tude toward the prevention protocol than by their own,20 and assessing ..... HCI 2 mg, pseudoephedrine HCI 30 mg, guaifenesin. 100 mg, codeine phosphate 10 ...
Research
Methodology of
Family-oriented 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 variableversus case- (person- versus family-) centered research design and analysis.
La pratique familiale et les soins de premiere ligne axes sur la famille sont dans une position privilegiee pour etudier la famille. L'auteur presente un cadre pour conceptualiser la recherche sur les families, la sante, la maladie et les soins. 11 discute aussi des moyens par lesquels les families peuvent influencer la sante de leurs membres, les controverses actuelles sur le sens de la famille, la logique des instruments de mesure dans la recherche sur la famille, la justification de la recherche sur Ia famille et la question du devis et de l'analyse de recherche axee sur les
variables versus le cas (la personne versus la famille). (an Fam Pyskn 1991;37:2433-2441.
C are DONALD C. RANSOM, PhD
HE IDEAS OF BETITER HEALTHH
care and more effective results are easily interchangeable. Ideally, these terms should mean the same thing, but to many they do not. Good health care and effective results are value-laden concepts. Both medical politics and economics decide what these terms should mean. Thus, the idea of effective results in relation to primary care cannot be assumed to mean the same thing from country to country. When I have suggested to health maintenance organization insurers in California that it makes good sense to invest in a broad or universal family-centered approach to care because it will pay off in the long run, I have been informed that there is no long run. The average length of enrolment for subscribers is so brief (about 3 years) that it makes no economic sense to spend time and money investing in an individual or a family who will be gone before a dividend can be collected. Californians play musical chairs, if not with their jobs, with the health
plans those jobs offer. They switch to one .
E E E E E E E 0
* 0 0 0 0 0 0 0 0 - - * 0 0 0 - 0 0 9 0 0 0 - * @ - 0 0 9 @
Dr Ransom is Professor of Family and Communiy Medicine, Center for the Study of the Family & Health, School of Medicine, Universiy of California, San Francisco, and is Behavioral Science Coordinator, Family Practice Residency Program, Communiy Hospital, Santa Rosa, Calf
of several choices that looks promising during open enrolment each year, or they are told that the plan they are being offered is the only one their company can offer. In Canada, individuals are covered through a federal universal health care system that supports each province in the creation of provincial insurance plans that are available at either no charge or a minimal charge to individuals of that province. This coverage is minimal, and most individuals supplement these plans with other plans offered by either their employers or private insurance companies. This difference in approach to health care influences what types of questions will be studied and funded, especially questions about the family and family-centered care. Family-centered care is often inconvenient and unwieldy: it broadens the health care provider's focus and responsibility to include others who have an investment in the patient; it forces one's practice to be more visible; it requires regular communication with the patient alone and with both the patient and the patient's family; and it puts pressure on the physician by forcing the physician to deal in person with what is important to both patient and family members. Family-centered care can, however, increase patient satisfaction and lead to better co-operation and better health in the long run. Canadian Family Physician VOI. 37: November 1991 2433
Family medicine and the family dimension In 1970, I reviewed the relevant literature and identified four overlapping categories that outline the focus and content of the family dimension of family practice. ' It was important to define family medicine as a field of inquiry and to establish a frame of reference that would both bind its concerns and distinguish its intraindividual biological approach from its broader community and public health approach. Clearly a middle range of variables invites opportunities to study familial and other primary social environments in relation to health, illness, and care. This middle-range view is not partial to any given family form but calls attention to family as a proxy for primary human relatedness and the relevant contexts of the patient's life, and emphasizes the meaningfulness of symptoms, intervention, and all behavior related to health, illness, and care. Because meaning is always a social construct, this necessarily means studying those contexts of meaning or categories that apply to questions of interest in the provision of primary and personal care. These categories can be outlined as follows: * family roles in the etiology, predisposition, mediation, and maintenance of illness; * effects on the family and its members of illness and the treatment of illness; * family and health services provider relations; and * families as their own health-restoring and health-promoting agencies.'
New variables and new approaches The reason family physicians are interested in the family is because expanding the conceptual field within which health and pathology are understood, coupled with enlarging the focus of interventions to include the immediate social environment, leads to more effective and humane care of the person.2 This perspective is not meant to limit the physician to treating the individual in the context of the family; this approach does not go far enough, either in practice or in research, because, although it includes the family as a relevant environment, that environment is flattened on a single logical 2434 Canadian Family Physician VOL 37: November 1991
plane and simply adds to a set of variables that can either help or hinder the physician's efforts to work with the patient. In the conventional model the family is viewed as a field of forces impinging upon the patient and the physician, and family relations are not viewed as constituting, in any essential way, both the patient's condition and the caregiving process (neither are physician-patient relations, for that matter). In contrast, the significance of a family-centered approach, and the challenge for future research, is how the structure and process of persons living and behaving together as family affects the minds and bodies of those persons. The relations family members experience are inscribed in and lived through the persons we see in the office every day.3 This approach encourages family physicians to break loose from the restraining image conveyed by their more biomedicine-oriented teachers. A case in point is the 60-year-old mother who has recurring hospitalizations because she cannot breathe, whose three grown sons' respective obesity and ulcer, law breaking, and depression and chronic unemployment all have a common family history and a mutually constructed reality that organizes a pattern of finely tuned roles. One could never be assured of this without knowing each family member, seeing the members together, and observing them in their home. Caring for individuals in the context of their families is no small feat. Researching family relations, health, and care is an even greater challenge. I am not suggesting adding a few social variables to an extended biopsychosocial model. What is involved, ultimately, is documenting how families create health conditions in each other and determining how family physicians can understand and make use of this process. When we think about family process in this way and then think about the aims of family practice - ie, to provide comprehensive and continuing care to persons, to work with those persons to prevent disease and maintain health, and to effectively deal with whatever a patient brings to the physician's office -we can easily see that research in family medicine involves new outcomes and new variables. Of course we should be studying the natural history of
disease and the treatment of common problems, but when we think of the family as a unit of care in the broader sense, together with the ambitious aims and responsibilities of modern family practice, we catch a glimpse ofwhy we cannot confine ourselves to studying only variables and outcomes that are of interest to our subspecialty colleagues. Neither should we adopt models of studying practice that assume all physicians and all patients are interchangeable or models that do not identify the effects of intervention with one person on another. I recently saw a list of 23 criteria for auditing charts to evaluate the quality of care of diabetes. Nowhere on that list was any mention of whether patients felt better over time or felt more in control of or confident in managing their illness. No attention was given to whether the illness was affecting their lives or causing a problem for anyone else, or whether any other person was helping or hindering the process of controlling the diabetes. This was an illness without a person and a patient without a family or othtr significant relationships. The patient was being viewed implicitly as a container of a disease that was unconnected to any other person. This is both a fictitious and an impoverished set ofcriteria for supposed "good" care. Further, it provides a limiting set of variables for interesting research. It is this sort of example that leads me to suggest that the distinction between individual-oriented primary care and family-centered primary care is misplaced. A greater contrast exists between a disease- or procedure-oriented approach and a pers6ha-oriented approach. If individual means person, then treating the person's mind and body necessarily means including significant other people and relationships in that person's life. Who makes the difference in the patient's health, how, and in what way are good questions for researchers to study. If we consider the variety of ways in which families make a difference in the health of their members, the implications for family-centered primary care and the identification of new variables and the approaches to management those variables suggest can be addressed. Each of the following variables overlap but differ enough to suggest distinct research questions and
strategies.
Resources and support. Families can provide material resources and instrumental support for its members. This includes both the capacity and the proclivity of the family to provide food, clothing, shelter, money, and access to health care, and the availability of community resources to the family.
Health-related habits. Through modeling, teaching, encouraging, and reinforcing, family members form health-related habits and practices. Families play a principal role in shaping personal lifestyle that, in turn, shapes health. Doherty and Campbell4 place primary emphasis on the family's influence on smoking, alcohol use, diet, exercise, periodic screening, and adherence to safe driving and seat belt use - six major causes of premature death according to the American Surgeon General.5 Values and beliefs. Families transmit and reinforce values and beliefs. The family is a filter and conveyer of cultural and ethnic beliefs. Over time, families also construct their own paradigms or "characterological" styles.6'7 These family belief systems shape health and health practices.
Communication. Families create structures that organize and constrain both intrafamilial and extrafamilial communication. This includes rules that prescribe family member behavior. Pratt's theory of the energized family8 is rooted in this dimension, as is, for example, most work on the circumplex model9 and health.
Information filtering. By defining and translating information from within (the family) and from without (the wider natural and social environment), family members label processes within each other's minds and bodies and appraise particular illness episodes (ie, potential disequilibrating events). Family interaction also helps in the assimilation and accommodation of potential informational incongruities.'0
Belonging and purpose. Families provide a sense of belonging and having a meaningful place; families also provide roles that involve mutual obligation and dependence. Family life creates opportunities Canadian Family Physician VOL 37: Novernber 1991 2435
for members to exercise and sustain personal commitment, to engage in meaningful activities with a purpose or goal, and to affirm their innermost opinions, values, and beliefs. "
The family as shelter. Families provide a sense of being nurtured, loved, valued, esteemed, and cared for. Feelings of being loved and cared for generated within the family can enhance health and contribute to resisting disease, even in the face of other known environmental and biological risk factors. I,3
Family mood and emotion. The family environment contains members' emotional life and regulates family member's moods and emotions. In particular, anxiety and potential fight or flight responses are modeled by family interaction. The internal environment. By creating and sustaining an internal environment that is either devoid of stress or full of stress, family relations can be potentially harmonious, peaceful, and supportive or abusive, exploitive, full of conflict, tense, and full of worry.
Self-sacrifice and co-operation. Families by nature create conditions in which one or more member can be forced to accommodate another. Everyone is familiar with the way a variety of health-related problems are created through codependent behavior and transformed when someone breaks away from that codependency. I refer here also to any change in health status that will significantly affect others if they are to maintain their relationship. Illness as a symbol. Sometimes families induce members to enact roles in which symptoms and illness are symbolic and purposeful in maintaining family relationships. The playing out of politics and intrapsychic dynamics within the family shapes members' physical, emotional, mental, and social development.Jackson's'4 early work on family homeostasis, Laing's'5 6 concept of "transpersonal defense" and his use of the process of "mystification," the exploration of "enmeshment" by Minuchin et al'7 and Kerr's and Bowen's"8 use of the concepts of "triangles" and the "family projection pro2436 Canadian Family Physician VOL 37: November 1991
cess are all examples ofwork that has contributed to research on this complex source of family influence on health.
Approaches to management. These variables suggest two approaches to investigating the outcome of management: designs in which intervention with one member is assessed in terms of measuring its effect on another and designs in which work with one member, or a subgroup of the family, can be assessed in terms of measuring a change in the status or process of the immediate family. Several examples of the first approach are Hoebel's success in modifying cardiac risk-related behaviors of husbands by working only with their wives,"' the finding by Doherty et al that husbands' adherence to a regimen of coronary risk-reduction medication is in some ways better predicted by their wives' attitude toward the prevention protocol than by their own,20 and assessing the impact on other family members of intense intervention with the immediate patient. Medalie's2' cryptic tale of the "hidden patient," in which his singular focus on a post-coronary husband allowed him to miss the wife's suicidal behavior, is an often quoted example. A cardiologist might not think of this sort of occurrence as within the scope of either his or her medical responsibility or the research agenda, but a family physician should. An example of the second approach is Schroder's, Casadaban's and Davis's22 work with the parents of children with cystic fibrosis. The aim of the study was to increase the communication and problem-solving skills of parents and thus improve the care they could provide for their child as well as to increase the likelihood of their dealing effectively with each other, and this, in turn, would reduce individual stress and marital morbidity. Although most of our studies will focus on the health status of individual members of families, it is also useful to look at aggregate family statistics and family group functioning. For example, efforts to help family members deal successfully with managing a chronic illness in one member might lead to reduced use of health care for the entire household over the course of the next year, or to a change in the pattern of use. Similarly, the effects of such a focus could be
ascertained in terms of how differently and how well the family functions as a group in the face of the next crisis. Such process data are complex and much more difficult to measure than data about one person; however, much of the best work in primary care is done out in the shadows away from the lamp light.
Challenges of family-centered research We all know intuitively what a family is, but what is a family, or what stands for the family, for the purposes of research? In research terminology, the family is a construct. As such it can be defined according to the researcher's aims, but it can never be directly measured. Famnily research using numbers depends on the construction of reliable and valid indices to represent an idea of a family, which can then be subjected to further analysis. The great difficulty for research is that the family construct is both multidimensional and multileveled. Families are composed of persons of different sexes and generations who are similar and different from each other in potentially interesting ways. Each person occupies a different role in the family and has a unique memory of family history. The individuality of each person's part in the family composition is important, as are patterns of family interaction. The challenge for measurement is that the family is not a homogeneous "thing" that can be described in an undifferentiated fashion or a group whose members can be assumed to be affected similarly. The variety of meanings of the term family, the multidimensional and multileveled nature of those meanings, and the extraordinary range of assessment and measurement techniques available to tap them have combined to create a pervasive condition of confused and sometimes confounded investigation and reporting.23 Further, as the popularity of family systems theory has increased, researchers have felt the need to construct measures and report results in terms that reflect the family as a whole. Some of these measures, unfortunately, have added to instead of reduced the confusion. Do we know what we're studying? The most common source of logical incon-
gruity threatening the validity of conclusions drawn in family research is the implicit and often unexamined assumption of identity between the concepts or units of interest, the units of analysis, and the unit actually being measured. For too long too many family researchers have labored under the illusion that what they are studying is what they are interested in when, unfortunately, their data do not truly answer their questions. One approach to handling this problem is found in a heuristic classification scheme that identifies a set oflinks among the types of family data that are obtainable, the specific measurement methods that can be employed, and the kinds of statements and conclusions that the data can logically support.23 The scheme identifies three distinct ways that the family can be described and measured. 1. Families can be described according to member composition or a unit characteristic; families can be categorized or ordered according to some group attribute, such as family size or income or whether a family contains a member with a chronic illness. 2. Families can be described according to family member descriptions or ratings of expressed ideas and feelings about family life and other family members. This captures a central dictum of symbolic interactionism, well put by Harley Shands: "At the point of sophisticated acculturation we find .., a central paradox: the human being lives in system which in an important sense lives only in him."24 3. Families can be assessed in terms of a functioning unit, qua unit, that involves descriptions or ratings of family interaction or accounts of the joint products of family interaction. This type of family data represents a range of traditions from unobtrusive naturalistic observation to structured family interaction tasks performed in the laboratory under highly controlled conditions. The distinguishing feature of such data is that they are obtained when the relevant group is convened, and thus can speak either to the group processes themselves or to the effects of group processes on the individual participants. I suggest that data of this type provide the best grounds for diCanadian Family Physician VOL 37: November 1991 2437
rect statements about family interaction or family functioning. One simple observation to illustrate why it is important to think clearly about these issues when planning future studies is the following. Self-report questionnaires are
rity. WVhen a subset of girls who scored high on psychological and social measures of maturity were compared with a contrasting group who scored low, from a sample of 99 families participating in the study, low-scoring girls came from families in which scores
best used when they provide information about an individual's affective and cognitive world. WVhat people think and feel about their families is as important to know as is how family members solve a problem together in the laboratory. How much sense does it make, however, to ask three individuals in a family to offer their perceptions or rate their feelings about something and then add these scores together, divide by three and produce a measure that represents the family? After going through the trouble of selecting items, scaling dimensions, and performing the psychometric work necessary to produce a reliable and valid questionnaire, why leap over the level of personal responses (the data) in order to compute a spurious average phenomenology of the family? Families don't think or feel, persons do. The abandonment of individual scores in favor of a contrived family measure leaves the most interesting and potentially valuable information out of the analysis. Future work would be better served if such information (individual scores) were preserved, patterned, and analyzed to reveal the rich varieties of family composition that we know exist. In the past several years, family researchers have shown an increasing awareness of this issue, and the use of a mean score to represent the family unit in studies based on self-report is declining. For the same reason it is unwise and unnecessary to characterize a family by means of only one member's appraisal, it is also a gamble to assume that family process (or, for that matter, a particular kind of family-centered medical intervention) affects all members in the same way. In data analyses, a family should not be thought of as a homogenized vector that affects each member identically. Differences in sex, generation, birth order, and role in the family system all need to be considered when considering variations in family influence. A good example from the family literature is a study by Bell and Bell25 of the effects of family climate on female adolescent matu-
scapegoating and cross-generational coalitions were high. It would be tempting to conclude that the types of families that produce girls with low ego development had been identified and described. Yet this would not be true, because a subsequent analysis found the siblings of these low maturity girls to have relatively high maturity scores. These siblings were also less likely to have been involved in cross-generational coalitions. This suggests that it is the particular role relations within the family that make the difference, and in the study of relative adolescent maturity, generalizations about what kinds of families produce what would not hold up.
2438 Canadian Family Physician XVOL. 37: November 1991
on
Do we recognize restrictions? The assessment of families in most family and health literature has been restricted both in scope and in depth.2" There are some noteworthy exceptions, but, in general, studies have proceeded as though a group of families were assembled only to conceal the richness and variety of their internal structure and their opinions and points of view and, from time to time, to uncover some information about each family. This information would then represent the family. The family was rarely seen to be working together or to be talking among its members; even its composition and the individual differences of its members were typically not recorded. There are serious sampling problems with this procedure. Consider for a moment that an investigator's idea of what is interesting about families spans rules, customs, and communication, and each of these in turn has several facets, such as the clarity, quantity, and distribution of communication when parents talk to one another. How does the investigator know the primary construct has been adequately sampled with the data collected, and, further, what are the grounds for thinking that the aspects chosen shed more light on the research question than other features that describe a family? The common presence
of this problem explains in part why correlations between family measures and health are usually low and difficult to interpret, and why studies are so difficult to replicate.
Because there is no single indicator of family functioning or family member attitude, it is important, instead, to identify patterns among various family facets and to determine which facets and which patterns depend on the particular questions being asked. Multimethod, multileveled studies are, therefore, desirable, and multivariate analysis
is
essential.
From variables to persons If family and health investigators are to produce research that is more vivid and useful to clinicians in the future, they will need to shift from the nearly exclusive convention of variable-centered to family- and person-centered studies. Most clinicians are unaware that there is a variable-centered versus case-centered issue in research design and analysis. They generally assume that all research conclusions apply to the subjects on whom the data were originally collected rather than to the sample as a whole - a kind of imaginary subject - on which the analysis is performed. The statistical analysis, in most studies, is performed on group means and on the correlation matrix of the variables measured for the set of subjects, in which the variables are the units of analysis, not the cases (ie, persons or families). This distinction does not amount to much practically when only one independent variable is measured. For example, if you ask 100 subjects the question, "How satisfied are you with your family life?" the responses can be scaled from 0 to 5, and the data can be analyzed as a continuous variable in relation to, for example, the number of visits to the physician in the past year. The conclusions about high and low satisfaction and physician visits based on the group means can be thought of in terms of the individuals without a breach in logic. People at one end of the continuum can be thought of as satisfied, and those at the other end as dissatisfied. The switch from thinking in terms of variables to thinking in terms of subjects is automatic because it is the score on one variable that locates the subject. Conclusions couched in language such as, "people who
dissatisfaction with their families are likely to visit their family physician," have meaning to the clinician. But in multivariate research designs, which are now rapidly surpassing univariate studies, the situation is different and potentially problematic. Imagine a large sample of subjects measured on three additional continuous family variables that might influence physician visits instead ofjust the one, and that all four contribute significantly to a multiple regression analysis. Imagine further that the four variables together form a predictive equation that accounts for a quarter of the variance in visits to the physician (r- .50). It is natural to think, as in the single variable example above, that persons who are dissatisfied with their families, as well as those who score high on the second two variables and low on the last variable, have higher utilization rates. But the regression equation does not model the individuals as discrete units in the analysis; it works on the variables across all subjects taken express more
as a whole. The intuitive translation from the variables to the subjects is inappropriate. In fact, it is possible, though unlikely, that no single subject in the entire sample can be described meaningfully in terms of the regression model. To be confident in speaking in terms of individuals or families, the units entered in the analysis must be individuals or families. This is not the case in multiple regression and path analysis, in which equations provide the best prediction or model for the sample as a whole. The regression approach to modeling can be optimal for use by the public health officer or the national policy maker, but clinicians see patients one by one and in many situations benefit more from conclusions that can be described in terms of actual patients, instead of in terms of sample or population tendencies (ie, variables). This immediately suggests a need to enrich our research options, adding to the variable-centered tradition by searching for ways to create case-centered approaches for primary care research; types of cases that could be referred to as "kinds of people" or "kinds of families," a reference that fits the clinician's frame of mind.
Is family-centered research more effective? Family medicine has perhaps unnecessarily I
Canadian Family Physician VOL 37: November 1991 2439
undertaken the responsibility of proving that its methods and approach to patients are more effective than what is conventionally called the individual approach.27 This position implicitly assumes that the individual approach has already been spelled out and proved effective, an assumption that might not be warranted. Standard approaches to patient care have not been routinely subjected to systematic comparison; neither are they always supported by research evidence. They prevail because they have become conventional ways of behaving within an established group. Of course, context-oriented primary care should study its practices systematically and make every effort to produce research of the highest quality. There is no need or good reason, however, to wait until a family-centered approach has been proved more effective than an individual-centered approach. I am wary of this needing to prove to proceed position for three reasons. First is the problem of commensurate approaches to management introduced earlier. What desirable approaches to management over what period are actually being sought? A second issue is the more immediate question of preferred styles of intervening and doctoring. Talking with family members to influence the care of a patient is not like prescribing an untried drug. If a family physician decides a patient has hypertension and wants to prescribe a change in diet and exercise along with taking pills, should he or she hesitate to meet with the person in the family who does most of the grocery shopping and food preparation or resist bringing in the entire household to review what hypertension is, why it must be treated, and how the suggestions being made are supposed to help, simply because there is no proof that this approach is effective? I think not.3 My third concern about waiting for proof is that the payoff reasonably expected from such a position is based on a mistaken notion of how everyday science normally progresses.28 I doubt that, if research proves convening the family is useful for many types of problems, the typical internist or cardiologist will change his or her style of practice. Perhaps a new generation of family physicians will, but not primarily because of the research evidence. It will be because of a socially constructed 2440 Canadian Family Physician VOL 37: November 1991
change in the sense of professional identity that includes seeing families as part of everyday practice. For the same reasons that I think we should not adopt a wait and see attitude, I also think we should not be intimidated by those who say that only prospective research is worthwhile or that clinical studies without control groups are useless. Such designs are desirable, but they are necessary only for certain kinds of studies that are often expensive and difficult to conduct. Again, we should be rigorous and strive to collect trustworthy data, but at this stage of development, creativity and exploration are as necessary to the success of family-centered health research as are tight controls and statistical analyses that strive primarily for significant P values and secondarily for new insights and understanding. Likewise, we need good "sawdust" research as much as we need well-funded studies whose designs are set well ahead of data collection.29 Conclusion Implications that the special nature of primary care and family study hold for the design of future research have been reviewed and directions for that research suggested. The ambitious scope of practice combined with the multileveled and multidimensional nature of families creates investigative challenges that we have only begun to address. As our efforts mature beyond frameworks supplied by those who have taught us, we might be able to shift our analytic focus from variables to persons and families and provide answers to questions in terms that are useful to the world of everyday practice. e Acknowledgment 7The research for this paper was funded in part by NIMH Grant No. 38468. Requests for reprints to: Dr Donald C. Ransom, Department of Family & Community Medicine, AC-9, Box 0900, UCSI, San Francisco, CA 94143 USA
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*CoActifed*t* (Tfprolidine-Codeine-Pseudoephednne) Indications: CoActifed 3. Ransom DC. Random notes: on light versus electron microscopes in family research. Fam Systems Med 1987;5:383-90. 4. Doherty WJ, Campbell TL. Families and health. Beverly Hills, Calif: Sage Publications, 1988. 5. Califano JAJ. Healthy people: the surgeon generals report on health promotion and disease prevention. Washington, DC: Government Printing Office, 1979; DHEW Pub No. 79-55071. 6. Reiss D. Thefamily' construction of realiy. Cambridgc, Mass: Harvard University Press, 1981. 7. Steinglass P, Bennett LA, Wolin SJ, Reiss D. 'The alcoholic family. New York, NY: Basic Books, 1987. 8. Pratt L. Family structure and effective health behavior: the energizedfamily. Boston, Mass: Houghton-Mifflin, 1976. 9. Olson DH, McCubbin HI, Barnes H, Larsen A, Muxen M, Wilson M. Families: what makes them work. Beverly Hills, Calif: Sage Publications, 1983. 10. Moss GE. Illness, immunity and social interaction: the dynamics of biosocial resonation. New York, NY: Wiley, 1973. 11. TIotman R. Social causes of illness. New York, NY: Pantheon Books,1979. 12. Medalie JH, Goldbourt U. Psychosocial and other risk factors as evidenced by a multivariate analysis of a five year incidence study. Am]3 Med 1976;60:910-21. 13. Sagan LA. The health of nations: true causes of sickness and well-being. New York, NY: Basic Books, 1987. 14. Jackson DD. Family homeostasis and the family physician. CalJf Med 1965; 103:239-42. 15. Laing RD. Individual and family structure. In: Lomas P, editor. The predicament of the family. London: Hogarth Press, 1967. 16. Laing RD. Mystification, confusion and conflict. In: Boszormenyi-Nagy I, Framo J, editors. Intensive family therapy. New York, NY: Harper & Row, 1965. 17. Minuchin S, Rosman BL, Baker L. Psychosomatic families. Cambridge, Mass: Harvard University Press, 1978. 18. Kerr M, Bowen M. Family evaluation: an approach based on Bowen theo?y. New York, NY: W.W. Norton, 1988. 19. Hoebel FC. Brief family-interactional therapy in the management of cardiac-related high risk behaviors. J Fam Pract
1977;3:613-20. 20. Doherty WJ, Schrott HG, Metcalf L, Iasiello-Vailas L. Effect of spouse support and health beliefs on medication adherence. J Fam Pract 1983; 17:837-44. 21. Medalie J, editor. Family medicine: principles and application. Baltimore: Williams & Wilkins, 1978.
22. Schroder KH, Casadaban AB, Davis B. Interpersonal skills training for parents of children with cystic fibrosis. Fam Systems Med 1988;6:51-68. 23. Draper TW, Marcos AC, editors. Family variables: conceptualization, measurement, and use. Newbury Park, Calif: Sage Publications, 1990. 24. Shands HC. The war with words: structure and transcendence. The Hague: Mouton, 1971. 25. Bell LG, Bell DC. Family climate and the role of the female adolescent: determinants of adolescent functioning. Fam Relations 1982;31:519-27. 26. Fisher L, Terry HE, Ransom DC. Advancing a family perspective in health research: models and methods. Fam Process 1990;29: 177-89. 27. Schmidt DD. Letter to the Editor. Fam Systems Med 1987;5:377-9. 28. Kuhn T. The structure of scientific revolutions. Chicago, III: University of Chicago Press, 1970. 29. Huygen FJA, van den Hoogen HJM, van EijkJTM, Smits AJA. Death and dying: longitudinal study of their medical impact on the family. Fam Systems Med
1989;7:374-84.
FOR ONE BILLION PEOPLE,THIS IS A TOXICA SUBSTANCE.
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Expectorant: To facilitate expectoration and control cough associated with inflamed mucosa and tenacious sputum. CoActifed Syrup and Tablets: The treatment of cough associated with inflamed mucosa. Precautions: Before prescribing medication to suppress or modify cough, it is important to ascertain that the underlying cause of the cough is identified, that modification of the cough does not increase the risk of clinical or physiologic complications, and that appropriate therapy for the primary disease is provided. In young children the respiratory centre is especially susceptible to the depressant action of narcotic cough suppressants. Benefit-to-risk ratio should be carefully considered, especially in children with respiratory embarrassment, e.g., croup. Estimation of dosage relative to the child's age and weight is of great importance. Since codeine crosses the placental barrier, its use in pregnancy is not recommended. As codeine may inhibit peristalsis, patients with chronic constipation should be given CoActifed preparations only after weighing the potential therapeutic benefit against the hazards involved. CoActifed contains codeine: may be habit-forming. Use with caution in patients with hypertension and in patients receiving MAO inhibitors. Patients should be cautioned not to operate vehicles or hazardous machinery until their response to the drug has been determined. Since the depressant effects of antihistamines are additive to those of other drugs affecting the CNS, patients should be cautioned against drinking alcoholic beverages or taking hypnotics, sedatives, psychotherapeutic agents or other drugs with CNS-depressant effects during antihistaminic therapy. Adverse Effects: In some patients, drowsiness, dizziness, dry mouth, nausea and vomiting, or mild stimulation may occur. Overdose: Symptoms: Narcosis is usually present, sometimes associated with convulsions. Tachycardia, pupillary constriction, nausea, vomiting and respiratory depression can occur. Treatment: If respiration is severely depressed, administer the narcotic antagonist, naloxone. Adults: 400 ,ug by I.V., I.M. or S.C. routes and repeated at 2- to 3-minute intervals, if necessary. Children: 10 ,ug/kg by I.V., I.M. or S.C. routes. Dosage may be repeated as for the adult adminristration. Failure to obtain significant improvement after 2 to 3 doses suggests that causes other than narcotic overdose may be responsible for the patient's condition. If naloxone is unsuccessful, institute intubation and respiratory support or conduct gastric lavage in the unconscious patient Dosage: Children 2 to under 6 years: 2.5 mL 4 times a day; 6 to under 12 years: 5 mL or /2 tablet 4 times a day. Adults and children 12 years and older: 10 mL or 1 tablet 4 times a day. Supplied: Expectorant: Each 5 mL of clear, orange, syrupy liquid with a mixed fruit odor contains triprolidine HCI 2 mg, pseudoephedrine HCI 30 mg, guaifenesin 100 mg, codeine phosphate 10 mg. Available in 100 mL and 2 L bottles. Syrup: Each 5 mL of clear, dark red, syrupy liquid with a pineapple odor and a sweet black currant flavour contains triprolidine HCI 2 mg, pseudoephedrine HCI 30 mg and codeine phosphate 10 mg. Available in 100 mL and 2 L bottles. Tablets: Each white to off-white, biconvex tablet, code number WELLCOME P4B on same side as diagonal score mark, contains triprolidine HCI 4 mg, pseudoephedrine HCI 60 mg and codeine phosphate 20 mg. Each tablet is equivalent to 10 mL of syrup. If tablet is broken in half, it reveals a yellow core. Bottles of 10 and 50 tablets. REFERENCES: 1. AMA Department of Drugs: AMA Evaluations, Ed. 6. Littleton,
Mass., Publishing Sciences Group Inc., September 1986;383. 2. Data on file Burroughs Wellcome: TKMD/84/0026-1. 3. Data on file Burroughs Wellcome: TKMA/87/0004. 4 CoActited Prescribing Intormation
Additional prescribing information available on request. CoA 9t07 *Trade Marl
