Developing a strategy for managing behavioral health care within the context of primary care.

Although most patients with psychological disorders are diagnosed and treated within the primary care setting, there are few guidelines to help primary care physicians and managed care plan administrators construct programs of behavioral health care that are compatible with the primary care environment. We report the findings from a review of the literature from 1970 to 1996 on factors that predict the use of mental health and substance abuse services with specific reference to primary care. We use a heuristic framework of service use that includes the characteristics of patients, primary care physicians, practice settings, and managed care plans. Recognizing that the factors associated with the use of services center on the primary care practice, we argue that programs of behavioral health care will work best when they are decentralized to account for variations among primary care patients, physicians, and practices; when they are integrated clinically, financially, and administratively within the primary care setting; and when primary care physicians are active leaders in the design and implementation of these services, for clinical and financial reasons.

An empirically derived typology of families: I. Relationships with adult health.

In this report we describe the development and partial validation of an empirically derived typology of families based on 11 family variable composites derived from the California Family Health Project. Our goal was to use the typology to condense and integrate the findings from previous analyses of a large group of family variables and to account for differences in the self-reported health of adult family members. Exploratory and confirmatory cluster analyses conducted separately by gender classified 97% of the sample into four parallel types for husbands and wives: Balanced, Traditional, Disconnected, and Emotionally Strained. A 1-way MANOVA indicated that all 11 family variable composites significantly differentiated the four family types for husbands and wives. Significant differences among the four family types were also found on 10 demographic and other family variables, using ANOVA. Using MANOVA, we compared the four family types on 12 self-reported health and well-being variables by gender. Both husbands and wives from Balanced and Traditional families reported higher health scores than spouses from Disconnected and Emotionally Strained families, but no single profile of health scores was unique to a particular family type. The four family types provide an integrated and comprehensive framework for describing the family in health research.

An empirically derived typology of families: II. Relationships with adolescent health.

In this report from the California Family Health Project, we describe the relationship between an empirically derived family typology based on parent data, and the self-reported health and well-being of 151 adolescent offspring. The typology is comprised of four family types: Balanced, Traditional, Disconnected, and Emotionally Strained. Three adolescent health indices were constructed from 13 self-reported health variables using principal components and multidimensional scaling analyses: Physical Health, Emotional Health, and Alcohol Abstinence. ANOVA indicated that Physical Health was significantly different among adolescents in the four family types. The findings varied, however, depending upon whether the typology was based on mothers' or fathers' appraisals of the family. In the father-based typology, adolescents from Traditional families scored highest while those from Emotionally Strained and Balanced families scored lowest. In the mother-based typology, adolescents from Balanced, Traditional, and Emotionally Strained families scored equally high, while those from Disconnected families scored significantly lower than those from the other three family types. Differences on Abstinence were significant only in the father-based typology. Adolescents from Traditional and Emotionally Strained families drank less than adolescents from Disconnected families. No significant differences among adolescents were found for Emotional Health, and adolescent gender did not interact significantly with family type to affect any of the three health indices. Traditional and Disconnected family types had offspring who clearly stood apart with higher and lower health scores, respectively. The results are discussed in terms of the current literature on social environment and health.

The California Family Health Project: VII. Summary and integration of findings.

In a series of reports, we have observed the relationships between four domains of family life (World View, Emotion Management, Structure/Organization, Problem Solving), and the health of husbands and wives in a community-based sample of 225 families. In this final article of the series, we provide an overview and summary of the results, by gender, including the structure and patterning of variables both within each family domain and among all four family domains analyzed together. In addition, we review the associations between each family domain and adult health (unidomain analyses), and among all four family domains taken together and adult health (multidomain analyses). Prominent differences in family and health relationships based on gender are described from the perspective of socially and culturally supported sex-role expectations and behavior. The results support the use of a multidimensional family assessment framework in health research that can lead to the further development of empirically based models of family process.

The California Family Health Project: IV. Family structure/organization and adult health.

This research explores the relationships between each of four "domains" of family life and the health of husbands and wives in a community-based sample of 225 families. In this article we report the association between Family Structure/Organization and adult Health. This family domain refers to the architecture of the family or the structural frame of roles and rules within which the family operates. Interrelationships among 13 self-reported, family Structure/Organization scales are described, using principle components analysis (PCA) and multidimensional scaling analysis (MDS). Derived, joint-spouse or couple Structure/Organization variables also were created using inter-battery factor analysis. The PCA yielded a poor solution, whereas the MDS yielded a good two-dimensional solution, which roughly displayed the scales in a circular pattern for both husbands and wives. The analyses indicated that no single dimension or set of separate subdimensions adequately described the Structure/Organization variables. All 13 scales than were associated with a battery of 14 adult health scales for husbands and wives separately, using canonical correlation. Different aspects of family Structure/Organization were correlated with health for husbands and wives: Organized Cohesiveness, Sex Role Traditionalism, Role Flexibility and Shared Roles for husbands; and Organized Cohesiveness and Differentiated Sharing for wives. Different patterns of health scores also emerged by gender, with behavioral indicators, such as Smoking and Drinking, more salient for husbands, and mood indicators, such as Anxiety and Depression, more salient for wives.

The California Family Health Project: V. Family problem solving and adult health.

This article explores the relationship between family Problem Solving and the Health of adults in a community-based sample of 225 families. Family Problem Solving refers to the ways in which the family conducts itself to resolve a shared problem. Sixteen observer ratings of family Problem-Solving behavior during a 30-minute task were developed, based on the Simulated Family Activity Measure (SIM-FAM), and good interrater agreement was achieved. Principal Components Analysis (PCA) yielded a set of three well-constructed, interpretable dimensions: Problem-Solving Effectiveness, Problem-Solving Style, and Sociomotor Activity. Multidimensional scaling analyses (MDS) suggested that family problem-solving behavior involved an organized, means-end sequence of family behaviors in which aspects of style served problem-solving effectiveness. All 16 Problem-Solving variables were analyzed with a set of 14 health variables, for husbands and wives separately, using canonical correlation. No subset of Problem-Solving variables was significantly associated with a subset of Health variables for either husbands or wives, although there was a significant association between the two sets of variables when taken as a whole. Given previous research on family Problem Solving, we conclude that the absence of significant associations between particular aspects of family Problem Solving and Health may be due to our use of a community-based rather than a stressed or clinical sample. Associations between Family Problem Solving and Health might best be viewed in the context of other family variables.

The California Family Health Project: II. Family world view and adult health.

This article explores the pattern of relationships between family World View and adult Health in a community-based sample of 225 families. Family World View refers to the beliefs, appraisals, and values that define a family's orientation to the world. The interrelationships among eight self-reported family World View variables are described, using principal components analyses (PCA) and multidimensional scaling analyses (MDS). Derived, joint-spouse World Views also are examined using inter-battery factor analysis. The World View variables then are analyzed as a set with 14 self-reported health variables for husbands and wives separately, using canonical correlation. The PCAs for family World View yielded poor solutions for both husbands and wives. The MDS displayed the eight variables in a circular pattern for husbands and for wives, indicating the absence of a single broad dimension, or subgroupings of separate dimensions, that could be used to "describe" the domain. In the canonical analyses, family World View was a strong correlate of Health, with approximately 50% of the variance accounted for by the respective canonical variates. For husbands, what we called Family Coherence, Family Religiousness, Family Life Engagement, and Family Optimism, were correlated with Health. For wives, Family Coherence, Family Religiousness, and Family Optimism, were correlated with Health. Different patterns of health scores emerged by gender, with behavioral indicators, such as Smoking and Drinking, more salient for husbands, and mood indicators, such as Anxiety and Depression, more salient for wives.

The California Family Health Project: I. Introduction and a description of adult health.

Little research has addressed patterns of family and health relationships that reflect both the scope and complexity of family life and the breadth and diversity of health. In the first of a series of articles, we describe the California Family Health Project, a study in which four large "domains" of family life (Structure/Organization, World View, Problem Solving, and Emotional Management) were mapped, described, and compared with a large battery of adult health measures. We first present a brief critical overview of the literature on family and health research, then explain our rationale, define our approach to the multivariate analysis of family and health data, and describe our sample of 225 community-based families. To prepare for analyses with the family variables, we next present descriptive data based on separate principal components analysis (PCA) and multidimensional scaling analysis (MDS) of 14 self-reported health scores for husbands and for wives. No grouping or clustering of health variables emerged for either husbands or wives in the PCAs. A two-dimensional MDS analysis for husbands and for wives displayed the health variables in a circular pattern in which no predominant descriptive dimension or group of discrete dimensions emerged. Consequently, we decided that all 14 health scores will be used in the analyses, with the family variables to follow.

The California Family Health Project: III. Family emotion management and adult health.

This article explores the broad patterning of interrelationships between family Emotion Management and adult Health in a community-based sample of 225 families. Emotion Management refers to how emotion is expressed, acknowledged, and managed by the marital partners. Fifteen reliable-observer ratings of husband-wife behavior were made during each of three 10-minute Emotion Management Interaction Tasks (EMITs). Each of the three tasks "pulled" for the expression of a different emotional theme: loss, intimacy, or conflict. A principle components analysis of the 15 ratings yielded a poor solution. A nonmetric, multidimensional scaling analysis described a two-dimensional, bipolar display with ordering among the variables in each of two wings. One dimension reflected positive versus negative Emotion Management characteristics, and the second reflected active and overt versus passive or covert emotional expression. The pattern of relationships among the couple ratings was similar for each of the three tasks. Using canonical correlation, the couple ratings demonstrated significant associations with 14 adult Health scores for both husbands and wives for the intimacy and conflict tasks, but not for the loss task. Specific gender patterns also emerged. In general, couple overt emotional aversiveness was negatively associated with husbands' health, and couple emotional avoidance/distance was negatively associated with wives' health.

Voices from family medicine: Donald Ransom. Interview by William B. Ventres and John J. Frey.

Family medicine is a discipline of inclusion. It has welcomed, from its inception, a diversity of professionals and educational approaches. In this transcript, the third in a series of oral histories focusing on the creation of the field, clinical psychologist Donald C. Ransom, PhD, discusses his early and continuing involvement with family medicine. Interviews forming the basis for this abridged version were conducted with Dr. Ransom in May and November 1991. Dr. Ransom is professor of family and community medicine in the Department of Family and Community Medicine at the University of California School of Medicine, San Francisco, and the behavioral science coordinator in the family practice residency program at Community Hospital in Santa Rosa, Calif. In 1986, he received the STFM Certificate of Excellence; in 1989, NAPCRG and STFM jointly honored him with their Weatherby Award for outstanding clinical research in primary care.

Research Methodology of Family-Oriented Care: How relevant is family health research?

Family practice and family-centered primary care have a special role in studying the family. A framework for conceptualizing research on families and health, illness, and care is presented. The author discusses ways in which families can influence the health of their members, current controversies about what family means, the logic of family research measurements, whether family research is warranted, and the question of variable-versus case- (person- versus family-) centered research design and analysis.

Advancing a family perspective in health research: models and methods.

In this essay we review and respond to four problems that have impeded the application of family theory to health research: the difficulty in translating family concepts to empirical health research; the confusion and uncertainty in measuring "wholes" and "parts" of a family in a single health project; the apparent conflict between circular-causal and linear perspectives in model building; and the putative, implicit "violation" of a family perspective by the employment of certain data management and design strategies. We argue that current, complex conceptualizations of the family have to be matched with equally complex research designs and methods, and that techniques are available to reach these goals. We distinguish between theoretical models and research methods, and review several strategies, design issues, and alternatives for data analysis. Throughout, we point to 1) the need to maintain consistency among theory, construct, and indicator, 2) the employment of multidimensional family assessment in health research, and 3) the use of readily available but infrequently used methods and procedures for appreciating the richness of multivariate family data.

Alternative strategies for creating "relational" family data.

A major problem facing family clinicians and researchers is creating data that will reflect the family as a unit. To address this problem, we present a framework for family assessment based on three measurement strategies: individual family member assessment, relational family assessment, and transactional family assessment. Within this context, we present several categories of methods for combining individual family member data into "relational" scores that reflect the couple or family as a unit. The problems and benefits of each method are presented, and it is suggested that the choice of method is dependent upon the content of the assessment, the theory underlying the content, and the statistical properties of the individual family member scores.