THE FAMILY in HEALTH and DISEASE: The Illness Trajectory DEPT. OF PUBLIC HEALTH & PREVENTIVE MEDICINE FACULTY OF MEDICINE PADJADJARAN UNIVERSITY

Learning Objectives Describe the effect of family on the health of its member (C2) Recall the definition of diseases and illness (C1) Discuss the meaning of illness for the family (C2) Understand the illness trajectory (C1) Describe the impact of illness on the family (C2)

MAIN EFFECTS OF FAMILY ON THE HEALTH

WHAT ARE THE SIX MAIN EFFECTS ON THE HEALTH OF ITS MEMBERS OF THE FAMILY ? THE FAMILY HAS SIX MAIN EFFECTS ON THE HEALTH OF ITS MEMBER, THOSE ARE : 1. GENETIC INFLUENCES every individual is a product of interaction between his genotype and environment recent advances in our genetic aspects of disease has made this an important subject for the family physician  genetic counseling 2. THE FAMILY IS CRUCIAL IN CHILD DEVELOPMENT : there are many evidence supporting the relationship between family dysfunction and childhood disorders (physical and behavioral)

THE FAMILY HAS SIX MAIN EFFECTS ON THE HEALTH OF ITS MEMBER (cont’d) 3. SOME FAMILIES ARE MORE VULNERABLE TO ILLNESS THAN OTHERS 4. INFECTIOUS DISEASE SPREADS IN FAMILIES, e.g., streptococcal infection is related to acute and chronic family stress, respiratory and intestinal infection decrease in frequency with increasing age and the number infections falls rapidly as immunity is acquiried during the early school years

THE FAMILY HAS SIX MAIN EFFECTS ON THE HEALTH OF ITS MEMBER (cont’d) 5. FAMILY FACTORS AFFECT MORBIDITY AND MORTALITY IN ADULTS. severe family problems  angina pectoris ⇑ widow or widower  mortality in the first year after bereavement. 6. THE FAMILY IS IMPORTANT IN RECOVERY FROM ILLNESS family support is an important factor in the outcome of all kinds of illness, especially in chronic illness and disability

Impact of Illness on the family

IMPORTANCE OF STUDYING THE IMPACT OF ILLNESS Sickness causes suffering and disruption for the family Sickness can be disruptive to family life and hazardous to health Sickness is embedded in a whole matrix of difficult family problems

Impact of Illness on the family: Disease, Illness and the Family Illness Trajectory Major illness may have a devastating effect on whole family If the physician is to successfully treat the disease of the identified patient, the psychosocial problems of both the patient and the family must be recognized, diagnosed and addressed.

Health, Normal/Abnormal, Disease, Illness Health: A state of complete physical, mental and social well-being and is not merely the absence of disease or infirmity (WHO) … struggle to achieve ! Normal/Abnormal: Physiological values or Psychological values e.x.: Hypertension/ no Hypertension Consideration: Human variability Individual variation: vary minute to minute, hour to hour, day to day, week to week : manifestations of the adaptability to the environmental change Variation between individuals : genetics and adaptation to different environments

Disease: primary biologic and psychophysiologic disorder. Illness: disease + the sufferer’s experience of the disease and the broad range of dislocations felt by both the sufferer and his/her family  meaning of illness is deeply embedded in the social, cultural and family context of the person who is ill.

Meaning of Illness for the Family Physicians investigate disease in their patients by examining clinical and laboratory evidence of biological and psychophysiologic dysfunction. Physicians investigate illness by exploring the meaning of illness for both their patients and the patient’s families.

Prosedures to investigate the meaning of illness The patient’s explanatory models (explain the nature of their illness according to their perception) provide the cognitive framework for patient understanding the reason for onset of their illness, etiology, pathophysiology, course and outcome of their illness and how appropriate treatment may affect the trajectory of their illness.

Prosedures to investigate the meaning of illness Investigation of the patient’s semantic illness network  the set of meanings, experiences and concerns that patients associate with their illness (previous experience with a disease or therapy) Investigation the family members' meaning of illness  sudden sense of being vulnerable to disease

Passage through suffering: The family Illness Trajectory The natural history of an illness episode or the normal course of the psychosocial aspects of sickness for the patient and family Every stage of the natural history of disease has different meaning of illness to the family and family members.

Natural History of the disease Pre-pathogenesis Pathogenesis Before man is involved The course of the disease in man Interrelation of the various: - AGENT - HOST - ENVIRONMENT factors (known & unknown) which bring AGENT & HOST together, or produce a disease-provoking STIMULUS in the human HOST Early pathogenesis Discernable early lesions Advanced disease Convalescence Interaction of HOST & STIMULUS HOST reaction STIMULUS & AGENT becomes established & increases by multiplication or increment Tissue & physiologic changes Signs & symptoms Illness Disability Defect Chronic state DEATH RECOVERY Immunity & resistance

Understanding of such an illness trajectory allows FP to predict, anticipate and deal w/ family’s response to illness What responses are normal What responses are pathologic

Patient and family member Stage I: Onset of Illness Stage 2: Reaction to Diagnosis – The Impact Phase Stage 3: Major Therapeutic Efforts Stage 4: Early Adjustment to Outcomes- Recovery Stage : 5 Adjustment to the permanency of the outcome Role of physician Patient and family member Psychological state of patient and fam. is an important determinant of choice of therapeutic plan . Depends on patient education, reassurance, lifestyle, culture, economic Responsible for making a clinical judgment about the amount of information the patient can absorb. Encourage to clear the nature of illness Develop plan for realistically coping w/ them Prediagnostic phase about the patient and the fam. Ease the patient and fam. anxieties & concerns Illness Denial, fears Convince the doctor that something is wrong - Depends on the disease … shock & overwhelming anxiety. Choice of therapeutic plan Emotional not well equipped Responsibility of the process treatment Depression Anger and disappointment : economic factor Uncertainty about the outcome Second crisis occur because of permanency & disability Unwillingness to incorporate the reality Active role Serve the fam. well, trying to find out just how the member understand what has happened Alert about potential problem Anticipate the second crisis of adaptation to permanency of the outcome Help the family deal with it openly and directly The family Illness Trajectory

The family Illness Trajectory Reaction and meaning of illness depends on Rapid onset/acute : accidents Clear onset and therapy Chronic Hypochondria

References Mc Whinney. A textbook of Family Medicine. Third Edition, Oxford New York, 2009. pp 217-45. Lee Gan, Azwar.A, Wonodirekso. Family Medicine Practice. Singapore, 2004. Section 3 chapter 2 pp 56-62. Good BJ, Good MD, Burr BD. Impact of Illness on the Family: Disease, Illness and the Family Illness Trajectory. In Robert T. Family Medicine Principles and Practice. Springer – Verlg. New York. 1978. pp 32 – 44.