org/10.6018/eglobal.16.3.255721 Received: 04/04/2016 Accepted: 08/08/2016 ABSTRACT: Introduction: Family health has been a concern for all those working with the family. The way how the family has to face the stressful events and vital process is known as family coping and has impact on family health. Objective: To find family coping strategies and their relationship to family health. Methods: A review of the scientific literature was conducted through the following databases: PubMed / Medline, Scopus, PsycINFO and Dialnet from 2010 to 2016. Results: The initial search strategies identified a total of 1074 results that finally being selected 23 studies. The main stressful family situations were: chronic diseases, Autism Spectrum Disorders (ASD), mental illness, addictions, accidents and disability, family adjustment, labor and financial problems. And the main family coping strategies were: positive like finding information, search family, social or spiritual support, acceptance and improved self-esteem. And negative like denial, concealment, disconnection, self-blame, emotional detachment, substance use, among others. Conclusions: Stressful events alter the dynamic balance family, hence the importance of the family unit have a good coping strategies. On the other hand, it is important that health professionals know the main stressors, as well as positive family coping strategies, so by promoting health, to prevent problems arising from inadequate family coping. Key words: Family health; Coping Behavior; Adaptation, Psychological; Health. RESUMEN: Introducción: La salud familiar ha constituido una preocupación para todos aquellos que trabajan con la familia. La forma que tiene la familia de enfrentarse a los acontecimientos y proceso vitales estresantes es conocida como afrontamiento familiar y tiene repercusión en la salud familiar. Objetivo: Conocer las estrategias de afrontamiento familiar y su relación con la salud familiar. Metodología: Se realizó una revisión de la literatura científica a través de las siguientes bases de datos: PubMed/Medline, SCOPUS, PsycINFO y Dialnet, desde 2010 hasta 2016. Enfermería Global Nº 47 Julio 2017 Página 593 Resultados: Las estrategias iniciales de búsqueda identificaron un total de 1074 resultados, siendo finalmente seleccionados 23 estudios. En cuanto a las principales situaciones familiares estresantes fueron: enfermedades crónicas, Trastornos del Espectro Autista (TEA), enfermedades mentales y adicciones, accidentes y discapacidad, reajuste familiar, problemas laborales y financieros. Y las principales estrategias de afrontamiento familiar fueron: positivas como búsqueda de información, búsqueda de apoyo familiar, social o espiritual, aceptación y mejora de la autoestima. Y las negativas fueron negación, ocultación, desconexión, auto-culpa, distanciamiento emocional, consumo de sustancia, entre otros. Conclusiones: Los acontecimientos estresantes alteran el equilibrio dinámico familiar, de ahí la importancia de que la unidad familiar posea buenas estrategias de afrontamiento. Por otro lado, es importante que los profesionales de la salud conozcan los principales estresores, así como las estrategias de afrontamiento familiar positivas, para mediante la promoción de la salud, poder prevenir los problemas derivados de un inadecuado afrontamiento familiar. Palabras clave: Salud de la familia; Estrategias de Afrontamiento; Ajuste psicológico; Salud. INTRODUCTION Family health has been a concern for all those who work with the family(1,2). In Spanish we can find two related concepts about family health, although both are closely related have different meanings(3). Family health was defined as the health of all members in terms of effective family functioning (internal dynamics, performance of duties and change adaptation). This promotes growth and development according to the demand of each stage of life(3,4). According to Lima et al.(3) raised that family health is composed of fundamental dimensions, such as: family social climate, family integrity, family functioning, family resistance and family coping. The relationship between individual health and family health is reciprocal because any individual health problem might develop a family health problem and vice versa. For this reason, an unhealthy family life could make family members sick(2,4). Moreover, coping is a dynamic process which is defined as the set of resources that a person usually uses to solve or improve a problematic situations, and to reduce the tensions that these situations might generate(5-9). These resources can be beliefs, motivations, social skills, social support and material resources(7). Extrapolating this concept to the family system, the family coping concept appears, which is the capacity of the family to confront, mobilize and put into action measures to act in front of changes or to the appearance of stressful events(3,5,7,10). In addition, it involves behavioural and / or cognitive efforts, which are aimed to manage or regulate the stressful situations, that are generated in the system, to ensure the health of its members(1,5). Family coping strategies can potentially strengthen and keep family resources, in order to protect them from stressful situations and ensure proper management of their dynamics(5,6). These are manifested through communication, links and the promotion of positive self-esteem among its members(5). However, it must be taken into account that coping changes over time and as a result of the stressor, the severity of the conflict, the extent and accumulation of other demands, the number of disturbances in the family system, and the availability and use of intrafamily and community resources(6,7,10,11). Therefore, coping strategies in Enfermería Global Nº 47 Julio 2017 Página 594 families are not created in a single moment, but are formed and modified over time(5,7,11). Moreover, It should to highlight that these strategies fulfil a number of functions, such as maintaining the internal conditions satisfactory for communication and family organization, promoting the independence and self-esteem of its members, maintaining the bonds of coherence and family unity, maintaining and developing social support and community relations, as well as monitoring the impact of situations and change in the family system(7). For all of this, the goal of this work was to know the different strategies of family coping and their relationship with family health. METHODOLOGY A review of the scientific literature was performed following the guidelines of the Cochrane Handbook(12) and the recommendations of the PRISMA report(13), for making the methodology of this review. Thus, searches of studies published between 2010 to 2016 was carried out in the following electronic databases: PubMed/Medline, SCOPUS, PsycINFO and Dialnet. The topic of search was family coping strategies and their influence on family health. Regarding to the descriptors of searches, we used the Health Sciences Descriptors (DeCS) and Medical Subject Headings (MESH). The intersection (AND) and the summation operator (OR) were used as the boolean operators. In addition, we used truncations when were necessary. The descriptors employed were:  English: “Family Health”, “Family Well-being”, “Health”; “Strategies”; “Coping Behavior”, “Behavior, Adaptive”, “Adjustment, Psychological”, “Adaptation, Psychological”; “Family Relations”, “Family Relationship” y “Family”.  Spanish: “Salud”; “Adaptación Psicológica”, “Conductas Adaptativas”, “Familia”. In the table I shows the search strategies used in each of the databases. Table I. Selected search strategies. DATABASE DESCRIPTORS PubMed ("family health"[All Fields] OR "family well-being"[All Fields] OR "health"[All Fields]) AND "Strategies"[All Fields] AND ("Coping Behavior"[All Fields] OR "Behavior, Adaptive"[All Fields] OR "Adjustment, Psychological"[All Fields] OR "Adaptation, Psychological"[All Fields]) AND ("family relations"[All Fields] OR "family relationship"[All Fields] OR "family"[All Fields]). SCOPUS (TITLE-ABS-KEY(("family health" OR "family well-being" OR "health")) AND TITLE-ABS-KEY ("Strategies") AND TITLE-ABS-KEY (("Coping Behavior" OR "Behavior, Adaptive" OR "Adjustment, Psychological" OR "Adaptation, Psyc hological")) AND TITLE-ABS-KEY (("family relations" OR "family relationship" OR "family"))) PsycINFO (“salud” AND (“conductas adaptativas” OR “ajuste psicológico”) AND (“relación familiar” OR “Familia”)). Dialnet salud AND familia* AND ("conduct* adaptativa" OR "adaptacion* psicologica") Regarding to the selection criteria, these were: 1. Qualitative and quantitative scientific articles; 2. Fully published between 2010-2016; 3. In Portuguese, Spanish or English; 4. The quantitative studies must get a moderate or strong methodological quality through the EPHPP (Effective Public Health Practice Project)(14); 5. The qualitative Enfermería Global Nº 47 Julio 2017 Página 595 studies must get an affirmative answers in the first two questions of the CASPe quality tool (Critical Appraisal Skills Program)(15). After a complete reading were excluded those studies that did not cover coping strategies in the family unit or addressed the different strategies in a single member instead of the family unit. Also, those studies that the full text didn't be available Finally, after the searches, we removed articles that did not meet the inclusion criteria, through the reading of the title, abstract and full text of potentially relevant works. RESULTS A total of 1074 results was identified in the initial search which 23 studies was selected (Figure 1). Of these, 12 were qualitative and 11 quantitative. Regarding to the qualitative studies, 8 were phenomenological, 3 ethnographic and a case study. And about the quantitative studies, 8 were observational studies, 2 descriptive and a clinical trial. Figure 1. Flowchart of the review. Source: Own elaboration. Do not meet quality criteria (n= 0) Total Included Studies (N=23) Concordant to Full Text (N total= 23) - PSYCINFO (n= 2) - SCOPUS (n= 10) - PUBMED (n= 11) - DIALNET (n= 0) Articles Found in Each Database (N total= 1074) - PSYCINFO (n= 301) - SCOPUS (n= 346) - PUBMED (n=379) - DIALNET (n=48) Not concordant with the subject of study (n= 975) Concordant to Titles and Abstracts Reviewed (N total= 99) - PSYCINFO (n= 11) - SCOPUS (n= 44) - PUBMED (n= 41) - DIALNET (n= 3) Duplicates (n= 5) Do not meet selection criteria (n=50) Not available full text (n= 21) Enfermería Global Nº 47 Julio 2017 Página 596 Regarding to the language, 22 studies were published in English and 1 in Spanish. Moreover, 6 of these studies were developed in Europe, 8 in America, 4 in Asia, 3 in Oceania and 3 in Africa. It should be noted that one of the studies was conducted simultaneously in the United States and Australia. Table II shows the characteristics of the included studies, based on the Cochrane Handbook(12). It includes the following sections: author and year, objective and design, methodology and main results. In addition, the valuations of the EPHPP(14) and CASPe(15) instruments. Table II. Characteristics of included studies and assessments of quality instruments according to the kind of study. Author / Quality Objective and Design Methodology Results Espada et al., 2010(16). ** CASPe: 8 affirmative answers. - Design: Qualitative study (DELPHI). - Sample: 16 psychologists. - Country: Spain. - DELPHI evaluation of a short film. The short film was visualized twice and questionnaire of 10 items. - 25% didn´t cover all the problems of oncology. - 70% taught coping strategies to parents. Simon et al 2010(17). *EPHPP: Moderate. ** CASPe: 9 affirmative answers. - Design: Mixed (Quantitative and qualitative). - Duration: 2004-2006. - Sample: 7 cases and their families. - Country: Australia. - Interviews and questionnaires; Coping Questionnaire (WOCQ24). - High anxiety status in families in combination with ineffective coping strategies may predict poorer functional performance. Wiedebusch et al 2010(18). *EPHPP: Moderate. - Design: cross-sectional observational study. - Sample: 195 families. - Country: Germany. - Questionnaires: Impact on the Family Scale, Social Orientation Questionnaire for Parents of Disabled Children and Freiburg Questionnaire. - Father faced their child's illness in diverse ways. Mothers most often use most coping strategies. Dussel et al., 2011(19). *EPHPP: Moderate. - Design: Cross-sectional observational study. - Duration: 1997-2001 (USA), 2004-2006 (Australia). - Sample: 141 families and 89 families. - Country: USA and Australia. - USA: Telephone surveys. - Australia: Interviews divided into two sections. 1st. Personal interview and 2nd. Semi-estructured questionnaires. - American Families: 52% raised funds as coping strategies. - Australian families: 33% raised funds as a coping strategy. Hall et al., 2011(20). *EPHPP: Moderate. - Design: Descriptive cross-sectional study. - Duration: 2007-2008. - Sample: 73 families. - Country: USA. - Semi-structured interview, and selfadministered surveys (Family Support Scale (FSS)). - Parents seek and use social support, self-respect, emotional strength, family adjustment, teamwork, and a positive sense of the situation. Lu et al., 2011(21). *EPHPP: Moderate. - Design: Cross-sectional observational study. - Duration: 2009. - Sample: 194 families. - Country: China. - Questionnaires: Family Scale of Adaptation. - Adaptation related to family resources, marital satisfaction and the sex of the baby. Moriarty et al., 2011(22). **CASPe: 9 affirmative answers. - Design: Qualitative study. - Sample: 19 families. - Country: New Zealand. - Semi-structured interviews were conducted with some members of the families. - The strategies found were: minimizing the problem, denial and / or self-deception, and emotional distancing. Enfermería Global Nº 47 Julio 2017 Página 597 Wang et al 2011(23). *EPHPP: Moderate. - Design: Descriptive study. - Duration: 2007-2009. - Sample: 386 families. - Country: China. - The packages contained the original Questionnaire on Resources and Stress (QRS), the COPE Inventory of responses or coping strategies. - Coping strategies most used: acceptance, coping, positive reinterpretation, repression of activities, and planning. Bingham et al., 2012(8). **CASPe: 8 affirmative answers. - Design: Qualitative study. - Sample: 6 families. - Country: USA. - Interviews were conducted for approximately 1 hour. The number of interviews ranged from 3 to 5. - The main coping strategies were: searching professional support, information, social support, and spiritual support. Medeiros et al., 2013(24). **CASPe: 8 affirmative answers. - Design: Qualitative study. - Duration: 2008-2009. - Sample: 3 families. - Country: Brazil. - Semi-structured interviews were conducted during the hospital stay. - Families create coping strategies to carry out their new roles and face the diagnosis. Karnieli-Miller et al., 2013(25). **CASPe: 9 affirmative answers. - Design: Qualitative study. - Sample: 12 parents. - Country: USA. - 2 discussion groups with relatives, 90 minutes long. - They used flexible strategies based on their personal resources, the motivation and the will of their relatives. Nadkarni et al., 2013(26). **CASPe: 9 affirmative answers. - Design: Qualitative - Sample: 29 men with AUD and 10 relatives. - India country. - Semi-structured interviews. - Coping strategies: avoidance, substitution, distraction, religious activities, AA support / friends / family and restriction on drinking and anger management. Oyebode et al., 2013(27). **CASPe: 9 affirmative answers. - Design: Qualitative. - Sample: 6 first-degree relatives of patients with fvFTD. - Country: United Kingdom. - Data collection was done through semistructured interviews. - Internal and external coping strategies were found. Shaibu et al., 2013(28). **CASPe: 9 affirmative answers. - Design: Qualitative study. - Sample: 12 grandparents. - Country: Republic of Botswana. - Semi-structured interviews were conducted in the participants' homes. - They reported little support to extended families, and their health problems endangered their financial situation. Mullen et al., 2014(29). *EPHPP: Moderate. - Design: Cross-sectional observational study. - Duration: 2006-2009. - Sample: 47 families of children with PH. - Country: USA. - A questionnaire was carried out which included family coping strategies. - 34% of parents used psychological coping strategies. Pozo et al., 2014(30). *EPHPP: Moderate. - Design: Cross-sectional observational study. - Sample: 59 mothers and 59 parents - Country: Spain. - 7 questionnaires to evaluate the double ABCX model: Brief Coping Orientation of Experimced Problems (Brief-COPE). - Coping strategies are related to coping, active avoidance to deal with FQOL for parents. Van der Sanden et al., 2014(31). **CASPe: 9 affirmative answers. - Design: Qualitative study. - Duration: 2012-2013. - Sample: 23 relatives. - Country: Netherlands. - Semi-structured interviews were conducted through openended questions. - They used strategies focused on problems and focused on emotions. Xue et al., 2014(32). *EPHPP: Moderate. - Design: Descriptive study. - Sample: 65 families. - Country: Singapore. - Questionnaires on coping strategies were administered. - Useful strategies such as integration, optimism, understanding of the disease, development of self-esteem and psychological stability. Enfermería Global Nº 47 Julio 2017 Página 598 Alli et al., 2015(33). **CASPe: 8 affirmative answers. - Design: Qualitative Study - Sample: 10 parents. - Country: South Africa. - Semi-structured interviews were conducted with open and closed questions. - Different communication strategies (speech and language therapy). Imperatore et al., 2015(34). **CASPe: 9 affirmative answers. - Design: Qualitative Study - Sample: 15 parents of 13 families. - Country: USA. - Semi-structured interviews were conducted in depth. - They used as strategies: to treat stigma and isolation, changes in routines, service utilization. Laar et al., 2015(35). *EPHPP: Moderate. - Design: Quantitative study. - Sample: 1745 families. - Country: Ghana. - Questionnaires on coping strategies were administered. - Strategies of negative coping such as skipping meals, eating less, begging, taking children out of school, migration, etc. Sabanciogullari et al., 2015(36). *EPHPP: Strong. - Design: Cross-sectional observational study. - Sample: 134 families. - Country: Turkey. - Questionnaires to evaluate individual characteristics of the family, experienced difficulties and needs in terms of information and support in the disease and coping strategies. - Use coping strategies of psychological, cognitive, behavioural, emotional and social. Senger et al., 2016(37). *EPHPP: Moderate. - Design: Cross-sectional observational study. - Sample: 231 parents. - Country: USA. - Questionnaires were administered with: demographic data, information on the disease and the stress of the parents. - Parents using integration, family and social support behaviours reported less stress, communication difficulty and emotional distress. *EPHPP (Effective Public Health Practice Project): Instrument of quality measurement of quantitative studies(14). **CASPe (Critical Appraisal Skills Programme): Critical reading program for the evaluation of methodological quality of qualitative studies (15). Source: Own elaboration, based on the Cochrane Handbook(12). Table III shows the different coping strategies found according to the stressors of the studies analyzed. These have been classified into positive coping strategies and negative coping strategies. Table III. Stressors and their main strategies of family coping. Stressful Situations Author and Year Coping Strategies Chronic diseases Espada et al., 2010(16). Positive coping strategies, aimed at emotion (affective regulation, searching social and family support) and the problem (information searching, value restructuring and distraction). Wiedebusch, 2010(18). Positive coping strategies (spiritual support, searching information, collaboration, and mutual support). Medeiros et al., 2013(24). Families develop coping strategies during the diagnostic process. In this way, they can carry out their new roles. Mullen et al., 2014(29). Negative coping strategies (evasion). Laar et al., 2015(35). Negative coping strategies (reduce food intake, buy low-quality and cheap food, begging). Senger et al., 2016(37). Positive coping strategies (family integration, searching information and social support). Enfermería Global Nº 47 Julio 2017 Página 599 Autistic Spectrum Disorder (ASD) Hall et al., 2011(20). Positive coping strategies (searching social support, improving self-esteem and emotional strength). Wang et al., 2011(23). Positive coping strategies (acceptance, positive reinterpretation and planning). Negative coping strategies (suppression of activities). Pozo et al., 2014(30). Positive coping strategies aimed at the problem. Xue et al., 2014(32). Positive coping strategies (family integration, cooperation, being positive and searching information). Alli et al., 2015(33). Positive coping strategies (searching information, adopting a new form of communication and interaction, building new unions). Negative coping strategies (increased protection). Imperatore et al., 2015(34). Positive coping strategies (searching information, family support, social and spiritual support). Negative coping strategies (negation and social isolation). Mental diseases Kamieli-Miller et al., 2013(25). Negative coping strategies (hide the disease). Oyebode et al., 2013(27). Positive coping strategies (good humour and positive interaction). Van der Sanden et al., 2014(31). Positive coping strategies aimed at the problem (searching social, instrumental, and emotional support, and organization of support systems) and directed to the emotions (self-distraction and acceptance). Negative coping strategies targeting the emotions (avoiding the problem, avoiding stigmatizing conditions and overloading, negation, behavioural disconnection). Sabanciogullari et al., 2015(36). Positive coping strategies (acceptance, searching solutions to the problem, searching family support). Negative coping strategies (ignore the problem, isolation, blame others and get angry). Addictions Moriarty et al., 2011(22). Positive coping strategies (strategies aimed at recovery and adaptation). Negative coping strategies (minimization and normalization of the problem). Nadkami et al., 2013(26). Positive coping strategies (searching social, spiritual, and family support, distraction, restrict access to drugs and money). Negative coping strategies (avoidance). Accidents and Disability Bingham et al., 2012(8). Positive coping strategies (searching information). Negative coping strategies (avoidance, minimization, negation and self-blame). Simon et al., 2010(17). Negative coping strategies (avoidance and negation). Family Readjustment Lu et al., 2011(21). Positive coping strategies (family support). Shaibu, 2013(28). Positive coping strategies (family readjustment, spirituality and resilience). Job and Financial Problems Dussel et al., 2011(19). Positive coping strategies (fundraising, retrenchment and no debt). Source: Own elaboration. Enfermería Global Nº 47 Julio 2017 Página 600 The studies that were analyzed highlighted family coping strategies in a variety of stressful situations. These were: 6 studies about family coping strategies in chronic diseases(16,18,24,29,35,37), 6 about Autism Spectrum Disorder (ASD)(20,23,30,32-34), 4 about mental illness(25,27,31,36), 2 about addictions(22,26), 2 about accidents and disability(8,17), 2 about family readjustment(21,28) and 1 about the loss of work and financial difficulties(19). DISCUSSION This paper presents different coping strategies used by families in different stressful situations which disturb the functioning of the family unit. Stressful events happen in both functional and dysfunctional families, as these are situations that happen during the vital process. The difference between these two kind of families, lies in how to deal with the events, which depend on family characteristics, the severity of the event and social supports. Therefore, these characteristics will be directed towards the growth of the group members or towards their deterioration(6,38). Regarding to our results, these seemed to indicate that the studies that analyze the different strategies of family coping mainly focused on stressful negative events for the family and that usually trigger some kind of family crisis, such as the onset of a chronic illness(16,18,24,29,35,37), accidents(17), disability(8), job loss and financial problems arising from this(19), among others. And in most cases, it was the children who suffered them(16,18,20,23,24,29,30,32-34,37). Furthermore, few studies analysed the coping strategies used by families in different natural events that arise throughout the family life cycle, such as the formation of the couple, birth and brought up of child, adolescence, middle age, among others, that even being a stressor for the family, should not lead to any family crisis. This fact could be derived from the existence, even today, of the Medical Model focused mainly on the disease. And that is why most studies with families are focused on studying the responses to some pathological process in one of its members. In addition, another aspect to be highlighted in our results was that they seemed to indicate that negative family coping strategies are more common in certain stressful events such as accidents(17), disabilities(8), mental illness(25,27,31,36) and addictions(22,26). The most commonly used coping strategies were avoidance, denial, and concealment of the problem. These results agree with those found by other authors, such as García et al.(39). Also, according to other authors, these kind of strategies are aimed at reducing the emotional disturbance caused by a stressful situation, which they think can´t do anything to modify it(40). Therefore, hiding the mental illness, addiction or disability of a family member is aimed at defending against the stigma, because this carries a great emotional cost at the family level, due to the alterations that these situations cause in health family and its different dimensions, family relationships and social networks about this(22.25). However, Lazarus(41) affirmed that the use of this type of coping strategies can sometimes precede the use of coping strategies focused to the problem and that lead to the survival of family time. However, the use of positive coping strategies is more prevalent in the rest of the stressors found. Among the most commonly used were those designed mainly to look for information and support, whether family, social or spiritual. This is consistent with the results found by other authors(5,6), where the main family coping strategy was the use of community resources and social supports.