383145

383145CheslaJournal of Family Nursing

The Author(s) 2010

JFN16410.1177/1074840710

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Plenary Address from the 9th International Family Nursing

Conference, Reykjavik, Iceland, June 2009

Do Family
Interventions
Improve Health?

Journal of Family Nursing

16(4) 355377
The Author(s) 2010
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DOI: 10.1177/1074840710383145
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Catherine A. Chesla RN, DNSc, FAAN1

Abstract
The central aim of this article is to examine the evidence that family interventions improve health in persons with chronic illness and their family members, across the life span. The review focuses on recent meta-analyses of
randomized controlled trials of family intervention research. In adults, evidence supports the salutary effects of family interventions versus usual medical care for patient health and mental health, and for family member health.
In children, robust evidence supports family-based multimodal interventions
for obesity treatment. Reasonable evidence supports family approaches to
type 1 diabetes treatment in children. Nurses led the research or were members of interdisciplinary research teams in several of these literatures, representing one quarter to one third of the research cited, but were absent in
other literatures, such as family treatment of childhood obesity.
Keywords
chronic illness, family intervention, family nursing, family treatment, metaanalysis
Family nursing comprises an orientation to the care of families in health and
illness that is based on a set of theories (Patterson, 1988; Rolland, 1994;
1

University of California, San Francisco

Corresponding Author:
Catherine A. Chesla, RN, DNSc, FAAN, Professor and Shobe Endowed Chair, Family Health
Care Nursing, University of California, San Francisco, 2 Koret Way, Box 0606, San Francisco,
CA 94143-0606
Email: kit.chesla@ucsf.edu

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Journal of Family Nursing 16(4)

Wright, Watson, & Bell, 1996) that sensitize and guide the practitioner, a
body of empirical literature about families and their treatment, and a unique
collection of practices that skillfully engage families in the care of one another.
Research with families has provided careful, systematic study of family processes and relations that support or impede health of family members or of
the family as a unit (Fisher & Weihs, 2000). Similar attention to developing
family interventions or translating research into practice has lagged (Duhamel,
2010). If the hope of family nursing is to be realized, then we must redouble
our efforts to move knowledge into practice. In so doing, we must rely on the
knowledge generated in multiple disciplines and through multiple routes
(Chesla, 2008; Leahey & Svavarsdottir, 2009) to fuel development of our
practice. In this article, I summarize extant research, in an effort to stimulate new efforts and to demonstrate the successes in past research on family
interventions.
The central aim of this article is to examine the evidence that family interventions improve health. The review focuses on recent meta-analyses and
narrative summaries of what is known. Intervention research, rather than
descriptive research, was the focus, and I weighed more heavily randomized
clinical trials (RCTs). Nursing contributions to the body of evidence that has
been amassed will be examined. Looking over the many meta-analyses that
are available, I will parse what we know about what works for whom. I close
by offering some suggestions for future research.

Method
To describe in an overview fashion, the state of knowledge about family interventions in health, recent meta-analyses, and literature summaries conducted in
the past 5 years were reviewed, by searching CINAHL, Medline, and PsychInfo.
Knowledge is developing in multiple fields, including family psychology, family social science, family therapy, and family nursing, and thus broad, interdisciplinary knowledge bases regarding family intervention required consideration.
Within the reviews, the numbers of investigations that were directed by nurses
or had research teams that involved nurses were evaluated.
I focused on reviews and meta-analyses on family psychosocial treatments of physical health conditions or chronic illnesses of a family member
across the life span, although some meta-analyses included dementia-type
illnesses. This review did not include family interventions in mental health
and illness, primary health promotion or prevention programs (e.g., parenting
healthy children), smoking cessation, alcohol or drug use interventions, or
family interventions to address conduct disorders or antisocial behaviors in

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children. The major findings to be reviewed derive from three major metaanalyses that were conducted on family interventions in the care of adults
with diverse chronic illnesses (Hartmann, Bazner, Wild, Eisler, & Herzog,
2010; Martire, 2006; Martire, Lustig, Schulz, Miller, & Helgeson, 2004). In
addition, meta-analyses of family interventions in children with obesity
(McGovern et al., 2008) and diabetes (Armour, Norris, Jack, Zhang, & Fisher,
2004) are reviewed. No meta-analyses were located that examined in a noncategorical manner family interventions with child chronic illnesses, clearly
an important gap in existing literature.
In addition, recent systematic reviews of the family intervention literature
were reviewed for salient themes (Boschen, Gargaro, Gan, Gerber, & Brandys,
2007; Epstein, Paluch, Roemmich, & Beecher, 2007; Ireys, Chernoff, Stein,
DeVet, & Silver, 2001; Kazak, 2005; Luker, Chalmers, Carees, & Salmon,
2007; Nowicka & Flodmark, 2008; Palmer & Glass, 2003; Wilfley et al., 2010),
and this contributed to a contextual understanding of the nature and focus of
family interventions in chronic illness across the life span. However, to arrive
at a unified sense of the effectiveness of family psychosocial interventions,
quantitative comparisons were used.
The family field of study has begun to grow beyond the possibility of
recounting strengths and weaknesses of individual studies. Meta-analyses
provide a mechanism for combining research results (Rosenthal & DiMatteo,
2001) to obtain perspective on the broader landscape, a view from 10,000 ft.
In addition, meta-analyses allow all studies to contribute to the evidence,
despite the size of the study and regardless of whether it demonstrated significance. This is particularly useful when examining family intervention
research because the complexity of these projects frequently leads to smaller
sample sizes. Meta-analyses are certainly not without limits. They require
rigor in systematically examining the research and formulating clear hypotheses to be tested. Judgment is required to determine the quality of various
studies, inclusion and exclusion criteria, and outcomes. In sophisticated analyses, mediator and moderator variables can be examined, to begin to determine with whom and in what forms the interventions of interest are most
effective (Lipsey & Wilson, 2001).

Family Interventions in Adult Chronic Illnesses

Martire and colleagues (2004) evaluated three and one half decades of RCTs
that compared family psychosocial interventions in adult chronic illnesses
with usual medical care. This thoughtful analysis is reviewed first and in
greater detail because many important issues of concern in treating families

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Journal of Family Nursing 16(4)

were identified. The strengths of the review include a systematic, inclusive,

and careful approach to searching the literature; clear descriptors of what
comprised family research; and a detailed examination of varying outcomes
for patients and family members. Research was reviewed via OVID from each
of the following electronic databases from their inception to 2002: CINAHL,
CancerLit, Medline, PsychInfo, and the Cochrane database. The authors
additionally searched databases that might yield studies in the fields of social
work, education, psychology. Search terms included the following: patient,
ill, illness, health; family, caregiver, caregiving, marriage, marital, spouse, spousal, couple or partner; treatment, intervention, support. Interventions were
searched that met the following criteria: nonmedical interventions, that are
psychologically, socially or behaviorally oriented and that involve a member
of an adult patients family or both the patient and family member (Martire
et al., 2004, p. 601).
Using these search methods the team identified 225 studies. Applying four
additional quality criteria, 70 studies were identified for analysis. To be included,
each project had to employ a RCT design with pre- and posttreatment measures, compare family psychosocial interventions to usual medical care, whether
the program enrolled patients and families, at least 90% of patients had to
have family participation, and the project reported an outcome variable of
interest for the patient, family member, or both. Outcome variables investigated for both patients and spouses included depressive symptoms, anxiety
symptoms, and relationship satisfaction. Patient-specific outcomes additionally included degree of physical disability and mortality. One family-specific
outcome investigated was caregiving burden. For each of these outcomes, the
Martire team analyzed measures reported that might serve as appropriate markers; for example, varied measures of depression reported on in separate studies were used to evaluate depressive symptoms.
Martire and colleagues (2004) additionally examined potential moderators
of the family psychosocial intervention to learn whether additional specificity
might be identified for efficacious family interventions. Moderators examined
included the disease process being treated, particularly whether it was a physical or a dementia-type disorder, and whether the focus of the intervention
was spouses only or mixed family members. A third moderator was who was
included in the intervention, family members only or patients and family
together. Finally, the content of the intervention, be it relationship focused or
focused on illness issues for patient and family member, was explored.
Because of the historical period covered, multiple results reported in this
meta-analysis are of interest. For example, the number of family interventions
directed to different disease processes suggests which fields have been most

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engaged in family interventions. In 70 studies, the following disease processes were represented: dementia (44.3%), heart disease (21.4%), frail older
adults (15.7%), and cancer (7.1%). Additional diseases addressed in a small
number of studies (n = 3 or less) were chronic pain, stroke, rheumatoid arthritis, and traumatic brain injury. Significant gaps are immediately apparent.
Diseases that are quite prevalent, such as diabetes or respiratory disorders,
have not been addressed in RCT family trials, whereas dementia, elder care,
and heart disease have had strong interest.
Nursing involvement in directing or assisting with family studies was also
assessed. A hand search of the articles included in the review (Martire et al.,
2004) was conducted to determine whether a nurse was the principal investigator
or appeared to direct the research. Involvement of nurses in the scientific team or
in the delivery of the intervention was additionally noted. A total of 16 of 70 studies (23%) were directed by nurses, and an additional 7 studies had nurses on the
research team. Therefore, 23 out of 70 studies (33%) had nursing involvement.
Reviewing family interventions from 10,000 ft requires some rubric for
describing the content of interventions. Classification of family psychosocial
interventions is far from standardized, and classifications offered in previous
reviews (Fisher & Weihs, 2000) have not been widely adopted. One distinction is between psychoeducational interventions and relationship-focused
interventions. Interventions labeled psychoeducational include those that
educate patients and family members about disease processes, requirements
for care, and basic information about how individuals and families are affected
by living with chronic illness. These interventions are largely directed toward
increasing knowledge and skill in disease management, such as managing
diet restrictions postcardiac surgery, and may address individual responses to
the demands of chronic illnesses and its care. In contrast, relationship-focused
interventions directly attend to skills for improving family relations while
living with the demands of chronic illness management. Such programs typically involve didactic and skill-building elements in problem solving, family
communication, conflict management, or cognitive-restructuring (Weihs,
Fisher, & Baird, 2002). In the meta-analysis considered first (Martire et al.,
2004), interventions were classified as relationship focused or not, in a manner that roughly paralleled this distinction.
Results of the meta-analysis (Martire et al., 2004) suggested that overall
family psychosocial interventions compared favorably with usual medical
care, on several outcomes of interest. Significant positive results are reviewed
here for patients and family members as are noteworthy negative findings. In
Table 1, significant positive effects are presented along with the number of
studies and patients examined, confidence intervals, and significance levels.

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Table 1. Meta-Analysis of Patient and Family Outcomes in Family Intervention

Outcome
Patient outcomes
Depressive symptoms
Spouses only (not mixed
family)
Patient mortality
Physical illness
Mixed family (not spouses
only)
Not relationship focused
Family member outcomes
Depressive symptoms
Physical illness
Mixed family involved
Family member only as
target
Anxiety
Relationship-focused
intervention
Burden
Dementia
Nondementia
Spouses only
Mixed family members
Family member as target
Patient & family member
as target
Relationship focused
Nonrelationship focused

No. of
studies
(No. in
sample)

Aggregate
effect size
(d value)

Confidence
interval

p
value

13 (3, 176)

.33

0.02-0.64

ns
.04

9 (4,030)
5 (3,053)
6 (1,550)

.08
.13
.14

0.00-0.16
0.00-0.26
0.02-0.25

.06a
.05
.02

7 (1,666)

.13

0.03-0.23

.01

41 (7,850)
18 (1,433)
29 (6,825)
24 (5,855)

.10
.17
.10
.15

0.02-0.18
0.02-0.32
0.01-0.20
0.03-0.27

.02
.03
.04
.01

14 (898)
9 (541)

.14
.21

0.01-0.29
0.00-0.42

.07a
.05

40 (7,951)
25 (6,604)
15 (1,347)
7 (651)
33 (7,300)
24 (5,885)
16 (2,066)

.10
.10
.20
.26
.09
.17
.11

0.06-0.15
0.04-0.16
0.09-0.31
0.11-0.42
0.04-0.14
0.08-0.26
0.03-0.20

.00
.00
.00
.00
.00
.00
.01

18 (1,826)
22 (6,125)

.22
.07

0.13-0.32
0.02-0.12

.00
.01

Source: Adapted from Martire et al. (2004).

Note: Only significant outcomes are reported.
a. Approaches significance.

Of the five patient outcomes examined (Martire et al., 2004), only one,
patient mortality, demonstrated that family care was significantly better than
usual medical care when including all studies analyzed for all outcomes.

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Overall, family interventions did no better than usual medical care in addressing patient depressive symptoms, anxiety, patient disability, and relationship satisfaction. Aggregate effect size (Cohens d; Rosenthal & DiMatteo,
2001) for family interventions on patient mortality (effect size [ES] = 0.08)
approached significance (p = .06). This suggests that, at a level approaching
significance, adult patients with chronic illness who received family psychosocial care lived longer than those receiving usual medical care. This finding
was based on nine studies involving 4,030 patients, and the findings were
heterogeneous.
However, when analyses were stratified by four moderator variables,
additional significant effects were revealed. For patient mortality, stratification into dementia or nondementia-type illnesses revealed that family care
significantly decreased mortality for those with physical illnesses, as compared to usual medical care (ES = 0.13). This same effect was not observed
in patients with dementia-type illnesses, and the subgroup ESs were significantly different (p < .001). Family treatment groups with mixed family members did significantly better than those in usual medical care (ES = 0.14), but
a similar effect was not observed in spouse-only groups. In a similar manner,
family interventions that were classified as not relationship focused decreased
patient mortality significantly more effectively than did usual medical care
(ES = 0.13), but a similar difference was not observed in relationship-focused
care. The authors cautioned that the latter two findings should be interpreted
with care, given that they were based on a small number of studies in some
subgroups (k = 2-3), and there was considerable overlap in the studies that
included mixed family members and nonrelationship-focused interventions.
Although the overall meta-analysis of family care contrasted with usual
care demonstrated no significant differences for patient depression, stratified
analyses revealed some groups for whom family care substantially improved
patient depressive symptoms. The 13 trials that treated only spouses demonstrated significantly better patient depressive outcomes than usual medical
care (ES = 0.33). Trials that treated mixed family members (k = 14) did not
reliably improve patient depressive symptoms better than usual medical care.
Considering family members, four outcomes were examined: depressive
symptoms, anxiety, relationship satisfaction, and burden (Martire et al., 2004).
In the central meta-analysis including all studies that observed these outcomes, family treatments demonstrated significantly better outcomes than
usual medical care in depressive symptoms and family member burden and
approached significance for family member anxiety. There was no evidence
that family approaches had an observable effect on relationship satisfaction.
A total of 41 studies including 7,850 participants contrasted the alleviation
of family members depressive symptoms in family versus usual medical care.

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A small but significant positive effect of family care was observed (ES = 0.10),
and the finding was heterogeneous. Additional analyses that examined moderators of this relationship yielded additional significant findings. Family
members depressive symptoms were alleviated in family care when the ill
member had a physical illness (ES = 0.17), an effect that was not apparent in
the dementia-type illnesses. Treatments that included mixed family members
had more beneficial effects on family members depression than did usual
medical care (ES = 0.10), but treatments that included spouses only did not.
Family interventions that treated only family members alleviated family member depression better than usual care (ES = 0.15), but treating family members and patients together did not positively affect family member depression.
Finally, relationship-focused care improved family member depression more
so than usual care (ES = 0.16), but nonrelationship-focused treatments did
not. Family member anxiety was only marginally improved by family interventions, but relationship-focused programs did demonstrate significantly
better anxiety outcomes than usual medical care (ES = 0.21).
The most compelling finding in this meta-analysis (Martire et al., 2004)
was in the area of family member burden. In 40 studies, including 7,951
participants, family care programs demonstrated a small but highly significant aggregate effect of family care over usual medical care on family burden (ES = 0.10); this outcome was uniform across studies. Stratified analyses
revealed a significant, homogenous, positive effect of family care on family
member burden in every subgroup evaluated, considering type of illness,
who in family was treated, and whether the treatment addressed relationship
issues or not.
In summary, this examination of family treatment effectiveness in adults
with chronic conditions provided several important findings. First, there is
fairly clear evidence that family care approaches were superior to usual medical
treatment in relieving family member burden; regardless of treatment approach,
target of the intervention or type of illness, burden was less in family-treated
groups. Second, depression in spouses was better in family treatment approaches
versus usual medical care when patients suffered from physical but not
dementia-type chronic illnesses. Frequently, the stresses of dementia care are
found to be more refractory to treatment than are those of physical care. That
relationship-focused therapies were more effective than medical care in relieving depressive symptoms in family members is an intuitively acceptable
finding; spouses and family members frequently feel the influence of chronic
illnesses through their relationships with the ill member. Focusing directly on
relationship issues in the treatment may relieve family members pressing
dilemmas and thus their depressive symptoms.

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Patient outcomes are remarkable for the fact that family treatment
approaches improved mortality over usual medical care across all studies where
the patient suffered from a physical illness. That family psychosocial interventions could effect better patient survival as compared with usual medical
care suggests, as have other reviews (Campbell, 2003; Weihs et al., 2002),
that the family context is a potent factor influencing illness course in chronic
conditions.
There were disappointing findings as well. This meta-analysis provides no
evidence that family-focused interventions were better than medical care
with patient disability or anxiety or in terms of anyones relationship satisfaction. Although the last is based on only a small number of studies (five), it
raises questions about the mechanisms by which family interventions might
achieve their effect. Theoretically, we would hope to positively influence the
quality of family relations as part of the process of influencing a change with
families coping with chronic illness. The negative findings raise questions
about why the change may not have been realized and whether measures
were sufficiently sensitive to indicate change over time.
A second, more recent meta-analysis of family interventions in chronic
physical diseases (Hartmann et al., 2010) provides further evidence that
family interventions are more efficacious than usual medical care for patient
and family member health and well-being. Hartmann and colleagues conducted a search including studies from the 1950s through 2007 that were
RCTs comparing family treatment versus usual medical care. This second
review was similar to the first (Martire et al., 2004) but employed slightly
different search terms (chronic diseases, family, information/education/
intervention/psychotherapy) and slightly different exclusion criteria. Their
extraction yielded 52 studies that focused on cardiovascular diseases (52%),
cancer (29%), arthritis (10%), diabetes (4%), AIDS (4%), and one study on
systemic lupus erythematosis.
Nursing representation in the publications was slightly greater (36.5%)
than in the prior review. As noted earlier, determining what comprises the
disciplinary contribution to any particular study is not straightforward. By
authorship, 11 of the 52 (21%) were led by nurses and thus represented
research conceived and supervised by nurse scientists. In an additional 8 (15%)
studies, nurses were named as part of the publishing team, although their role
was not specified. Also, although it was not always reported clearly, within
the 15 of the 19 studies with nurse involvement, the interventionist was a
nurse or a nurse was a part of a multidisciplinary team delivering the intervention. Social workers comprised the second most frequent discipline represented in the interventions followed by psychologists and/or dietitians. In

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the studies in which there were nurses involved, the interventionist was never
a physician.
To compare these first two meta-analyses, both considered family treatment of adult chronic illnesses as compared with usual medical care. The
second review (Hartmann et al., 2010) is more recent and thus includes studies conducted between 2002 and 2007 that were not previously examined.
Although Martire and colleagues (2004) included dementia-type disorders,
Hartmann and colleagues did not. Outcomes examined for patients and families were similar in the two reviews but were categorized into larger conceptual areas by Hartmann and colleagues; for example, they combined family
burden with family depression into a single category of family member health.
Although there was some overlap in the studies included in the two metaanalyses, 70% of the studies examined by Hartmann were unique from those
included in the earlier review. Twelve of the 36 unique studies were included
in the latter review because of slightly different inclusion/exclusion criteria,
not simply because of how recent the publication.
Hartmann and colleagues (2010) examined three categorical outcomes:
patient physical health, patient mental health, and family member health.
Patient physical health included markers of patient level of dependency, clinical symptoms and events, self-rated physical health, and disease management markers. Patient mental health included measures of depression, anxiety,
quality of life, general mental health, and self-efficacy. Health of family
members included measures of burden, depression, anxiety, general mental
health, and self-efficacy. There was no evaluation of family physical health,
and the rationale for this was not mentioned, but we may surmise that there
were insufficient numbers of studies that included measures of family member physical health to include in the analyses.
This meta-analysis (Hartmann et al., 2010) persuasively demonstrated
family interventions as superior to usual medical care in all outcomes evaluated (Table 2). An advantage of using a categorical approach for patient
outcomes was that all 52 studies, representing 8,896 participants, were
included in the meta-analysis. For each patient outcome, there was a small,
quite significant pooled effect of family treatment over usual medical care
for patients physical and mental health. At the first point of follow-up, the
ES (Hedges g) for patient physical health was small but significant (ES = 0.32).
Similar findings were observed for patient mental health (ES = 0.28). It is
noteworthy that although these ESs are by standard definitions small, they
are overall larger than those reported in the prior meta-analysis, where most
commonly aggregate ESs were in the 0.10 to 0.20 range. Family member

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Table 2. Meta-Analysis of Patient and Family Outcomes in Family Intervention
No. of
studies (no.
in sample)

Outcome

Effect size
(Hedges g)

Confidence
interval

p value

Patient outcomes
Patients physical health
First follow-up
Follow-up
7+ months later
Patients mental health
First follow-up

52 (8,896)
12 (not
reported)

.32
.21

0.18-0.45
0.09-0.33

.001
.001

52 (8,896)

.28

0.12-0.43

.001

Follow-up
7+ months later

12 (not
reported)

.29

0.02-0.56

.039

18
4

.35

0.05-0.66

.024
ns

Family member outcomes

Family members health
First follow-up
Follow-up
7+ months later
Source: Hartmann et al. (2010).

health was similarly significantly more positive in family treatment rather

than usual medical care (ES = 0.35). This finding was based on fewer studies
(18) and presumably a smaller number of participants, although this number
was not reported.
A strength of this review (Hartmann et al., 2010) is that the authors
examined the stability of the effect of family interventions over time. In
patient outcomes, they had a reasonable number of studies (12) from which
to compare patient outcomes measured 7 or more months after the completion
of the intervention. Encouragingly, the difference that family interventions
made over usual care in patient health (ES = 0.21) and mental health (ES =
0.29) remained significant. There were fewer studies that examined family
member outcomes over time (n = 4), and the aggregate effect of family
intervention on family member health was not significantly better than
usual medical care.
Hartmann and colleagues (2010) conducted additional analyses to examine whether type of treatment (psychoeducational vs. relationship focused),
disease group treated, and type of family member involved in the intervention

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(spouse or mixed family member) altered the results. Their findings were
largely unremarkable; family-involved treatment demonstrated better outcomes regardless of the moderator examined, except in a few instances. For
example, relationship-focused interventions had a salutary effect on family
member health, but psychosocial interventions did not. This finding approximates that found in the Martire review and again suggests that family members may be most helped by treatments that directly address family relationship
issues, rather than targeting only disease or personal management issues.
Regarding diseases, only studies focused on cardiovascular diseases were sufficient in number to meaningfully conduct a separate meta-analysis by disease. In this instance, the superiority of family intervention over usual care
was observed for patient health and mental health.
Additional factors such as length of treatment and quality of the study
were examined. Duration of intervention made no difference in either patient
outcome, but did in family member outcomes, with better outcomes observed
in interventions of longer duration. Hartmann and colleagues (2010) rated the
quality of studies based on their described randomization procedures, allocation
concealment, the number of participants lost to follow-up, and whether they
employed an intent-to-treat analysis. A separate meta-analysis of only the
high-quality studies did not substantially change the findings.
In summary, two high-quality meta-analyses suggest that family care in
adult chronic illness is superior to usual medical care for the health and general well-being of patients and family members who live with and care for
them. This broad empirical support for adopting family approaches in adult
chronic illness care is heartening and strengthens the justification for continued exploration and testing of appropriate approaches to most successfully
assist in varied conditions.
Additional inquiry is needed, however, to examine how well family psychosocial approaches compare with psychosocial interventions delivered to
individual patients in chronic illness. One question is whether involving family members in psychosocial treatment offers unique or added benefits to
psychosocial care of the patient. In a subsequent review, Martire (2006)
examined the relative efficacy of family versus individual psychosocial
interventions in adults with chronic illness using the same search methods
described earlier but updating the review to August 2003. The yield on this
rigorous search was disappointingly small. In a 30 year review, Martire uncovered only 12 RCTs. These studies addressed heart disease, chronic pain,
osteoarthritis, rheumatoid arthritis, and type 2 diabetes, and 4 of the 12 studies were directed by nurses. The evidence was equivocal. In 2 of the studies, family approaches had superior outcomes, and in 1 study individual

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approaches were more efficacious in improving patient status. In the

remainder of the studies, mixed results were observed, with each approach
demonstrating better outcomes on some indicators or at some time points, or
with no significant differences found between family or individual approaches.
In short, although there are pressing questions about the relative efficacy
of these two approaches in chronic illness, most of the work remains to be
completed.

Family Treatment in Childhood

Chronic Illnesses
Although there has been a significant amount of intervention research in
children with chronic illness conducted by nurses and others, reviews of
this work have been largely narrative (Weihs et al., 2002). There were no
noncategorical reviews of family interventions with children with chronic
illnesses located in the past 5 years. Given that the aim of this article was
to apply objective criteria to the question of whether family interventions
made a difference in health, treatment of childhood illnesses is reviewed
via the only meta-analyses that were located: treatment of childhood obesity and childhood diabetes. For treatment of obesity, several meta-analyses
and summative reviews examining family treatments have been recently
published (American Dieticians Association, 2006; McGovern et al., 2008;
Snethen, Broome, & Cashin, 2006; Young, Northern, Lister, Drummond, &
OBrien, 2007). The review by McGovern and colleagues (2008) will be
discussed because it is the most recent, comprehensive, and rigorously
conducted review. Observations from the other meta-analyses will be
included in the discussion of this body of literature. Regarding diabetes,
one review was located that analyzed the treatment effects of family
treatment versus individual care in the management of childhood diabetes
(Armour et al., 2004).

Childhood Obesity
In the interest of developing evidence-based treatment recommendations, a
comprehensive review of childhood obesity treatments was commissioned
by the Endocrine Society in the United States. The authors (McGovern et al.,
2008) reviewed RCTs of obesity treatment in children and adolescents that
were located via searches of multiple databases since their inception through
2006. Among the many strengths of this review is the fact that separate
meta-analyses were conducted for different forms of treatment, including

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pharmacological, dietary, physical activity, and combined lifestyle interventions. In addition, combined lifestyle interventions targeting families were
analyzed separately from those targeting children alone. On the whole, only
two types of interventions, pharmacological and combined lifestyle interventions targeting families, had a demonstrable positive effect on reducing
childhood obesity as measured by body mass index. In addition, one group
of physical activity interventions significantly positively affected childhood
obesity as measured by percentage of childrens body fat. Only the combined
lifestyle interventions will be reviewed in detail; pharmacological treatments
are considered a secondary treatment due to their side effects, potentially
negative physiologic effects, and brief duration of testing. In fact, based on
the review, the Endocrine Society formally recommended that clinicians
prescribe and support intensive lifestyle (diet, physical activity and behavioral)
modifications to the entire family and to the patient in an age-appropriate
manner as the prerequisite for all overweight and obesity treatment (August
et al., 2008, p. 4582, italics added).
In the meta-analysis of combined lifestyle interventions for childhood
obesity involving families, treatments typically included education about diet
and exercise, a structured approach to diet changes, such as the Stoplight Diet
(Epstein et al., 2007), and structured approaches to increasing exercise or
decreasing sedentary activities (Young et al., 2007). Coaching and practice in
family relationship skills, such as support, conflict management, communication, and teamwork were present in programs but in varying degrees of
structure and intensity (McGovern et al., 2008). Coaching in parenting skills
appeared to be a part of only some of the programs. Although all programs
were compared with a control condition and families were randomly assigned
to the treatment or control condition, the control conditions also varied widely,
with some comprising usual care, others a simple education program with no
family involvement, and some providing a true parallel program with a different focus.
The meta-analysis of combined lifestyle interventions for childhood obesity targeting families demonstrated a moderate, positive, and highly significant effect on child weight loss (ES = 0.64; CI = 0.88, 0.39; p < .00001).
A total of 11 separate RCT studies involving 514 participants were included
in this analysis. None of these projects were directed by nurses or had members of their teams who were nurses. In some of the studies, parents and
children were treated together, and in others parents were treated alone; these
two types of approaches were not separately analyzed. The crucial importance of family involvement is highlighted by the fact that combined lifestyle

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interventions delivered to children only (12 studies, 402 children) did not
demonstrate significant positive effects (McGovern et al., 2008).
The efficacy of multimodal family interventions with child obesity was
reflected in other literature. A separate but similar review (Young et al., 2007)
noted that better outcomes in childhood obesity treatment were obtained in
family-based treatments than in cognitive behavioral therapy treatments that
did not include families. Moreover, a substantial body of research, amassed by
one investigative team (Epstein et al., 2007), has led the field in developing
and refining family behavioral treatments for childhood obesity reduction.
Features of family interventions in childhood obesity reduction deserve
mention. Programs of longer duration (16 weeks to 6 months or longer) had
greater ESs than programs that were of shorter duration (8 weeks or less;
Snethen et al., 2006; Wilfley et al., 2010; Young et al., 2007). Also, programs
that incorporated a maintenance phase appeared to support continued weight
loss maintenance. Another factor that may have contributed to greater effectiveness, but requires further study, was greater structure in the intervention;
specific structured guidelines or protocols for diet and exercise appeared to
contribute to success (Snethen et al., 2006; Young et al., 2007). Finally, greater
parental involvement, and perhaps engaging parents in personal weight loss,
contributed to successful weight loss in obese children (Wilfley et al., 2010;
Young et al., 2007).

Childhood Diabetes
Family diabetes intervention research was searched in children and adults,
but the preponderance of studies was with children with type 1 diabetes,
and only these were included in the meta-analyses (Armour et al., 2004).
The general literature was searched from the earliest date of the compilation through February 2003 via EMBASE, CINAHL, PsychInfo, Web of
Science, Cochrane Library, Sociological Abstracts, and ERIC employing
data-base specific terms that approximated these search terms: diabetes,
family interventions, education, or training. A unique strength of this review
was that studies in any language were included. Only RCTs comparing
family treatment with a control condition were included; family was
defined as any family relation (e.g., parent, spouse, aunt, or grandparent)
with whom the patient lived. Other criteria for excluding studies were not
clearly described. Quality criteria included whether each study described
and applied appropriate randomization procedures, whether the data collector was blind to the treatment condition, and two criteria for attrition.

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Outcomes evaluated included changes in glycated hemoglobin (GHg), a

marker of the adequacy of glucose control over time, and parents diabetes
knowledge.
In eight RCTs that tested family interventions with childhood diabetes,
Armour and colleagues (2004) found a moderate, significant, positive effect
on glucose control as compared with control conditions (ES = 0.6% in
GHg; CI = 1.2, 0.1; p = .02). There was significant variability in the ESs
in the studies and many differences in the studies, including the age of the
child, type of intervention, the site of the intervention, and duration of the
follow-up period.
Of the eight studies that examined parents diabetes knowledge, five provided sufficient data to be analyzed. Family interventions demonstrated a
large and significant positive effect on parents diabetes knowledge as compared with the control conditions (ES = 0.95; CI = 0.67, 1.82; p = 0.35). The
authors also examined markers of family climate but declined to analyze
these results because they deemed the climate indicators to be too varied.
They noted but did not quantitatively analyze the results on family conflict;
in five of the six studies, family conflict was significantly reduced, whereas
in one study conflict was reduced but did not reach significance.
This childhood diabetes summary provides additional evidence of the
effectiveness of family interventions in achieving positive patient and family
outcomes in families living with a chronic illness. Although the authors did
not specifically select for this, the control condition in almost all the diabetes
studies was usual care. Family interventions varied and sometimes multiple
family treatment conditions were tested. The authors were not entirely clear
which family treatment condition was entered into the analysis, saying only
that the condition that was theoretically most effective was selected. This
choice may have falsely increased the pooled effects reported on. Despite
this limitation, the positive changes in glucose control in children and adolescents with type 1 diabetes are clinically significant. In addition, the large
change in family knowledge about diabetes management that was observed
in the family treatment conditions is equally clinically relevant.

Discussion
In this discussion, I will summarize this body of research by answering three
interrelated questions: How effective overall are family interventions in
chronic illness, what forms of intervention work best, and with which illnesses have we the most evidence?

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How Effective Is Family Intervention in Chronic Illness?

This overview of family interventions supports the effectiveness of family
interventions over usual medical care and in some instances over individual
psychosocial care. The strongest evidence in adults is that family care is
more beneficial than usual medical care for patients physical and mental
health, primarily depressive symptoms, and family member health or burden.
In adults, although the ESs are small (0.3 range), they are statistically significant. In children with obesity and diabetes, family interventions have
demonstrated considerably greater power, in the 0.6 for biological markers
and in the 0.9 range for knowledge. In more recent reviews (Hartmann et al.,
2010), the ESs appear to be, on average, slightly larger than in the earlier
review, in the 0.28-0.35 range rather than the 0.10-0.20 range.
The outcomes observed in family treatment of adult chronic illnesses
remain clinically significant. As Hartmann and colleagues (2010) note, an ES
in the 0.3 range corresponds to an odds ratio of 1.72-1.84, which means that
adult patients in a family-treated group have a 72% to 84% chance of improved
physical or mental health than the usual care group. In addition, family treatment effects had some stability, demonstrating lasting power, at least over a
brief follow-up of more than 7 months.
There is much less information regarding how well family-focused interventions fare when compared with other individually focused psychosocial
interventions, primarily because there have been so few direct comparisons.
Family psychosocial interventions can, however, be indirectly compared with
individually focused psychosocial interventions. For example, in multiple
meta-analyses of behavioral interventions with individuals with varied chronic
illnesses, treatment effects were mostly in the 0.25 to 0.35 range (Rosenthal
& DiMatteo, 2001) with some studies demonstrating much less power to
effect change. In children, particularly regarding obesity treatment (McGovern
et al., 2008; Young et al., 2007), there is better data comparing family versus
other psychosocial interventions, and here family interventions are much more
effective by comparison.
Childhood obesity interventions are a good model for how best to advance
efficacious family care. Systematic, careful accretion of knowledge, within
a large program of study has provided significant tests of varied family
interventions and led to the refinement of a multimodal family intervention
strategy. Such systematic application of knowledge in other disease processes and in other stages of family development would likely yield positive results.

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What Are the Most Efficacious Forms of Intervention?

Even a cursory look at the interventions that were included in these metaanalyses suggest that they range from very simple, designs that involve a
home visitor to teach and coach the patient and family (Burton & Gibbon,
2005), to complex, multimodal interventions that are delivered under carefully developed and monitored protocols (Epstein et al., 2007). Much recent
research seems to test multimodal approaches, combining education with
family support and/or skill building in disease management. Relationshipfocused psychosocial interventions additionally include skill building in
communication, problem solving, conflict management within the family relations. Overwhelmingly, these latter interventions employ a cognitive-behavioral
skill model, although there is variability. One general comment can be made:
In complex conditions requiring multiple lifestyle changes, conditions like
diabetes or obesity, multimodal approaches show greater promise in effecting
change. Multimodal interventions may be required, and single-focus interventions, particularly educational interventions alone, may not be sufficient.
However, straightforward interventions that address expressed family need or
distress and are based on well-thought-out nursing strategies (Burton & Gibbon,
2005) need our continued attention and support.
A provocative finding is that interventions that most benefit family members may be different from those that are most efficacious with the patients.
The difference was repeatedly evident in interventions that were or were not
relationship focused, with family members benefiting more from the former.
This finding sets up an important line of inquiry: to design studies to investigate forms of treatment that affect patients differentially from family members. It may be that family interventions operate quite differently for family
members than they do for patients, which should not surprise given that family members positionality on the illness. In addition, broadening investigations to include investigations of family climate, not just family or patient
health, will also contribute to our overall understanding of how family interventions affect health.
Multiple investigations of childhood obesity treatment programs all point
to the effectiveness of multicomponent treatments and to the superior weight
loss outcomes for treatment programs that involve family members. There is
even sufficient evidence to suggest the kinds of family member involvement
associated with superior outcomes. High levels of parent involvement and
parent involvement committed to personal weight loss alongside weight loss
efforts in the child demonstrate better outcomes (Wilfley et al., 2010).

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Despite some clear findings about appropriate and efficacious treatment

approaches, many questions remain. The necessary intensity of treatment,
treatment duration, whom to involve in programs (spouses or family members), and how to configure the treatment groupings (family member alone or
conjoint work with patients and family members) are important questions
that have been addressed but for which there are inconsistent findings. There
are, however, provocative suggestions. Regarding duration, the trend is for
better outcomes the longer the duration of treatment; this finding was more
clear in family member outcomes than in patient outcomes (Hartmann et al.,
2010). Regarding whom to treat and in what configuration, one interesting
finding is that when family members only were treated, family burden was
similar to that of programs delivered to dyads. Future research should be flexible regarding involving family members only, particularly if the primary
concern is for family member/caregiver health and well-being.

What Chronic Illnesses Are Best

Treated With Family Modalities?
Family treatment of physical illnesses demonstrate better results than do
treatment of dementia-related disorders (Martire et al., 2004). Care of the
family in the presence of cardiovascular diseases continues to predominate in
adults; this was the case in earlier meta-analysis and continues to the present. Why there is this focus on cardiovascular disease is unclear. It is interesting to note that fewer studies in this literature focus on relationship features,
perhaps because of the necessary, but perhaps insufficient, focus on cardiac
rehabilitation. Newer interventions focusing on cancer, arthritis, and to a
much lesser extent, diabetes do seem to focus more on the family relationship and the emotional aspects of care. In children, it is clear that obesity is
well treated in family modalities and that family treatment of diabetes also
shows promise. There is a driving need for research on other chronic conditions in children and for systematic reviews that summarize what is known
in this field.

Future Research Needed

Although the view from 10,000 ft is promising for the future of family
nursing, vast work remains. Many illnessesespecially those with considerable family involvementhave not been well examined; designing and
testing family care in highly prevalent diseases, such as diabetes or asthma,

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is called for. There is growing interest in family treatment in cancer, and

exciting innovations are happening in that field that deserve careful
monitoring. More research is needed that compares varied individual psychosocial interventions with family interventions. As demonstrated (Martire,
2006), direct comparisons of family treatment with other efficacious treatments have been extremely limited in number and have mixed results. As
the field moves forward, there is a need to examine outcomes in patients
and family members simultaneously. In this review, there were a sizeable
number of studies that examined outcomes for the chronically ill patient
and the family member involved, but those that exclusively focus on the
ill member continue to predominate. Inquiry into the specific needs and
responses of culturally diverse families has been almost entirely overlooked, and as resources allow, longer term effects of family treatments
require examination.
In this field, as in almost every field of clinical study, more complex, theoryguided designs are needed to allow examination of additional factors that
may influence relations (moderators). In family intervention research, inclusion of several factors may strengthen what is learned including physical
comorbidities of patient and family, perceived support and quality of family
life including relationship satisfaction, and differences that arise depending
on the age or gender of the patient. In childhood studies, additional concerns
arise that could meaningfully be included, such as the developmental age of
child, how parenting practices intersect with illness care, and issues of attachment between parent and child.
Finally, mixed method designs that examine how family interventions
improve relations and health outcomes for patients and families are strongly
needed. Within this review, distinct patterns of care within varied interventions, the view from 30 ft, were not examined. However, I am left with
pressing questions that deserve further thought. Is nurse-directed research
distinct or different from that directed by other disciplines? Is there a recognizable disciplinary element to family interventions that are nurse led? Do
nurses as members of an interdisciplinary team alter the approach employed
with families? I hope that I and others can continue to pursue these questions
in the continual evolution of our knowledge devoted to the betterment of
families lives.
Authors Note
Earlier versions of this article were presented at the 9th International Family Nursing
Conference in Reykjavik, Iceland in 2009 and at the 2010 Midwest Nursing Research
Society Conference in Kansas City, Missouri.

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Declaration of Conflicting Interests

The author(s) declared that they had no conflicts of interest with respect to their
authorship or the publication of this article.

Funding
The author(s) disclosed that they received the following support for their research
and/or authorship of this article: Funds for the development of this article provided
from the Thelma Shobe Endowed Chair.

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Bio
Catherine A. Chesla, RN, DNSc, FAAN, is a professor and Shobe Endowed Chair
in ethics and spirituality at the University of California, San Francisco. Her interests
are interpretive research methods and family care with chronic illness in adult family
members. For more than a decade, she has conducted mixed-method studies of type
2 diabetes in families in diverse ethnic groups. Currently, she leads an interdisciplinary team in a community-based participatory research project to adapt and test a
family-centered cognitive-behavioral intervention for Chinese American immigrants
with type 2 diabetes. Recent publications include Translational Research: Essential
Contributions From Interpretive Nursing Science in Research in Nursing & Health
(2008), Cultural and Family Challenges to Managing type 2 Diabetes in Immigrant
Chinese Americans in Diabetes Care (2009, with K. Chun & C. Kwan), and
Understanding Complexity of Asian American Family Care Practice in Archives of
Psychiatric Nursing (2010, with M. Park). She is a proud contributor to an important
methodology text titled Interpretive Phenomenology in Health Care Research (2010,
G. Chan, K. Brykczynski, R. Malone, & P. Benner, Eds.). She coauthored a chapter
titled Why Study Caring Practices? with A. Kesselring and V. Leonard.

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