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Try out PMC Labs and tell us what you think. Learn More. Objective To examine the extent to which the family influences individual use of general practitioner care. De Retrospective cohort study of all consultations in one calendar year. Multilevel modelling was used to analyse contact frequencies of individuals within families within practices. Participants 42 families with children aged years registered in 96 practices. Main outcome measures Family influence on individual frequency of contact with general practice and correlation in frequency of contacts between parents and children.
This means that contact frequencies of family members within families resemble each other, whereas differences in contact frequencies exist between families. The strongest correlations were found between mothers and children and between children. Conclusions The extent of shared help seeking behaviour within families has considerable implications in the context of the practice. Efforts by general practitioners to promote good health or to influence consultation patterns may conflict with their patients' family habits and attitudes at home.
In general practice the family was long considered as a starting point for treatment. Families are important social contexts within which illness occurs, lingers, or resolves. Families share the same lifestyle and home environment, and they share beliefs and behaviours relating to illness and health, thereby influencing each other's use of medical care. Family members show similar help seeking behaviour with regard to morbidity over time 7 and the relation between morbidity and attendance, 8 while consultation patterns within the family are even transferred to succeeding generations.
Research on the role of the family, however, mostly dates from the s and s and the family is scarcely mentioned thereafter, let alone used as a unit in analysis. Have individualisation theory, evidence based medicine, and a patient centred approach suppressed the ideas of family medicine? The individualisation hypothesis suggests that attitudes and behaviour are increasingly based on personal choice and are less dependent on tradition and social connections.
One parent families are now more common in the Netherlands. In two parent families, one parent more often is not the biological parent, and both parents more often have paid jobs. We examined the extent to which families continue to influence individual use of general practitioner care. We used data from the second Dutch national survey of general practice. The survey recorded all consultations in for general practices in the Netherlands, comprising general practitioners serving patients.
The minimum age of the children was set at 2 years because children below this age also attend baby or child health clinics. For all family members we selected only those consultations for new problems, as these are the contacts in which the initiative of the patient is most clear. We excluded eight practices from the analysis, mainly because of technical problems with registration. Additional analysis showed that excluded practices did not differ from the included practices in terms of practice size, practice type, and degree of urbanisation.
Relation between frequencies of first contacts and patients' age and sex, corrected for influences of family and practice. We considered context in the analysis because this influences people's care needs, what they want to do, and what they can do.
In addition to the individual level, we considered two kinds of contexts: the family and the practice. Multilevel analysis enabled us to analyse the impact of the family on individual frequency of contacts while also considering another important context related to contact frequencies—that is, the practice. Multilevel analysis extends single level regression analysis to settings with hierarchical data. We calculated the variance in frequencies of contacts due to differences between individuals, differences between families, and differences between practices.
We identified the family impact by the amount of variance in the frequency of first contacts with the general practice at family level. Greater impact of family background should result in more variance at family level, indicating more resemblance between family members with respect to frequency of contacts.
At the same time, shared help seeking behaviour within families indicates more differences between families. We calculated the variance when all family members were included in the analysis and then carried out a second analysis in which only siblings were included. We further described the family impact by correlation coefficients to evaluate the magnitude of the family impact in relationships between parents and children.
Frequencies of contacts are not normally distributed; they are discrete rather than continuous and usually skewed. Therefore, we used a Poisson distribution in the multilevel analyses a linear model was used for the estimates of the variances on the three levels because correlations within classes cannot be estimated correctly on the individual level when applying a Poisson distribution.
Frequency of contacts also differs by age and sex figure. To capture the non-linear relation between age, sex, and frequency of contacts, we modelled age as a separate effect for four groups father, mother, son, daughter. Table 1 shows the composition of the study population. We included over 42 families with children aged years living at home people in total. The average of children per family was two, with a maximum of This means that more than a fifth of the variance in contact frequencies relates to shared help seeking behaviour within families.
Table 2 shows the correlations between family members according to sex. The strongest correlations were between contact frequencies for mothers and children and between children. The association between contact frequencies for fathers and children was about the same as the association between parents: somewhat lower but still substantial. The association between parents shows that resemblances in contact frequencies between family members cannot be ascribed to genetic factors alone. Almost all non-institutionalised Dutch citizens are registered with a general practice and family members are usually registered with the same practice.
General practices therefore provide good information about frequency of contacts within families. Our study provides empirical support for regarding families as important social contexts for use of health care. Illnesses at the individual level still for most variance in contact frequencies, but a substantial amount of the variance can be attributed to the context in which the individual functions. The rationale of family medicine has not disappeared, so why is the family so seldom addressed in current healthcare research. We argue in favour of putting the family back on the agenda.
Why do frequencies of contacts in general practice cluster within families? We identified three possible mechanisms: selection, socialisation, and shared circumstances. These should be further studied because they can explain shared help seeking behaviour within families and between generations. Selection refers to homogeneity of background characteristics of family members, such as children's inheritance of vulnerability to illnesses and responses to stress. Another kind of selection process is known between partners: there is a tendency for healthy people to select healthy partners.
Socialisation refers to a more gradual process of resemblance. The people most likely to influence whether adults consult their general practitioner are their partners. Parents also learn from their children and adjust their parenting accordingly.
Families are seen as the most influential context for socialisation, compared with school or other peer groups, as family life contains many different situations, habits, and views, relationships are close, and family members live together for years in an informal safe setting. Finally, the members of one family share a collective context. Common physical, economic, and social circumstances in daily life may lead to specific family behaviour with accompanying harms or improvements to health.
Families with children share the same living arrangements, for example, and infections can easily be transmitted from one family member to another. Furthermore, parents and children usually also share another context—that is, the general practice. General practitioners differ in the patients they attract, and they influence their patients' help seeking behaviour, which may explain part of the variance at practice level. Recent studies of help seeking behaviour do not take the family into consideration and society has changed profoundly.
Similarities in consulting behaviour within families continue to exist despite profound changes in society, such as an increasing focus on individuality and changes in parenting and family composition. In practice, the concepts of selection, socialisation, and shared circumstances can serve as a framework for a family case history. Research on use of health care will profit from adding a family level as a unit of analysis.
We focused on describing the relation between individual, family, and practice contact frequencies. Explaining the observed resemblances in help seeking behaviour will be a next step. To our knowledge, our methods of analysis have not been used before in relation to this subject. Multilevel analysis is relatively new in health care but is increasingly being used as a way of analysing individual data while taking the context into .
Our multilevel analyses, including a practice level, enabled us to control for the effect of clustering of patients within practices, while making it possible to estimate the extent of variation at the practice level at the same time. The impact of individual variation will be over-rated if the context is not included because the variance at the level of the context will be ascribed to the individual.
Although the influence of the practice may be minor compared with the influence of the family, this does not imply that general practitioners cannot influence frequencies of contact. Our study supports the idea that interventions targeting families may be more effective than those targeting individuals. In practice, the identified mechanisms selection, socialisation, and shared circumstances can serve as a framework for a family case history; the context of the family may shed a different light on strategies for prevention, treatment, or recovery. Other research has shown that the main problem is integrating biomedical knowledge with a family approach as family theory and health care have developed from two different traditions.
Finally, additional services or applications within the medical record that would draw the general practitioner's attention to striking consultation behaviour on an aggregated family level, for example, could be helpful. In countries with free access to specialists, general practitioners will usually have fewer opportunities of obtaining insight into family patterns of illness and help seeking behaviour, which may lead to less effective treatment strategies.
Contributors: All authors were responsible for conception and de, and revision and final approval of the paper. MC drafted the paper. National Center for Biotechnology Information , U. Journal List BMJ v. Author information Copyright and information Disclaimer. Correspondence to: M Cardol ln. This article has been cited by other articles in PMC. Abstract Objective To examine the extent to which the family influences individual use of general practitioner care. Setting General practice in the Netherlands.
Introduction Efforts by general practitioners to promote good health or to influence consultation patterns may conflict with their patients' family habits and attitudes at home. Method We used data from the second Dutch national survey of general practice. Open in a separate window. Figure 1. Father Mother Son Mother 0. Discussion Almost all non-institutionalised Dutch citizens are registered with a general practice and family members are usually registered with the same practice.
Possible mechanisms Why do frequencies of contacts in general practice cluster within families? What is already known on this topic Family background influences help seeking behaviour Recent studies of help seeking behaviour do not take the family into consideration and society has changed profoundly What this study adds Similarities in consulting behaviour within families continue to exist despite profound changes in society, such as an increasing focus on individuality and changes in parenting and family composition In practice, the concepts of selection, socialisation, and shared circumstances can serve as a framework for a family case history Research on use of health care will profit from adding a family level as a unit of analysis.
Taking of context We focused on describing the relation between individual, family, and practice contact frequencies. Family medicine Our study supports the idea that interventions targeting families may be more effective than those targeting individuals.
Notes Contributors: All authors were responsible for conception and de, and revision and final approval of the paper. Competing interests: None declared. Ethical approval: Not required. References 1. Mechanic D. The influence of mothers on their children's health attitudes and behavior. Pediatrics ; 33 : Huijgen FJA. Family medicine; the medical life history of families. Nijmegen: Dekker and Van de Vegt, Litman TL.
The family as a basic unit in health and medical care: a social-behavioral overview. Soc Sci Med ; 8 : Family health. Med Care ; 25 : Wilcox-Gok VL. Sibling data and the family background influence on child health. Med Care ; 21 : Bosch WJHM van de. Epidemiologische aspecten van morbiditeit bij kinderen [Epidemiological aspects of morbidity in children] [thesis].Seeking others with family
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