INTRODUCTION

Family health has been a concern for all those who work with the family¹⁾⁽². In Spanish we can find two related concepts about family health, although both are closely related have different meanings³.

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 life³⁾⁽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 sick²⁾⁽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)(6)(7)(8)(9}. These resources can be beliefs, motivations, social skills, social support and material resources⁷.

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 members¹⁾⁽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 dynamics⁵⁾⁽⁶. These are manifested through communication, links and the promotion of positive self-esteem among its members⁵.

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 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 system⁷.

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 Handbook¹² and the recommendations of the PRISMA report¹³, 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:

In the Table 1 shows the search strategies used in each of the databases.

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 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 

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 2 shows the characteristics of the included studies, based on the Cochrane Handbook¹². It includes the following sections: author and year, objective and design, methodology and main results. In addition, the valuations of the EPHPP¹⁴ and CASPe¹⁵ instruments.

Table 2 Characteristics of included studies and assessments of quality instruments according to the kind of study 

Source: Own elaboration, based on the Cochrane Handbook¹².

Table 3 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 3 Stressors and their main strategies of family coping 

Source: Own elaboration

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)(33)(34}, 4 about mental illness^{25)(27)(31)(36}, 2 about addictions²²⁾⁽²⁶, 2 about accidents and disability⁸⁾⁽¹⁷, 2 about family readjustment²¹⁾⁽²⁸ and 1 about the loss of work and financial difficulties¹⁹.

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 deterioration⁶⁾⁽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}, accidents¹⁷, disability⁸, job loss and financial problems arising from this¹⁹, among others. And in most cases, it was the children who suffered them^{16)(18)(20)(23)(24)(29)(30)(32)(33)(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 accidents¹⁷, disabilities⁸, mental illness^{25)(27)(31)(36} and addictions²²⁾⁽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 it⁴⁰. 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 this²²⁾⁽²⁵. However, Lazarus⁴¹ 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 authors⁵⁾⁽⁶, where the main family coping strategy was the use of community resources and social supports.

Along this line, some authors affirmed that in this kind of situations, there are capacities to self-organize and achieve a transformation, as far as possible, of individual or collective mobilization to overcome the crisis, whether unexpected, related to evolutionary development, or generated by the initiative of the members that make up the family⁶. For this reason, the most important defence mechanisms that the family should face a situation were the internal and external resources, their knowledge and their previous experiences³. Regarding to external resources, mention that a good option for support before a particular event is the one provided by community services through the so-called Mutual Support Groups (MSG) and that it is currently booming.

Another important aspect to emphasize is the influence that the culture has in the family coping regarding to the different stressful events. Because coping in each cultural system is based on the social system, religion and the way that people receive support from their personal relationships³⁹.

The kind of family coping is different depending on the sociocultural context in which the members of the families are immersed, because they form different interactions and diverse ways of proceeding contextualized within the cultural framework⁵. Cultural beliefs about health care, the stigma of certain diseases, religion, the role of the family in providing support and the role of women in the family are factors that influence when it comes to carrying some coping strategies or others. According to Imperatore et al.³⁴, a negative culture related to these above factors, could adopt passive coping strategies to stressful events and can help delay the help needed. Moreover, in the specific case of very believing cultures, they affirmed that these could be a double-sided factor. On the one hand, it can favour the adoption of positive family coping strategies such as seeking spiritual support, and on the other hand, this same factor can carry out negative consequences, delaying the search for support from other services.

Moreover, within the same sociocultural context, there may be differences due to numerous factors¹⁰⁾⁽⁴², such as the socioeconomic level of the family, level of education, accessibility to different services, etc. This make in the same context families develop some strategies of coping instead others.

According to family health, this corresponds to the satisfaction of the needs of each of its members, the interactions between the family and society, and what concerns us, the solution of problems or the ability to cope and adapt to situations of crisis. Therefore, the basic dimensions of family health are family social climate, family integrity, family functioning, family defence mechanisms and family coping³. It is also important to note that in order to keep adequate family health, it is necessary for the family to mobilize its resources and take the appropriate decisions to cope the new situation⁴³. Because, it should highlight the importance that families could develop good strategies family coping, for coping effectively to any demand that disturb its balance and to keep optimum performance, improving family health.

Regarding to the future prospects, it would be ideal for health professionals to make a deeper assessment of the family unit and not focus on individual members. In addition, it is important that professionals working with families know the main stressors and the coping strategies used before them, so that health promotion interventions could be carried out to promote adequate coping strategies and to improve family health.

Regarding to the implications for practice, to know how impact the events in family health, helps us the possibility of assuming strategies of health promotion that are aimed at developing a better family adaptation. Also, it helps us to promote coping strategies that make it possible to reduce vulnerability to such events and increase family well-being.

Finally, the limitations of this review, could be related to the bias of selection and publication inherent in any review. For this we had pretend to solve it through different quality instruments. In addition, caution should be exercised in interpreting the results, due to their heterogeneity, although, it is considered a source of valuable data for research, provided that it is treated methodically¹²⁾⁽⁴⁴, as this review.

CONCLUSIONS

Stressful events, like any other unusual physical and/or psychological demand, cause an anxious state of the family system, altering the dynamic equilibrium of the family system. Hence, the importance of the family unit having good coping strategies to cope different stressful events and thus, optimally keep family functioning and, therefore, family health.

Moreover, the coping strategies most used by families were those aimed at finding out information or searching family, social or spiritual support. The dissemination of different resources in the community should be encouraged, and thus make them easier to families the ability to access them. In addition, it is necessary that we must continue working to eradicating the social stigma associated with certain situations which involve the use of certain negative coping strategies such as avoidance, denial and/or concealment, causing an alteration in family health.