W0115-12.

qxd 9/30/03 2:20 PM Page 304

Family Health Protection

12 David R. Langford

The primary goal of health protection is the removal or avoidance of

encumbrances throughout the lifecycle that may prevent the emergence of
optimum health.
— Nola J. Pender

OBJECTIVES
On completion of this chapter, the reader will be able to do the following:
1. Differentiate between the concepts of health promotion and health
protection.
2. Discuss the role of the family in the development and practice of health
protective behaviors.
3. Identify threats to health for families as they pass through the family life
cycle.
4. Assess the adequacy of health protective behaviors currently practiced by
a family.
5. Identify nursing roles that facilitate family health protective behaviors.

The family is critical to development of the values
and routines protecting the health of family
members. Major threats to health no longer come
from disease-producing bacterial or viral agents
but rather from chronic conditions produced and
fostered by lifestyle-related factors or environ-
mental hazards. Health-related decisions regarding
diet, location and quality of residence, health care
use, and leisure time activities affect all family
members. Health practices of children and adoles-
cents are greatly influenced by the values and
examples set by parents and others within the
family. Behaviors adopted in childhood will
influence health and health-promoting behaviors
later in life. Behavior patterns such as overeating;
lack of exercise; use of alcohol, tobacco, or drugs;
and poor coping are often established in childhood
304
and adolescence and carried into adulthood (Allen
& Warner, 2002; Keltner, 1992; Pender, Murdaugh,
& Parsons, 2002).
This chapter explores the family processes of
protecting members from threats to their health.
It describes health protective characteristics in
families and identifies some common health
threats and the role family nurses play in helping
families to protect their health. One of the
This chapter is a revision of the chapter by Karen K.
Szafran in the second edition of this book.
The author would also like to acknowledge the
contributions of Karen Joyce, RN, and Richelle Kay, RN,
in supporting the development of this chapter. Both
are graduate students in the School of Nursing at the
University of North Carolina at Charlotte.
W0115-12.qxd 9/30/03 2:20 PM Page 305
functions of families is to ensure the health and
safety of all family members and to establish
these lifelong healthy lifestyle patterns. Specific
behaviors that protect family members’ health
and reduce the threats of illness, disease, or
accidents during each developmental stage of the
family can be adopted. Nurses play a vital role in
helping families to identify risk factors and make
the lifestyle changes that will preserve their
health. The role of the family nurse is to provide
the education and support families need to
identify and assess their health risks, to support
families’ incorporation of heath protective behav-
iors into their daily routines, and to advocate for
adequate resources so that families can achieve
their health protection goals.
Defining Family Health Protection
Pender, Murdaugh, and Parsons (2002) define
health protection as “behavior motivated by a
desire to actively avoid illness, detect it early, or
maintain functioning within the constraints of
illness” (p. 7). Therefore health protection is
specific to actual or perceived health threats and
seeks to avoid or minimize insults to health and
well-being. Central to this definition of health
protection are the family’s perceptions of risk and
risk factors. Risk factors generally fall into six
categories: genetic, age, biological, personal heath
habits, lifestyle, and environmental (Pender,
Murdaugh, & Parsons, 2002). The quality of family
dynamics is an additional risk factor of concern
because of the effects that open communication,
shared decision making, and family coping
processes have on how families fulfill the health
function (Friedman, Bowen, & Jones, 2003).
Harris and Guten (1979) introduce the term
health protective behavior in an exploratory study
in which they focused on a wide range of health
behaviors that extend beyond those normally
defined as preventive or protective by health care
professionals. Health protective behaviors are
defined as behaviors aimed at protecting,
promoting, or maintaining health regardless of
health status and whether the behaviors are
effective. Harris and Guten conclude that virtually
everyone performs at least some routine behaviors
related to protecting or maintaining health. They
identify five dimensions of health protective
Chapter 12 Family Health Protection
305
behaviors that are very much a part of most
families’ daily lives: personal health practices,
safety practices, preventive health care, environ-
mental hazard avoidance, and harmful substance
avoidance.
The framework of primary, secondary, and
tertiary prevention may be useful in determining
the appropriate goals and lifestyle changes needed
according to the absence or presence of a specific
disease. Health protection in families includes
identification of risk factors and adoption of life-
styles aimed at promoting health (primary
prevention), preventing the occurrence of disease
by early screening and detection of disease and
through risk reduction (secondary prevention),
and preventing exacerbation and complications
once the diagnosis of a chronic disease is made
(tertiary prevention).
There is considerable disagreement in the mean-
ing and use of the concept of health protection
(Kulbok, Baldwin, Cox, & Duffy, 1997). In fact,
Kulbok and colleagues suggest that health
protection is conceptually part of health
promotion. They explain that health promotion
includes both general wellness-focused behaviors
such as maintaining a healthy diet and regular
exercise and specific avoidance behaviors such as
not smoking or routinely wearing seatbelts. Healthy
People 2010, an outline of U.S. national health
priorities, has also made a fundamental shift from
presentation of health protection as a focus for
health care providers to a consumer-oriented per-
spective of 10 health determinants from which
families can gain the knowledge, motivation, and
opportunities they need to make informed
decisions about their health (U.S. Department of
Health and Human Services, n.d.). This change in
emphasis is consistent with other attempts to locate
health protection behaviors under a larger umbrella
of health promotion.
The motivation behind health protective
behaviors can be vague or confusing when those
actions are not related to preventing a specific
disease. Although some authors argue that the
definitions of health protection and health
promotion are conceptually distinct, they are by
no means mutually exclusive. Pender, Murdaugh,
and Parsons (2002) clearly differentiate health
protection from health promotion. Health
promotion focuses on well-being and actualizing
W0115-12.qxd 9/30/03 2:20 PM Page 306
306
III Family Nursing Practice
human health potential, whereas health protection
focuses on behaviors in response to perceptions of
risk or threat. However, disease-preventive and
health protection measures do also promote or
maintain health and wellness. Health promotion,
defined as health practices aimed at achieving
wellness, is an integral part of disease detection and
management (Kulbok & Baldwin, 1992). For
example, avoiding excessive dietary sodium and
maintaining recommended body weight are health-
promoting behaviors for most young adults.
However, for a young African American adult with
a strong family history of hypertension, these
behaviors also meet the goals of health protection.
Thus many health-promoting behaviors meet
functions of both prevention and protection.
Caution must be exercised in shifting the
responsibility for family health protection entirely
to a consumer-oriented perspective. It is overly
simplistic to define family health protection as
only self-care and expect families to identify their
health risks and implement behaviors to elimi-
nate or reduce threats. Although lifestyle is a
major contributor to individual and family health,
Liaschenko (2002) is critical of intertwining
health protection and self-care. Thinking of health
protection as only a self-care issue focuses too
much attention on the individual, who often has
little control over many social and environmental
characteristics related to health status. Families
often minimize the responsibility the health care
system has for ensuring that basic health
promotion is available to all families. Health care
providers often have little knowledge about how
families learn to identify their health risks. How-
ever, when families do not identify or adopt the
recommended preventive behaviors, health care
providers often have attitudes of contempt and
blame families for not changing the unhealthy
lifestyle behaviors.
Advances in understanding the genetic contri-
bution to disease and disease risk have compli-
cated family health protection and further confuse
definitions of what constitutes health promotion
and health protection. The presence of genetic
or hereditary risk creates new opportunities for
working with families in identifying family history,
genetic markers, and the appropriate health
protective behaviors. Genetic risk factors have
generally been considered unchangeable; how-
ever, once families identify a genetic history or
risk, they have an opportunity to modify health
habits by changing their health-seeking behaviors
and altering unhealthy environments in such a way
as to potentially delay the onset of some diseases
and identify the onset of others at the earliest
detectable stage before symptoms appear.
How families interpret genetic risk is complex.
The relationship of genetic risk and behavioral
risk to specific diseases is often not linear and
therefore difficult for many families to under-
stand. For some, knowledge of a significant family
history of cardiac disease has led them to smoke
less (Hunt, Davison, Emslie, & Ford, 2000); but
for others, the relationship of family history and
prevention is less clear. Some families are able to
see the importance of a family history of heart
disease and diabetes but emphasize the impor-
tance of protective lifestyle behaviors for only
some diseases such as heart disease and cancer
(Ponder, Lee, Green, & Richards, 1996). Yet other
families determine their risk based on the number
and closeness of relatives affected by a disease and
their own age in relation to the age of the family
members at risk. Even when individuals acknowl-
edge that heart disease runs in their family,
perceptions of themselves as different in critical
ways from their relatives diminish their perception
of personal risk (Hunt, Emslie, & Watt, 2001).
Differences in perceptions of risk lead to mis-
understandings between families and their health
care providers, which delay important screenings
and lifestyle changes.
Health protection for aging families in which
caregiving is needed is just emerging as an area of
study. Messecar, Archbold, Stewart, and Kirschling
(2002) examined the use of home modification
strategies used by family caregivers of older adults.
They found that a number of strategies were used
not only to promote safety but also to allow
increased efficiency in family caregiving, make the
home environment more pleasant and meaningful,
supplement the older family member’s function and
independence, and increase access to professional
health care providers and necessary equipment.
However, as more family members care for their ill
and aging spouses or parents, health protection
practices for the caregivers must be stressed.
It is not surprising that family caregivers prac-
tice significantly fewer health promotion behaviors
W0115-12.qxd 9/30/03 2:20 PM Page 307
than noncaregivers (Acton, 2002). Many family
caregivers experience health-threatening condi-
tions resulting from fatigue and increased stress.
Family Characteristics of Health
Protection
Many of the same family functions appear to aid
families in practicing and maintaining health
promotion and health protection behaviors.
Family health promotion is presented in detail in
Chapter 3 and is only discussed here as it relates
to family perceptions of risk and specific health
threats. Family pride, family cohesion, mother’s
nontraditional gender role orientation, internal
locus of control, network, and community support
are predictive of one- and two-parent families’
participation in general health promotion
behaviors (Ford-Gilboe, 1997). Family function-
ing, family connectedness, parental expectations,
and parental monitoring are related to fewer
unhealthy behaviors and increased help seeking
in adolescents (Fallon & Bowles, 2001; Mellin,
Neumark-Sztainer, Story, Ireland, & Resnick,
2002).
Parental monitoring and disapproval appear
to be effective in preventing high-risk behaviors
among teens. DiClemente et al. (2001) found that
adolescents who perceived less parental monitor-
ing were more likely to have multiple sex partners,
not use contraception, and test positive for sexually
transmitted diseases. These same adolescents who
had little parental monitoring were also more
likely to have a history of alcohol and marijuana
use and a history of arrest.
Mothers have emerged as central figures in
health protection. They are responsible for
addressing daily health-promoting activities,
monitoring exposure to disease-causing agents or
other health-threatening behaviors, and guiding
individual health patterns (Denham, 1999;
Denham, 2003). A healthy and open communi-
cation pattern is a particularly successfully health
protection strategy used by families. Open com-
munication, especially with mothers, is an
important family strength responsible for reducing
high-risk sexual and drug use behaviors among
adolescents (Lehr, DiIorio, Dudley, & Lipana,
2000; McNeely et al., 2002). A mother’s relation-
ship with her teen, communication with the
Chapter 12 Family Health Protection
307
parents of her teen’s friends, and her strong dis-
approval of teen sex have greater significance for
teen daughters than for teen sons in regard to
delaying sexual intercourse (McNeely et al., 2002).
The presence of a social support network is
beneficial, especially as family members age.
Among persons in their fifties, married couples
living together and married couples living with
children report better health status than people
living in other types of households (Hughes &
Waite, 2002). Household structure has been found
to be an important contributor to health for adults
in late middle age. Adults living in households
with certain structures experience demands that
exceed their resources to cope with the stresses.
The stress of living in a household in which
demands exceed resources leads to poor health
behaviors and less time for self-care.
Adults in later life need companionship and
social interaction. The frequent company of other
people and the companionship of a household
pet can provide avenues for expression and add
meaning and a sense of purpose to persons in
later life (Murray & Huelskoetter, 1991). Older
adults living together have a greater survival rate
and retain their independence longer than those
living alone. The study of families in later life
and their health protection needs and practices
requires more research. Some parents outlive
their children, so to understand families in later
life, nurses may be required to re-conceptualize
the definition and boundaries of family.
Family routines and rituals also play an impor-
tant role in family health protective behavior (Fiese,
2000). Families can create routines that support
health-protecting or risk-reducing behaviors by
linking them to existing family routines. Often,
one family member, such as the mother, is
responsible for overseeing and sustaining health
and family routines. This family member is a key
person with whom the family nurse can work to
assess a family’s health-related routines and to
integrate health behaviors into ongoing family
routines or create new family health routines. For
example, routines can be created around regular
well-child health and dental visits, use of sun-
screen, or exercise as part of family recreation. In
addition, unhealthy routines such as overeating,
frequent snacking on high-fat and high-calorie
foods, and drinking behaviors related to alcoholism
W0115-12.qxd 9/30/03 2:20 PM Page 308
308
III Family Nursing Practice
should be changed and replaced with healthier
routines. In an interesting study of families of
alcoholics, routine practices such as family
dinnertime were found to protect children from
engaging in problematic drinking behavior
(Bennett, Wolin, Reiss, & Teitelbaum, 1987). In
families who eat together and celebrate other
family rituals, such as birthdays and holidays,
together, adolescents have fewer psychological
complaints (Compan, Moreno, Ruiz, & Pascual,
2002). See Chapter 16 for more information about
family routines.
Health protective behaviors are defensive
actions initiated for the purpose of removing or
avoiding actual or potential health problems.
Unlike health promotion behaviors, they are
focused on areas in which the family identifies
the risk and are therefore unique to each family.
Successful health protection in families is based
on characteristics of the family that foster pro-
active identification of health risks and adoption
of protective lifestyle changes and routines. Family
nurses and other health care professionals play a
vital role in helping individuals or families to
identify potential health threats and in develop-
ing, in partnership with families, effective strategies
for health protection.
Health Protection Throughout
the Family Life Cycle
Family lifestyle is a major determinant of indi-
vidual health. Accidents, heart disease, cancer,
cerebrovascular disease, and lung disease are five
of the leading causes of death in North America
(National Center for Health Statistics, 2001;
Health Canada, 2000). These leading causes of
death are directly linked to habits or lifestyle
factors related to diet, smoking, lack of exercise,
alcohol abuse, stress and exposure to environ-
mental hazards and are reflective of values and
behaviors learned in the family. Changes in the
leading causes of death for individuals as they age
reflect the changes in families as they pass through
developmental stages. Accidents are the leading
cause of death for persons ages 1 to 34 years, and
cancer is the leading cause of death for those ages
35 to 74 years. Table 12-1 identifies the five lead-
ing causes of death by age group. Much more
disturbing is the prevalence of homicide and
suicide among children and young adults ages 10
to 34 years. For families with children, protection
of members from accidental and intentional
injuries is a primary concern.
Families with children or adolescents or families
in which the adults are very young have additional
health protection challenges. Three fourths of the
deaths among persons ages 10 to 24 years are the
result of only four causes: motor vehicle accidents,
other accidental injuries, homicide, and suicide
(Centers for Disease Control and Prevention,
2002, June 28). Findings from the 2001 national
Youth Risk Behavior Survey (Centers for Disease
Control and Prevention, 2002), which reveal
some of the high-risk behaviors of high school
students, include the following:
• Fourteen percent had rarely or never worn
a seat belt.
• Thirty-one percent had ridden with a driver
who had been drinking alcohol.
• Seventeen percent had carried a weapon.
• Forty-seven percent had drunk alcohol.
• Twenty-four percent had used marijuana.
• Two percent had injected an illegal drug.
• Twenty-nine percent had smoked cigarettes
during the month preceding the survey.
• Nine percent had attempted suicide during
the year preceding the survey.
• Forty-six percent had had sexual intercourse.
• Forty-two percent of those who were
sexually active had not used a condom the
last time they had sexual intercourse.
• Eleven percent were overweight.
• Sixty-eight percent did not attend daily
physical education class.
For many teens and young adults, these be-
haviors will lead to unplanned pregnancy; early
parenting; exposure to sexually transmitted diseases
including HIV and human papillomavirus (HPV);
addiction; impaired judgment while engaged in
other activities; increased risk of illness such as
heart or lung disease, cancer, and diabetes; and
the potential for accidents and violence.
Chronic diseases such as heart disease, cancer,
and diabetes are responsible for 7 of every 10
deaths in the United States (Centers for Disease
Control and Prevention, 2002). In addition, dis-
ability resulting from chronic diseases affects 1 of
every 10 Americans and has an impact on millions
of families. These diseases account for 75% of the
W0115-12.qxd 9/30/03 2:20 PM Page 309

Chapter 12 Family Health Protection
309

TABLE 12-1 Five Leading Causes of Death by Age for All Races, Both Sexes

Age Causes of Death Age Causes of Death

1-4 yr Accidents 25-34 yr Accidents
Congenital abnormalities/malformations Suicide
Cancer Assault/homicide
Assault/homicide Cancer
Diseases of heart Diseases of heart
5-9 yr Accidents 35-44 yr Cancer
Cancer Accidents
Congenital abnormalities/malformations Diseases of heart
Assault/homicide Suicide
Diseases of heart HIV
10-14 yr Accidents 45-54 yr Cancer
Cancer Diseases of heart
Assault/homicide Accidents
Suicide Chronic liver disease and cirrhosis
Congenital abnormalities/malformations Cerebrovascular disease
15-19 yrs Accidents 55-64 yr Cancer
Assault/homicide Diseases of heart
Suicide Chronic lower respiratory disease
Cancer Cerebrovascular disease
Diseases of heart Diabetes mellitus
20-24 yr Accidents 65 yrs and over Diseases of heart
Assault/homicide Cancer
Suicide Cerebrovascular disease
Cancer Chronic lower respiratory disease
Diseases of heart Influenza and pneumonia

From National Center for Health Statistics (2001). Deaths: Leading causes for 1999. Retrieved October 10, 2002, from
http://www.cdc.gov/nchs/data/nvsr/nvsr49/nvsr49_11.pdf.

nation’s total health care costs. Although chronic
diseases are among the most prevalent and costly
health problems, they are also among the most
preventable.
The family plays a critical role in the develop-
ment of health behavior. Parental influence begins
at birth and is the single most important factor
affecting the child’s physical, emotional, and
cognitive development (Keltner, 1992). Many
health attitudes and practices are established in
early childhood. Lifestyle decisions that are made
in childhood or adolescence are often a product
of socialization within the context of the family.
Thus family values and practices largely deter-
mine the future health of individual family
members. Lifestyle behaviors adopted by parents
both influence the child and establish patterns of
health behavior that the child will follow through-
out the life span.
Health protective behaviors continue to be
important in aging families as they practice
behaviors aimed at maintaining their health and
delaying or controlling chronic diseases such as
arthritis, hypertension, heart disease, and arterio-
W0115-12.qxd 9/30/03 2:20 PM Page 310
310
III Family Nursing Practice
sclerosis. Even slight reductions in an older
person’s rate of decline can make a significant
difference in the quality of life and the degree of
independence associated with aging (Ruffing-
Rahal, 1991).
The developmental stages in the family life
cycle can be useful in understanding a family’s
health protection needs. For example, accidents
are the leading cause of death of individuals in
newly formed families and families with children
who are active in establishing a career and family
identity. Similarly, in families with teenagers, the
struggle for independence from parents and
feelings of alienation often lead adolescents to
engage in high-risk behaviors such as experi-
mentation with sexual activity or alcohol and
drug use. Other risks cumulate over a life span
and emerge as the family ages. Conditions such
as hypertension, heart disease, diabetes, and
cancer often show up later in the family life cycle
but also reflect health habits and family health
practices of the earlier stages of development.
Carter and McGoldrick’s (1999) stages of the
developing family are used in this chapter to
illustrate the relationship of family developmental
stages to health protection. The reader is referred
to Carter and McGoldrick’s text for descriptions
of developmental stages for a variety of family
types such as families of divorce, gay and lesbian
families, and African American families. A family’s
ability to master the tasks appropriate to each
stage of development determines how well that
family is able to meet the unique growth and
development needs of individual members.
Families have unique health protection needs
during the different stages of the family life cycle.
For example, risk taking and perceptions of
invulnerability by teenagers create very different
health protection challenges than those faced by
the family with young children or the aging family.
Table 12-2 provides an overview of the develop-
mental stages and corresponding health threats to
families throughout the family life cycle.
Three areas of family health protection are
discussed in the following sections: (1) safety and
family behaviors aimed at protecting family
members from accidents, (2) domestic violence
and its consequences for family health, and (3)
risks and family behaviors related to smoking and
tobacco use.
Safety and Family Health Protection
Safety may be the leading health protection issue
in families. In this section protection of the family
from unintentional and intentional injuries is
examined. Accidental and intentional injuries are
the leading causes of death and disability for
young people ages 1 to 30 years (Centers for
Disease Control and Prevention, 2001). Safety of
family members deserves sustained assessment
and intervention efforts by family nurses and
other health care providers. Values and beliefs in
the family about risk of injury influence indi-
vidual and family protective strategies. As a result,
accidental and intentional injuries differ by sex,
ethnicity, and age (Centers for Disease Control
and Prevention, n.d.). For example, most accidents
in families with infants and toddlers occur at
home. As infant and toddler motor skills develop
so do mobility and curiosity, which lead to
increased risks for burn injury, poisoning, and
drowning. Half of the young children killed in
automobile accidents were unrestrained. As
children age and become more mobile, trauma
resulting from falls; participation in sports; use of
bicycles, skateboards, and roller blades; and motor
vehicle accidents becomes more common. Deaths
from suicide, homicide, automobile accidents, and
drowning are greater for men than women. How-
ever, women are killed or injured in assaults by
intimate partners and family members more often
than men.
Accident prevention begins in the home. An
important element in ensuring family safety is
education regarding risk-taking behavior. Parents
can promote safety by helping their children to
identify and avoid potentially hazardous situations.
Family beliefs about safety and active enforce-
ment of protective behaviors such as always using
seat belts and car seats for children, wearing
bicycle helmets, and supervising and securing
swimming pools and firearms are necessary to
protect family members from injury.
Because of the vigilance required to prevent
many of the accidents in families with children,
promoting family safety should be a routine part
of nursing care. Gielen et al. (2002) found that
many low-income families do not have safety
gates for stairs or working smoke detectors and
do not store poisons safely. Families receiving
safety counseling during well-child visits and
W0115-12.qxd 9/30/03 2:20 PM Page 311
TABLE 12-2 Developmental Stages and Health Threats for Families across the Family
Life Cycle
Family Development Stage
Leaving home: single young adults
Joining families through marriage:
the new couple
Families with young children
Families with adolescents
Launching children and moving on
Chapter 12
Developmental Changes
Supporting Health Protection
• Developing supportive intimate and peer
relationships
• Establishing self-identity in relation to
family of origin and work
• Forming and adapting to marital
relationship
• Realigning relationships with extended
family, friends, and spouse
• Adjusting to addition of new family
members
• Defining and sharing child rearing,
financial, and household tasks
• Realigning relationships with extended
family, parenting, and grandparenting
• Redefining parent and child roles to permit
increasing independence of adolescence
• Refocusing on midlife marital and career
goals
• Beginning shift toward caring for older
generation
• Renegotiating marital relationship
• Developing adult relationship between
grown children and their parents
• Realigning relationships to include in-laws
and grandchildren
• Dealing with disability and deaths of
parents and grandparents
Family Health Protection
311
Health Threats and Issues
• Accidents and injury from driving, sports,
or other risk behavior
• Alcohol and drug experimentation or
abuse
• Tobacco use
• Dating violence
• Unplanned pregnancy or exposure to
HIV/STD from sexual practices and
experimentation
• Accidents
• Tobacco use
• Family planning
• Planned or unplanned pregnancy and
prenatal care
• Understanding genetic and family
hereditary history
• Domestic violence
• Accidents: burns, drowning, automobile
• Immunizations and infectious diseases
• Well-child care and screening
• Tobacco and drug use
• Healthy child-rearing practices
• Satisfaction and cohesiveness of family
• Communication in marital relationship
and with children
• Accidents and injury from driving, sports,
or other risk behavior
• Alcohol and drug experimentation or
abuse
• Tobacco use
• Unplanned pregnancy or exposure to
HIV/STD from sexual practices and
experimentation
• Satisfaction and cohesiveness of family
• Communication in marital relationship
and with children
• Care and assistance for aging parents
• Emergence of chronic illness
• Access to primary care for preventive
health care
Continued
W0115-12.qxd 9/30/03 2:20 PM Page 312

312
III Family Nursing Practice

TABLE 12-2 Developmental Stages and Health Threats for Families across the Family
Life Cycle—cont’d

Family Development Stage Developmental Changes Health Threats and Issues

Supporting Health Protection
Families in later life • Maintaining individual, couple, and family
functioning in face of physiological decline
• Supporting an increased role for middle
generation
• Making room for the wisdom and
experience of older generation
• Dealing with loss of spouse, siblings, and
peers
• Preparing for own death
• Declining health and chronic disease
• Loss of independence and acceptance of
caregiving
• Access to health care for health
maintenance and preventive care
• Immunizations, especially against
influenza and pneumococcal pneumonia
• Death of spouse or adult children
• Safety from falls and other accidents
• Alcohol and drug abuse
• Depression

Note: Family developmental stages are based on the work of Carter & McGoldrick (1999). The expanded family life cycle: Individual, family, and social
perspectives (3rd ed.). Boston: Allyn and Bacon. Adapted with permission.

those who visited a resource center with low-cost
safety supplies had higher rates of safety practices
(Gielen et al., 2002).
Prevention of falls again emerges as an impor-
tant safety concern and a major cause of mor-
bidity and disability among the elderly. Falls are
the leading cause of death related to injury in older
adults (Centers for Disease Control and Prevention,
n.d.). As the population ages and many aging
parents are cared for by their adult children, who
often have their own younger children living at
home, the importance of preventing falls becomes
more critical. Falls can be minimized by arranging
rooms to provide unobstructed passageways, using
night lights, and avoiding area rugs.
Protection from environmental hazards is
also important in maintaining family health. For
example, the link between exposure to direct sun-
light and sunburn as a child and the incidence of
skin cancer later in life is well documented. Sun-
bathing is a popular recreational activity for adoles-
cents and young adults. A deep tan is valued as
attractive and a sign of health and vitality. In fact,
teens often use sunlamps to enhance and main-
tain a tan.
For younger children, adequate protection
from the sun is dependent on parental beliefs and
values. A survey of parents with children ages 1
to 16 years revealed that only 43% regularly used
sun protection for their children (Johnson, Davy,
Boyett, Weathers, & Roetzheim, 2001). Sunscreen
creams and lotions were the most common form
of sun protection used, with the goal of preventing
sunburn. Many of the parents surveyed believed
that sun exposure was healthy, that children
looked healthier with a tan, and that long hours
of sun exposure were okay if children wore sun-
screen. Protective measures related to sun expo-
sure include educating families about the risks of
excessive sun exposure and tanning, the proper
use of sun-blocking creams and lotions to
prevent sunburn, and the signs and symptoms of
early skin cancer.
Motor Vehicle Accidents
Motor vehicle accidents are responsible for the
deaths of more children and young adults than any
other single cause (Centers for Disease Control
and Prevention, 2002). Use of safety belts reduces
the number of deaths associated with motor
vehicle accidents by 45% to 60%. Most states
have mandated the use of safety seats for small
children and passenger restraints for older
W0115-12.qxd 9/30/03 2:20 PM Page 313

Chapter 12 Family Health Protection
313

TABLE 12-3 Recommendations for Safely Restraining Children in Cars

Child Age Group Position Other

Infants (Birth to 1 yr and up to 20-22 lb)
Toddlers (Older than 1 yr and >20-40 lb)
Young and preschool
(4-8 yr, >40 lb, unless taller than 4’9’’)
School-age (≥80 lb)
Ride in back seat
Position seat center of car
Rear-facing position
Ride in back seat
Forward-facing position
Ride in back seat
Forward-facing position
Ride in back seat until
age 12 yr
Forward-facing booster seat
or lap and shoulder belt
Full-harness safety infant or rear-facing convertible seat
Full-harness safety seat
Keep in full-harness safety seat as long as possible—at
least to weight of 40 lb, then use a belt-positioning booster
seat, which helps the adult lap and shoulder belt fit better
(preferred for children between 40 and 80 lb)
Adult lap and shoulder belts normally do not fit a
child until he or she is about 4’9” tall and weighs
approx. 80 lb
Make sure the lap belt fits low and tight across the lap/upper
thigh area and the shoulder belt fits snug crossing the
chest and shoulder to avoid abdominal injuries

Data based on National Highway and Traffic Safety Administration, Child Passenger Safety. (n.d.). Proper child safety seat use chart. Retrieved October 11,
2002, from http://www.nhtsa.dot.gov/people/injury/childps/

children and adults. However, only 6% of parents Sports Injuries

with small children have correctly installed car
safety seats (Lane, Liu, & Newlin, 2000). Few
parents have received hands-on instruction on
properly installing a child safety seat. This hands-
on instruction is credited with reducing the
common errors parents make when installing
child safety seats. In many communities, police
and fire departments offer free programs to check
car seats and teach parents how to properly
install them. Parents are often confused about or
unaware of the guidelines for restraining children
in cars. Table 12-3 summarizes recommendations
from the Highway Safety Administration.
Driving represents a major step toward inde-
pendence and maturity for teens. However, parents
cognizant of the inherent dangers of driving and
risk taking common to adolescence may believe it
is necessary to set limits and restrict an adoles-
cent’s driving. Age alone does not automatically
determine readiness for such independence.
Establishing ground rules such as the mandatory
use of seat belts and absolute abstinence from
drinking when driving should be conditions for
use of the family car.
Sports activities have an important role in child
and adolescent development. They provide exer-
cise and valuable experience in competition and
teamwork and help develop a positive self-image.
In fact, young women active in sports have better
self-esteem and are less sexually active than young
women who are not participating in sports (Miller,
Sabo, Farrell, Barnes, & Melnick, 1998). However,
the rate of sports-related injuries is high among
child and adolescent athletes.
Approximately 600,000 injuries related to
high school football alone occur each year. Most
prevalent are injuries to the head, spine, and
extremities. Most sports-related injuries can be
prevented by following reasonable safety pre-
cautions appropriate to the sport. Participants in
potentially dangerous sports should wear proper
safety equipment and receive adequate instruction
(Mayhew, 1991). Sports-related physical exami-
nations are recommended to ensure that each
participant is physically capable of meeting the
demands of the sport. A recent report from the
Institute of Medicine (2002) recommends that
parents and families take a more active role in
W0115-12.qxd 9/30/03 2:20 PM Page 314
314
III Family Nursing Practice
protecting players from injury. In particular, the
report focuses on soccer and on better assessment
for concussion in children who have been hit on
the head.
Firearms
In one million homes where nearly three million
children live, firearms are stored in such a way
that they are accessible to children (Schuster,
Franke, Bastian, Sor, & Halfon, 2000). Many
parents store firearms that are loaded and
unlocked in their homes, and they overestimate
their children’s ability to tell the difference
between real and toy guns (Farah, Simon, &
Kellermann, 1999). Children often find these
firearms and take them to school where they are
used to threaten other children, play with friends,
or attempt suicide.
A study by Jackman, Farah, Kellerman, and
Simon (2001), describing how 8- to 12-year-old
boys respond when they find a handgun, produced
shocking results. The boys in the study were
observed while playing in a room where a handgun
had been hidden. While playing, the boys found
the gun and handled it. Nearly half of the boys who
found the handgun were unsure whether it was a
toy or real gun. Most disturbing was the finding
that 48% of the boys who discovered the real
handgun pulled the trigger. Parental estimates of a
child’s interest in firearms did not predict whether
a child would handle the gun. Boys believed to
have a low interest in firearms were as likely to
handle the gun or pull the trigger as boys believed
to have high or moderate interest in firearms. As a
routine part of family health assessment, nurses
must ask families about the presence of firearms in
the home and storage practices.
For nurses concerned with family safety, assess-
ment is not enough. As demonstrated in the study
by Jackman, Farah, Kellerman, and Simon (2001),
most 8- to 12-year-old children are curious and
unable to refrain from handling firearms that they
find. Therefore family nurses must include edu-
cation as part of well-child care and community
outreach. Parents must be given detailed instruc-
tions about securely storing firearms, and nurses
need to discuss with family members the risks
associated with curious children and the presence
of firearms in the home.
It is recommended that parents be taught to ask
about the presence of guns in the homes where
their children play, including relatives’ homes
(Ahmann, 2001). The ASK (Asking Saves Kids)
campaign provides materials for parents and
nurses on how to ask neighbors or relatives about
firearms. Educational efforts must also be directed
toward children. Children must be taught not to
handle firearms without adult supervision and to
tell adults if they find a firearm or know someone
who has brought a gun to school. In a society in
which toy guns are plentiful, look realistic, and are
often given as gifts to children, it is not surprising
that children are not intimidated by them and
cannot distinguish real guns from toy guns. Efforts
to promote gun safety in families will be very
challenging. More information on the ASK
campaign is available on the PAX Real Solutions to
Gun Violence website, which is listed in the
Website Resources box at the end of the chapter.
Family nurses also need to be actively engaged
in health policy discussions regarding firearms.
Issues such as gun control and requiring firearm
manufacturers to use technology to “personalize”
or lock firearms so they cannot be discharged
should be part of the professional dialogue about
promoting and ensuring family safety. The
Committee on Injury and Poison Prevention of
the American Academy of Pediatrics (2000) makes
the following recommendations:
• Firearm regulation and the banning of
some firearms are the most effective way to
protect against firearm-related injuries to
children and adolescents.
• Firearms should be subject to the safety
and design regulations of other consumer
products.
• Quality violence-free programming should
be developed, and the romanticization of
guns in media and entertainment should be
reduced.
• Injury prevention programs and strategies
such as alternatives to violence programs,
distribution of trigger locks and other
safety devices, and educational programs
for children and adolescents should be
evaluated.
• Health care providers should receive further
education on how to reduce the mortality
and morbidity associated with firearm use.
W0115-12.qxd 9/30/03 2:20 PM Page 315
Fear of Violence
Although not traditionally thought of as areas of
health protection, safety and the fear of violence
and crime are significant concerns for families.
Overcrowding and poor-quality housing have a
direct relationship to family health status (Bashir,
2002). Overcrowding discourages the interaction
among family members that is important for
maintaining family health. Overcrowding, unsafe
homes, and unsafe communities lead many family
members to isolate themselves, stay indoors,
increase snacking, spend more time watching
television, and reduce their physical activity. These
are also often the same families that have diffi-
culties accessing health care because of lack of or
inadequate insurance and fear of leaving home.
However, children’s perceptions of neighborhood
hazards do not necessarily lead to reduced levels
of physical activity as might be expected (Romero,
et al., 2001).
A mother’s open communication with her
children appears to be a protective strategy. In a
study of multiracial fifth and sixth graders from
low-income neighborhoods, children who talked
to their mothers about neighborhood violence
experienced less stress and fewer internalized
symptoms (Ceballo, Dahl, Aretakis, & Ramirez,
2001).
Family protection strategies may be different
according to neighborhood characteristics.
Protective behaviors such as strict parenting or
staying at home, often seen in low-income
neighborhoods, may be mistakenly credited to
race or cultural background when, in fact, differ-
ences in parenting may actually reflect differences
in neighborhood characteristics (Pinderhughes,
Nix, Foster, & Jones, 2001). Family nurses must
better assess homes and the conditions in which
families live to work with the families toward
health-protecting strategies.
School shootings, a number of high-profile
child abduction cases, and the terrorist attacks of
September 2001 have left families and commu-
nities of all socioeconomic groups more concerned
with physical safety. Although there is a relatively
small risk of experiencing these events, given the
much higher risks of death or injury resulting
from automobile accidents, drowning, and other
accidents, many families and communities have
been moved to change how they address safety.
Chapter 12 Family Health Protection
315
For example, many states such as California,
Texas, Maryland, and Virginia are reversing or
reconsidering long-standing bans on students
having cell phones at school. Likewise, parents
are increasingly vigilant of their children and
their surroundings while teaching children how
to avoid potentially dangerous interactions with
strangers.
Health Protection and Domestic
Violence
Approximately 20% to 25% of women seeking
care from primary health care providers are being
battered by an intimate partner (Naumann,
Langford, Torres, Campbell, & Glass, 1999).
Abuse of female partners has far-reaching and
serious health consequences for women. Besides
the obvious trauma, battered women have higher
rates of substance abuse, suicide, depression, and
poor pregnancy outcomes. The rates of headache,
back pain, vaginal and urinary tract infections,
digestive problems, and pelvic and abdominal
pain are 60% higher in battered women than in
nonabused women (Campbell et al., 2002).
Domestic violence consists of behaviors that
include repeated physical, sexual, and emotional
abuse used to control an individual. Use of physical
violence is the extreme manifestation of one
partner controlling the relationship and is usually
accompanied by other controlling behaviors such
as threats and intimidation, humiliation, social
isolation, and limiting economic resources. Many
subtle behaviors, once identified, can serve as
warning signs of the potential for abuse. Box 12-1
identifies common early warning signs of power
and control imbalances in a relationship. Teaching
young men and women to identify the early
warning signs of control and abuse holds promise
for reducing the incidence of domestic violence.
In particular, young men can be targeted for
interventions teaching equal and healthy adult
relationships.
Violent homes are characterized by sustained,
high levels of tension and fear as a result of
sporadic and unpredictable violence. The environ-
ment in the home created by the use of violence
and threats of violence has been described as
“social chaos,” in which rules governing behavior
are constantly changing and being redefined
W0115-12.qxd 9/30/03 2:20 PM Page 316
316
III Family Nursing Practice
BOX 12-1 Recognizing the Warning
Signs of Abuse
Does your partner or date:
• Put you down in front of other people
(belittle, ignore, minimize your ideas, or
berate you for not wanting to get high, have
sex, or comply with other requirements)?
• Act jealous and possessive toward you?
• Talk negatively about sisters or women in
general?
• Have a history of bad relationships, quick
temper, and violence toward others?
• Try to control your life and relationship (tells
you who you may be friends with, how you
should dress, or will not accept your opinion
or beliefs)?
• Become easily frustrated and angry?
• Go through extreme highs and lows (for
example, is kind one minute and cruel the
next)? (Does your partner scare you, or are
you afraid of how your partner will react to
things you do or say?)
• Blame you for his problems, including those
he brought on himself?
• Pressure you into doing things you do not
want to do, such as having sex or breaking
the law?
• Act in an intimidating way toward you (e.g.,
sits too close, speaks as if he knows you
much better than he does, touches you when
you tell him not to)?
• Constantly page, call, or use friends to keep
track of you?
• View you as unequal—because of being
older, male, or seeing himself as smarter or
socially superior?
• Threaten to hurt or kill himself if you leave or
break up?
(Langford, 1998). This leaves family members
uncertain about how to respond to the changing
demands and threats of the person using violence.
In addition, many children and adolescents grow-
ing up in this environment come to view the
chaos and unpredictability as normal.
Exposure of children to violence at home is
hypothesized as one of the risk factors for the use
of violence in adult relationships. Children are
profoundly affected by witnessing abuse and
those who do so exhibit a variety of emotional,
behavioral, and developmental problems (Martin,
2002). The Research Synopsis presents a study
about parental violence and dating violence
among adolescent boys.
Family members are not always a good source
of support for battered women. Many women have
talked to parents about the abuse and receive
little support (Rose, Campbell, & Kub, 2000).
For many women, friends provide the best source
of support. Jealousy, control, and threats of further
violence create conditions that make women
cautious about disclosing the abuse or forming
new relationships. Positive social support can
lead women to actively seek help from formal
organizations.
Humphreys (2001a) describes stages that
daughters of battered women go through as they
pass through their own developmental stages.
Early childhood vigilance, worry, and fear change
to anger and rebellious acting out as they become
teenagers. For young women exposed to violence
at home, protective behaviors include being
involved in school-based activities and spending
time with close friends. Although they do not
disclose the violence at home, they use these
activities to escape their troubled families. Indi-
viduals outside the immediate family such as
school counselors provide additional support.
The adult daughters of battered women identify
intelligence, attractiveness, optimism, a belief in
self, avoidance of feelings of responsibility for the
violence, perseverance, and keeping the violence
secret as characteristics that served as protective
factors in surviving (Humphreys, 2001b). Adult
daughters credit mothers and grandmothers for
reinforcing and sustaining their belief in self.
These personal characteristics plus the support
from friends and school counselors, as well as
opportunities to be involved in activities that
took them away from home, provided protective
mechanisms for women and allowed them to
understand and move beyond the violence they
had experienced.
Nurses’ skill in assessing and talking to women
about the experience of violence in their homes is
a first step toward protection. Nurses and other
health care providers are being urged to univer-
sally screen all women for domestic violence.
Screening for domestic violence allows nurses
W0115-12.qxd 9/30/03 2:20 PM Page 317
RESEARCH SYNOPSIS
PARENTING BEHAVIORS AND DATING VIOLENCE BY TEEN BOYS
Efforts to understand and prevent violence in dating
and intimate relationships have begun focusing on
the effects of witnessing violence at home. Children
who witness or experience abuse at home are
thought to be more likely to use similar violence in
their intimate adult relationships. A longitudinal study
by Lavoie and colleagues examines the link
between parenting behaviors in late childhood and
use of violence by adolescent boys in their dating
relationships.
Lavoie and colleagues collected data over
8 years. Participants were 717 boys from low
socioeconomic backgrounds who were enrolled
at age 10. A questionnaire was used to collect
data. Boys were asked about their mothers’ and
fathers’ parenting practices, witnessing parental
conflict and violence, and harsh parental
punishments at ages 10, 11, and 12 years. At age
15 years, the questions focused on delinquency
behaviors. At ages 16 and 17 years, the
questionnaire asked about dating and dating
violence.
to better assess the causes of women’s health
problems and gives nurses the opportunity to talk
to women about the violence. Effective screening
identifies survivors so nurses can assist women
in assessing their level of danger, identifying
resources, and outlining a feasible safety plan for
the workplace, school, and home for them and
their children. There are many resources to which
women and health care providers can be referred
for information.
The telephone numbers of local shelters for
battered women are inside the front cover of each
community’s telephone directory so women and
health care providers can have rapid access to
those resources. The National Domestic Violence
Hotline has information for victims of domestic
violence, as well as for nurses and other heath care
providers, through a toll-free telephone number
(1-800-799-7233) and a website. Website URLs
for this and other organizations serving domestic
violence victims are presented in the Website
Resources box at the end of the chapter.
Chapter 12 Family Health Protection
317
Boys living in homes where parents used hitting,
insulting, constant quarreling, and rejection were
abusive to their dating partners at ages 16 and 17
years. Delinquency at age 15 and lax parental
monitoring were also risk factors in boys using
violence against their dates. Conflict between
parents, family adversity, single parenting, and
parental age at birth of child were not associated
with dating violence.
Nursing care of families with children should
include healthy parenting as part of routine well-
child care. Alternatives to harsh or abusive
discipline and strategies for monitoring children’s
and teens’ activities while allowing them age-
appropriate independence are areas in which
nurses could assist many family health protection
efforts.
Lavoie, F., Herbert, M., Tremblay, R., Vitaro, F. Vezina, L., & McDuff, P.
(2002). History of family dysfunction and perpetration of dating violence
by adolescent boys: A longitudinal study. Journal of Adolescent Health,
30, 375-383.
Nearly half of the women in a study by Gielen
et al. (2000) supported the idea that health care
providers should routinely screen women for
domestic violence. However, nearly half of the
respondents preferred that women control the
information and did not support laws requiring
health care providers and others to report sus-
pected abuse to the police. A woman and her
family can be placed at greater risk of violence
from an abuser when information is shared by
health care providers without the woman’s
knowledge.
Many of the factors that are protective to
families involve community-based interventions.
Some of these include creating safe places such as
shelters and improving how law enforcement and
health care personnel identify and respond to
domestic violence. Other strategies involve
changing social and cultural norms supporting
the use of violence and control in families.
Parenting beliefs and practices about disci-
plining children are such cultural norms. Many
W0115-12.qxd 9/30/03 2:20 PM Page 318
318
III Family Nursing Practice
health care providers have begun discouraging
parents’ use of corporal punishment. Physical
punishment such as spanking not only harms the
mental and physical health of children but also
initiates the use of violence in family relation-
ships by becoming part of the family routines. The
relationship of spanking or “hitting” children as
a form of discipline and the use of physical
violence in adult familial relationships has been
questioned.
Spanking as a form of discipline is contro-
versial. In a meta-analysis of 88 studies of corporal
punishment published over the past 62 years,
Gershoff (2002) found that although spanking is
effective in achieving compliance, there is sub-
stantial evidence that it is associated with a higher
prevalence of abuse and other negative long-term
consequences on children’s health. Children reared
in homes where spanking is used as a form of
discipline have more delinquent behavior, are
more aggressive, have poorer mental health, and
have poorer parent-child relationships. The author
warns that there are a number of areas needing
further study before the outcomes of corporal
punishment are understood. First, there is no
standard definition or standardized measure of
corporal punishment. Second, the relationships
between spanking and its effects are not linear.
The effects of frequency and severity may be
different for children of different ages, ethnicity,
and socioeconomic status. There is some evidence
that spanking used rarely in anger may be more
detrimental for children than spanking used
frequently for control.
Substance Abuse Protection
Alcohol and Drug Use
Alcohol and drug use has major implications for
adolescent and family health. Approximately one
in four children 18 years of age and younger are
living in homes in which one or more of the adults
abuse alcohol or are alcohol-dependent (Grant,
2000).
Patterns of adolescents’ alcohol consumption
have recently attracted the attention of health care
providers and policy-makers. Four of five college
students drink and half engage in heavy episodic
drinking known as binge drinking (Task Force on
College Drinking, April 2002). Forty percent (2
of every 5 students) reported binge drinking in
the 2 weeks preceding the survey. Adolescent
drinking, particularly binge drinking, is related to
numerous high-risk behaviors with both short-
term and long-term health consequences (Maney,
Higham-Gardill, & Mahoney, 2002). Underage
alcohol use leads to such problems for teens as
motor vehicle accidents, unplanned sexual activity,
possible pregnancy, risk of HIV and other sexually
transmitted diseases, physical and sexual violence,
and increased conflict at home and with parents.
The report by the Task Force on College Drinking
(2002) includes recommendations to parents and
families on evaluating the drinking culture of a
college and staying engaged and monitoring
students during their college experience.
Misuse of alcohol can have many other effects
on family health. Alcohol ingestion during preg-
nancy has detrimental effects on the developing
fetus such as congenital defects and on pregnancy
outcomes such as low birth weight, premature
delivery, and stillbirth. Heavy use of alcohol during
pregnancy can result in the characteristic set of
abnormalities of fetal alcohol syndrome. Assess-
ment of alcohol misuse and dependence should
be part of the standard family assessment, and
family patterns and history of alcohol abuse can
easily be demonstrated in a genogram.
Family history of problem drinking was
identified as a predictor of alcohol abuse for men
(Committee on Substance Abuse, 2001). Home is
the leading source of alcohol access for adoles-
cents; older siblings often introduce or influence
younger siblings’ use of alcohol. However, exces-
sive drinking is more likely to occur with peers
than with family members.
Some family factors are effective in preventing
alcohol and drug abuse in children and teens.
Family cohesiveness, support, clear rules for
expected behavior, and high levels of parental
monitoring have the effect of mediating risk
factors and positively influencing teens’ alcohol
use behaviors (Loveland-Cherry, 2000). Genetic
risk of alcoholism or drug abuse can be moderated
by family and home environmental controls such
as limiting access and use. One of the greatest
risk factors is peer relationships. Loveland-Cherry
(2000) hypothesizes that peer selection is often
based on salient family values and beliefs and
W0115-12.qxd 9/30/03 2:20 PM Page 319
that parental involvement in peer selection is
protective.
Families need to recognize the early warning
signs of drug abuse in children and adolescents.
Parents can play a vital role in protection behaviors
related to discouraging alcohol use, limiting access
at home, and monitoring peer relationships. How-
ever, changes in behavior such as gradual and
unexplained deterioration in scholastic perfor-
mance, increasing difficulties with parents or peers,
increased frequency of accidents, and unexplained
absences from school can be early warning signs
that a family member is having problems with
drugs or alcohol. Strategies for prevention of
alcohol abuse in families should emphasize the
proper use of alcohol in family and community life.
Limited alcohol use is a part of many important
culturally based family traditions and ceremonies.
Smoking
Cigarette smoking is recognized as the single
most preventable cause of death in the United
States. Smoking during pregnancy is related to
risks of low birth weight and sudden infant death
syndrome. Infants exposed to maternal smoking
have increased morbidity associated with con-
ditions such as sudden infant death syndrome,
colic, lower respiratory tract infections, and
gastrointestinal reflux (Gaffney, 2001).
Cigarette smoking among adolescents is an
even more significant health problem. Most
smokers begin smoking in their teen years. The
average age smokers first try a cigarette is 14.5
years; the average age at which an individual
becomes a daily smoker is 17.7 years (Elders,
Perry, Eriksen, & Giorano, 1994). The younger
an individual is when he or she begins smoking,
the greater is the risk for lung cancer, heart disease,
stroke, emphysema, and bronchitis. Twenty-nine
percent of high school students currently smoke
cigarettes (Centers for Disease Control and
Prevention, May 2002). Although this figure is
down from 36% in 1997 and 35% in 1999, it is
still higher than the 22% of adults who smoke.
White and Hispanic students are significantly
more likely to smoke than African American
students. Also of concern is the recent upsurge in
the use of smokeless tobacco, particularly among
male adolescents and young adults.
Chapter 12 Family Health Protection
319
Family environment can have a significant
effect on the smoking behavior of children. Only
4% of teenagers from households of nonsmokers
will acquire the habit (Winkelstein, 1992). When
both parents smoke, there is a greater likelihood
that a child will smoke than if only one or neither
parent smokes. When an older sibling plus both
parents smoke, a child is four times more likely
to smoke than if the family includes no smokers.
Some research suggests that parental disapproval
of smoking reduces teens’ smoking behavior even
when parents themselves are smokers (Sargent &
Dalton, 2001). Messages from family members
discouraging adolescents from smoking affect
teens differently based on ethnicity (Kegler et al.,
2002). Teens who are African American, Asian
American, or Pacific Islander American are more
concerned that their parents will think less of
them if they smoke than are white and Hispanic
teens. It is more common for white teens and
teens of American Indian descent to feel that their
parents believe it is the teen’s decision to smoke
or not. Kegler and colleagues (2002) conclude
that teens receive a variety of “mixed signals”
from their families regarding smoking. Nurses
working with families need to help parents and
other family members reduce the mixed signals
they send about smoking during the sensitive
developmental stages.
Strategies to prevent smoking must include
those focusing on the individual, family, commu-
nity, and policy arenas. Prevention can start with
teaching parents how to clearly communicate
to their children that they disapprove of and
discourage smoking. Nurses can educate family
members about the risks of smoking during
routine preventive care visits for children or teens.
Promising family-focused interventions might
include addressing the extended family’s direct
and indirect influence on teen smoking, as well
as establishing household smoking restrictions,
better monitoring of household access to and
availability of tobacco supplies, and setting clear
expectations about not smoking (Kegler et al.,
2002). The nurse can initiate a number of indi-
vidual smoking cessation therapies for family
members who want to quit smoking. Likewise,
family nurses need to be involved in community-
based education and prevention efforts. Lantz
et al. (2000) conducted a comprehensive review
W0115-12.qxd 9/30/03 2:20 PM Page 320
320
III Family Nursing Practice
of the published literature addressing inter-
ventions to reduce teen smoking. They classified
tobacco prevention programs as school-based
efforts, community-based efforts, public educa-
tion, advertising restrictions, regulation of youth
access, and taxing tobacco. They conclude that
although the results have been mixed, efforts
must continue and the availability of tobacco
settlement money can provide opportunities for
innovation and testing of new interventions.
Family nurses advocating family heath protection
must put pressure on state legislators to fund and
support tobacco prevention programs.
Families’ Use of Complementary
and Alternative Therapies
Families from the many cultural traditions
represented in the United States often have
culturally oriented practices of health protection
based on different understandings of health.
Spector (2000) describes three of the most
common traditional health protection practices.
The first practice consists of wearing, carrying, or
hanging in their homes objects believed to have
protective value. The second consists of use or
ingestion of substances believed to offer health
protection. Diet is used by many cultures to protect
health; for example, kosher diets are followed by
some Jewish persons, the Chinese have dietary
customs that balance Yin (positive energy of light
and warmth) and Yang (negative energy of dark
and cold), and some Hispanic persons believe in a
balance of “hot” and “cold” foods. These foods are
often eaten in prescribed quantities, at defined
times, and in combination with other foods. The
third practice consists of religious rites such as
prayer, burning candles, and other rituals.
As health care has become increasingly
complex, a growing suspicion of pharmaceutical
companies and dissatisfaction with approved
Western medical treatment outcomes have left
many families looking for natural alternatives. It
is estimated that 40% of Americans now use some
form of alternative therapy, with herbal prepa-
rations being most commonly used by families
with children (Vessey & Rechkemoner, 2001).
These alternatives to traditional Western medi-
cine are known as complementary and alternative
medicines (CAMs).
The National Center for Complementary and
Alternative Medicine (NCCAM) is one of the
newer research centers in the National Institutes
of Health and reflects the increasing interest and
acceptance of CAMs. The NCCAM (2002) defines
complementary and alternative therapies by use
and not by treatment. Complementary therapies
are defined as those used together with conven-
tional medical practices, whereas alternative
therapies are defined as those used in place of
conventional medical practices. The NCCAM
divides the therapies into five types as follows:
1) Alternative medical systems therapies,
which include homeopathy, naturopathy,
and traditional Chinese therapies such as
acupuncture
2) Mind-body therapies, which include support
groups; prayer; meditation; and art, dance,
and music therapy
3) Biology-based therapies, which include the
use of herbs, foods, vitamins, and dietary
supplements
4) Manipulative and body-based therapies,
which include massage, chiropractic, and
osteopathic manipulation
5) Energy-based therapies, which include
therapeutic touch and the unconventional
use of bio-magnetic fields
Many of the complementary or alternative
therapies have a rich tradition, but until recently,
they have been the subject of little formal study.
Mantle (2002) has reviewed the research on CAMs
for obesity, addiction, anxiety, and depression and
concludes that limitations in research design and
methodology make it very difficult to interpret
the efficacy of CAMs used for health promotion.
Nurses working with families using CAMs or
nurses recommending any of the therapies need
to be knowledgeable about those therapies.
It is important for nurses to be aware that
many families are routinely using CAMs. Non-
judgmental questions about a family’s use of folk
remedies or other CAMs are an important part of
assessment. Educating families about the uses of
CAMs, and particularly about drug interactions
and side effects, is the next step in working with
families using CAMs. Families need to be
encouraged to discuss with their primary care
providers their use of CAMs and any implications
it might have for ongoing treatments for hyper-
W0115-12.qxd 9/30/03 2:20 PM Page 321
tension and other chronic health conditions (Kaler
& Ravella, 2002). Often, families are hesitant to
discuss unconventional therapies with their
health care providers because they fear their health
care providers will be judgmental or disapprove.
Excellent information about current clinical trials
and the latest alerts and advisories regarding drug
interactions and harmful side effects are available
at the NCCAN website, which is provided in the
Website Resources box.
Accessing Family Health Protection
Information on the Internet
The emergence of the Internet as a primary source
of health information for families has changed
their access to health-related information. Families
are now more knowledgeable than ever before
about health issues. They use the Internet to
research prescription medicines, explore ways of
preventing heart disease or cancer, learn the latest
on losing weight, and prepare for visits to their
health care providers. As many as 73 million
people in the United States (62% of Internet users)
have gone online to find health information; more
people get health advice online than actually visit
health care providers in a given day (PEW Internet
Project, 2002). Women and Internet users between
the ages of 50 and 64 years comprise the greatest
number of persons using the Internet to gather
health information.
Greater access to health information is a
dramatic advantage for families struggling to
introduce health protection activities, but it creates
new challenges for nurses in their relationships
with families. The Internet allows families to
educate themselves, supplement or question their
existing heath care, explore alternatives, and
participate in support groups or chat with others
having similar health concerns; and the relative
anonymity provided by the Internet allows family
members to explore sensitive questions and topics
(Borzekowski & Rickett, 2001). The Internet can
be a powerful tool in educating families and
assisting them in identifying risk and adopting
new health protective behaviors. The Internet
has radically altered the relationship of nurses
with families. Nurses must learn to interact with
families who have a lot of information but do not
necessarily know how to organize it. The Internet
Chapter 12 Family Health Protection
321
has changed families’ access to health information
in the following ways (Smith, 1999):
1) By shifting the control of information from
the health care provider to the consumer
2) By creating a learning environment on the
Web where persons get information from
multiple sources without any order or
sequencing
3) By reinforcing expectations that information
is always available and current and that it
defies geographical boundaries
4) By producing information overload that
often leads to confusion and paralysis
5) By creating new communication commu-
nities that include both other professionals
and lay persons
The interactive capability of the Internet
empowers families and is convenient for families
interested in exploring existing digital libraries,
asking questions of experts, or communicating
with others in a chat, e-mail, or discussion forum
(D’Alessandro & Dosa, 2001). In one study 49%
of teens reported using the Internet to retrieve
health information and scored the value of the
information available there as high (Borzekowski
& Rickett, 2001).
There are still many who do not have access
to the Internet. Because of the so-called digital
divide, Internet access is unevenly distributed
among families in the United States. Approxi-
mately 42% of American households have access
to the Internet, and two thirds of the families with
Internet access live in households with incomes
of $50,000 a year or greater (U.S. Department of
Commerce, 2000). The number of families with
access to the Internet is slightly lower (39%) in
rural areas. African American and Hispanic
families and the disabled lag behind: only 24%
and 22%, respectively, have household access to
the Internet. Two-parent homes are twice as likely
to have Internet access as single-parent homes.
Only one quarter of the Internet users report
following recommended steps for assessing the
accuracy, source, and timeliness of the health
websites they find (PEW Internet Project, 2002).
The material available is not always accurate,
helpful, or easy to understand. The text of most
health-related websites exceeds a high school
reading level, and nearly half of all Americans read
at an eighth grade level or below (D’Alessandro,
W0115-12.qxd 9/30/03 2:20 PM Page 322
322
III Family Nursing Practice
Kingsley, & Johnson-West, 2001). Berland and
colleagues (2001) also found the text of English-
and Spanish-language websites to require a high
school reading level or greater.
The vast amount of information available on
the Internet makes it difficult to find the infor-
mation desired. Berland and colleagues (2001)
searched the Internet for the topics of depression,
obesity, childhood asthma, and breast cancer.
They found that users of English-language search
engines have only a 1 in 5 chance of finding
relevant information on the first page of the
search result. For Spanish-language searches, the
chance of finding the information requested on
the first page of search results was 1 in 9. Fewer
than half of the health-related websites were
accurate or provided more than minimal coverage
on the topic. Much of the information retrieved
was superficial, wrong, or outdated.
As a result of the explosion of health infor-
mation available on the Internet and the
increasing use of the Internet as a source of
health information, many families need to
develop skill in determining the quality of the
information they access on the Internet. An
emerging role for family nurses is to assist
families in organizing the information available,
sorting out bias, and evaluating the validity of
the information they have found. Assessing the
quality of Internet-based information is parti-
cularly important as families investigate experi-
mental, complementary, or alternative ways of
protecting their health. The NCCAM and the
National Cancer Institute have criteria for
evaluating health information on the Internet.
See the Website Resources box for their website
URLs. Box 12-2 outlines criteria for evaluating
the validity of websites and information.
There is a dark side for families using the
Internet. Nineteen percent of teens who regularly
use the Internet received unwanted sexual solici-
tation in the year preceding a survey by Mitchell,
Finkelhor, and Wolak (2001). Sexual solicitation
over the Internet was very upsetting for those
solicited, especially the younger users. Parental
supervision such as limiting the hours spent
online, requiring permission before going online,
checking teens’ computer use while online, and
using filtering software appeared to have little
effect on solicitation risk. In a survey of adoles-
BOX 12-2 Questions to Ask When
Evaluating Internet Health
Information
Sponsorship and Bias
• Can you tell who operates and sponsors the
content or site? Often, the extension of the
website URL gives institutional information,
for example, “gov” (government), “edu”
(educational), “com” (company), “org”
(nonprofit organization), and “net” (often
personal or community websites). Look
beyond the extension. Is it a company
promoting a product or an organization
promoting a political viewpoint?
• What is the purpose of the site?
• Is there a clear disclaimer posted?
• Does the site provide contact information?
Accuracy
• Is there enough information to determine
whether the author is reliable?
• Is the content current?
• Is the content accurate?
• Does the site provide evidence-based
references for its content?
• Have the site and its contents been recently
updated? Material within the website may be
dated. Is there a date when the page was
last updated at the bottom of the Web page?
• Is the content opinion or research, and are
the sources clearly identified?
Other
• Is the intended audience made clear? Many
websites have areas for consumers and for
professionals. Are they clearly identified?
• What are the other links? Are they
advertising products?
• Do you have confidence that your privacy is
protected?
• Does the site ask the user for personal
information?
cent Internet users, Stahl and Fritz (2002) found
that 74% reported contact with a stranger using
e-mail or chat rooms and a quarter of those
acknowledged sharing personal and identifying
information such as a name, address, phone
number, and school name. Many of the adoles-
cents reported experiences of feeling unsafe while
using the Internet. Only a quarter of the partici-
W0115-12.qxd 9/30/03 2:20 PM Page 323
pants had ever discussed Internet safety with an
adult or parent.
Role of the Family Health Nurse
in Family Health Protection
The family health nurse plays a vital role in
developing and fostering health protective behav-
iors within the family. A family-centered approach
is particularly important for health protection
because many of the diseases or health conditions
to be prevented have a genetic basis or are related
to lifestyle. It is vital that the entire family address
its potential risks and work together to
implement protective behaviors (Bigbee & Jansa,
1991). The family health nurse can assist family
members in identifying actual or potential areas
of health risk, establishing health goals based on
the family’s needs and interests, and developing
an effective lifelong plan for health protection.
Family members often know little of their
family health history (Ponder, Lee, Green, &
Richards, 1996). Many stigmatized illnesses and
behaviors such as alcoholism and mental illness
are kept as family secrets, with only selected family
members serving as gatekeepers for the family
history. Use of genograms may help family mem-
bers to identify areas of family health history they
do not know and empower them to discover the
answers (see Chapter 11).
Health Care Services
Access to health care services and supervision
of a family’s health care are essential for family
health protection efforts. Family protection efforts
hinge on early identification of risk so that appro-
priate prevention strategies can be implemented.
Many families will place high priority on areas
of health protection if the threat of illness is
apparent and easily understood, and yet, families
often do not assess risk in the same way as their
health care providers do. A good example of this
can be seen in a study of mothers assessing the
health risk of their obese and overweight children
not by the children’s weight but by the children’s
level of activity (Jain et al., 2001). The health
care provider’s assessment of risk was consider-
ably different because he or she focused more on
weight and diet.
Chapter 12 Family Health Protection
323
Pender, Murdaugh, and Parsons (2002) identify
access to screening and risk identification through
health education as key protective behaviors. In
most cases, screening tests are not available to
families except through access to health care
providers. Periodic medical evaluations are an
established form of preventive health care.
Although some disagreement exists regarding the
recommended frequency of routine examinations
for healthy adults, it is generally acknowledged
that regular examinations are needed as family
members age. In families with young children,
the routine medical examination provides health
care providers with the opportunity to monitor
infant nutrition and growth, to assess develop-
mental progress, and to administer routine immu-
nizations. It also affords an excellent opportunity
to educate parents and other family members about
normal development, safety, and risk reduction.
As the family moves through the developmental
stages, screenings for common health problems
such as cervical, breast, prostate, and colorectal
cancers and hypertension, diabetes, and glaucoma
are recommended. Guidelines for preventive health
care indicate that counseling regarding accident
prevention, safe sex, and alcoholism and drug use
are an integral part of routine preventive care and
professional health supervision.
Screening guidelines have been developed
by groups such as the U. S. Prevention Taskforce,
the American Academy of Pediatrics, and the
American Academy of Family Physicians to help
family nurses and other health care providers
systematically identify health risks in family
members and aid families in identifying their health
risks so that appropriate protective behaviors can be
adopted. The Clinical Prevention Guidelines from
the U.S. Preventive Services Task Force for children
and adults are presented in Figures 12-1 and 12-2.
Not all families benefit from these prevention
guidelines. Swanson and Pearson (2001) found
that 40% of physicians are not screening family
members for known cardiac risk factors. In
addition, a number of the top-ranked prevention
recommendations such as tobacco cessation, vision
screening, colorectal cancer screening, screening
for chlamydia infection in young women, alcohol
abuse screening, and pneumococcal vaccinations
for adults reach less than half the country
(Coffield et al., 2001).
 Clinical Preventive Services for Normal-Risk Adults
Recommended by the U.S. Preventive Services Task Force

Year of Age 18 25 30 35 40 45 50 55 60 65 70 75
SCREENING Blood Pressure, Height and Weight Periodically
Cholesterol Men: Every 5 Years
Women: Every 5 Years
Pap Smear Women: Every 1 to 3 Years
Chlamydia
Mammography Every 1 to 2 Years
Colorectal cancer Depends on test*
324
III Family Nursing Practice
W0115-12.qxd 9/30/03 2:20 PM Page 324

Osteoporosis Yearly
Alcohol Use Periodically
Vision,Hearing Periodically

IMMUNIZATION Tetanus-Diptheria (Td) Every 10 Years

Varicella (VZV) Susceptibles Only–Two Doses
Measles, Mumps, Rubella (MMR) Women of Childbearing Age–One Dose
Pneumococcal One Dose
Influenza Yearly

CHEMOPREVENTION
Assess CVD risk and discuss aspirin Men: Periodically
to prevent CVD events
Women: Periodically
Upper Age Limits Should Be Individualized For Each Patient

COUNSELING Calcium Intake Women: Periodically

Folic Acid Women of Childbearing Age
Tobacco cessation, drug and alcohol use,
STDs and HIV, nutrition, physical activity,
sun exposure, oral health, injury prevention, Periodically
and polypharmacy

*See www.preventiveservices.ahrq.gov for U.S. Preventive Sevices PUT PREVENTION INTO PRACTICE
Task Force recommendations on colorectal cancer screening and U.S DEPARTMENT OF HEALTH AND HUMAN SERVICES • PUBLIC HEALTH SERVICES
other clinical preventive services. Revised January 2003
APPIP02-0022
Figure 12-1 Clinical Preventive Services for Normal-Risk Adults Recommended by the U.S.
Preventive Services Task Force. (Put Prevention into Practice, January 2003. Agency for
Healthcare Research and Quality, Rockville, MD, http://www.ahcpr.gov/ppip/adulttm.pdf)
CHILD PREVENTIVE
CARE TIMELINE
Clinical Preventive Services for Normal-Risk Children
IMMUNIZATION Month/Years of Age B 1m 2m 3m 4m 5m 6m 12m 15m 18m 2yr 4yr 6yr 11yr 12yr 14yr 16yr 18yr
Hepatitis B Dose 1 Dose 2 Dose 3 Y or Doses 1-3

Polio (IPV)* Dose 1 Dose 2 Dose 3 E Dose 4

Haemophilus Influenzae type B (Hib)* Dose 1 Dose 2 Dose 3 Dose 4

A
Diphtheria, Tetanus, Pertussis (DTaP, Td) Dose 1 Dose 2 Dose 3 Dose 4 Dose 5 Td Once
R
Measles, Mumps, Rubella (MMR) Dose 1 Dose 2 or Dose 2

Chickenpox (Varicella) Once S or Once

Hepatitis A Once in selected areas

W0115-12.qxd 9/30/03 2:20 PM Page 325

Pneumococcal Disease (PrevnarTM) Dose 1 Dose 2 Dose 3 Dose 4

SCREENING Years of Age B 1y 2y 3y 4y 5y 6y 7y 8y 9y 10y 11y 12y 13y 14y 15y 16y 17y 18y
Newborn Screening: PKU, Sickle Cell
Hemoglobinopathies, Hypothyroidism
Hearing
Head Circumference Periodically
Height and Weight Periodically
Lead
Vision Screening
Blood Pressure Periodically

Dental Health Periodically

Alcohol Use Adolescents

Chlamydia Adolescents

COUNSELING Years of Age B 1y 2y 3y 4y 5y 6y 7y 8y 9y 10y 11y 12y 13y 14y 15y 16y 17y 18y
Development, nutrition,
physical activity, safety,
unintentional injuries and poisonings, As appropriate for age
violent behaviors and firearms, STDs
Chapter 12

and HIV, family planning,

tobacco use, drug use

Revised January 2003.

Recommended by most U.S. authorities
*Schedules may vary according to vaccine type
The information on immunizations is based on recommendations
issued by the Advisory Commitee on Immunization Practices, the
American Academy of Pediatrics, and the American Academy of
Family Physicians
PUT PREVENTION INTO PRACTICE CHILD HEALTH GUIDE

Figure 12-2 Child Preventive Services for Normal-Risk Children Recommended by the U.S.
Family Health Protection
325

Preventive Services Task Force. (Put Prevention into Practice, January 2003. Agency for
Healthcare Research and Quality, Rockville, MD, http:// www.ahcpr.gov/ppip/childtm.pdf)
W0115-12.qxd 9/30/03 2:20 PM Page 326

326
III Family Nursing Practice

Barriers to access such as absence of insurance

and lack of qualified health care providers in rural TABLE 12-4 Families at Risk:
and other underserved areas are important health Who Are the Uninsured?
policy issues that should be addressed by family
nurses. Millions of families in the United States
have inadequate or no health insurance. Table 12-4 Uninsured 1999-2000
shows who is uninsured. For many families with- Type of Family Percentage of
out health insurance, preventive care such as
Uninsured
prenatal care or cancer and cholesterol screenings
is nearly inaccessible. Williamson and Drummond White 11
(2000) found that parents in low-income families Black 20
often do not know about the availability of pre- Hispanic 34
ventive services or low-cost and free health care Other 21
alternatives for their children and themselves. Also, Younger than 18 yr 12
inadequate health care insurance and lack of Age 19 to 64 yr 18
transportation limit parents’ ability to use child and
At lease one full-time worker 13
family health services they do know about. Family in the family
health protection depends on every effort being
made by family nurses to increase the availability Adapted from Kaiser Family Foundation. (2002). State health facts
and accessibility of health care services for all online. Retrieved September 10, 2002, from
families, particularly for poor families, racial http://www.statehealthfacts.kff.org
minorities, and adolescents. The Canadian Per-
spectives box details Canada’s publicly funded
immunization programs, which are a significant
part of the country’s plan for health protection.

CANADIAN PERSPECTIVES
FAMILY HEALTH PROTECTION THROUGH IMMUNIZATION
Karen Pielak, RN, MSN
British Columbia Centre for Disease Control

Canada’s national health insurance
plan is considered one of the hall-
marks of Canadian society and is
highly valued by Canadians. The
principles of this plan, as outlined
in the Canada Health Act (univer-
sality, portability, accessibility,
comprehensiveness, and public
administration), apply directly to
the provision of publicly funded
immunization programs (National
Forum on Health, 1997). Canadian
children in all provinces and
territories receive publicly funded
vaccinations against nine diseases:
diphtheria, pertussis, tetanus,
polio, Haemophilus influenzae
type b, measles, mumps, rubella,
and hepatitis B (Canadian Public
Health Association, 2001). Since
1997, all Canadian jurisdictions
have had the benefit of using a
pentavalent vaccine combination
of diphtheria, acellular pertussis,
tetanus, polio, and Haemophilus
influenzae type b. Adults are
offered booster immunizations
against tetanus and diphtheria.
Influenza and pneumococcal
vaccine programs are in place for
those 65 years of age or older and
for the younger high-risk groups.
The immunization of health care
workers against influenza and
hepatitis B has received increased
attention, as has the immuni-
zation of post-secondary school
students for measles and
meningococcal disease. Immuni-
zation programs also target
populations at increased risk for
pneumococcal a meningococcal
disease, hepatitis A, and influenza.
Immunization is not mandatory in
Canada, although some provinces
have legislation or requirements
for proof of immunization at
school entry.
W0115-12.qxd 9/30/03 2:20 PM Page 327
CANADIAN PERSPECTIVES
FAMILY HEALTH PROTECTION THROUGH IMMUNIZATION—cont’d
Vaccines are licensed federally
through Health Canada. The
National Advisory Committee on
Immunization (NACI) provides
recommendations on the use
of vaccines. This committee is
composed of specialists in public
health, infectious diseases, and
pediatrics from across the country.
However, each province and
territory decides which vaccine
programs will be publicly funded
and how they will be opera-
tionalized in the area. Immuni-
zation programs are implemented
through a mixed delivery system
of physician and public health
administration. Public health tends
to deliver immunization programs
in the more rural areas of the
country. Because the provision of
health care is a provincial/territorial
jurisdiction in Canada, there is a
lack of harmonization of vaccine
scheduling and programs. There
is an initiative currently under-
way, the National Immunization
Strategy, which is striving to
achieve universality and harmoni-
zation in the delivery of Canadian
immunization programs (Dr. Arlene
King, personal communication,
October 10, 2001).
Vaccine administration in
Canada is regarded as an inde-
pendent, advanced nursing com-
petency. Almost all provinces and
territories have implemented an
immunization certification process
that includes a written examination
and observation of immunization
technique. Community health
nurses must meet specific criteria
Canadian spelling is used.
Chapter 12
before they are permitted to
immunize. This immunization
certification process was spear-
headed by the Canadian Nursing
Coalition for Immunization [CNCI]
(2001). The CNCI membership
includes one nurse epidemiologist
or communicable disease nurse
specialist per province and terri-
ory. Its primary purpose it to
provide a forum in which to share
and develop “best practice” con-
cepts and to support standards to
optimize delivery of immunization
services in the provinces and
territories (CNCI, 2001).
Although there is general
support for immunization and
there are relatively high immuni-
zation rates in Canada, immuni-
zation of all family members
continues to present challenges
to Canadian community health
nurses. Members of the public
increasingly confront Canadian
community health with stances of
complacency or anti-immunization.
Accordingly, a current challenge
to Canadian health professionals
is to become proficient in vaccine
benefit-risk communication. The
onus is on clinicians to discuss
the most accurate and up-to-date
vaccine benefit-risk information
with their clients. The goal is not
to convince clients to accept
immunization but to provide
them with the information that
enables them to make the most
informed, comfortable decision
for themselves (Stoto, Evans, &
Bostrom, 1998).
Family Health Protection
327
Health care professionals also
need to continue to advocate for
the ongoing success of national
immunization programs in
promoting the health of the
Canadian population. Plotkin and
Orenstein (1999) claim that with
the exception of safe water, no
other modality, not even anti-
biotics, has had such a major
effect on mortality reduction and
population growth.
References
Canadian Nursing Coalition for
Immunization. (2001). Terms
of reference. Halifax, Nova
Scotia, Canada: Author.
Canadian Public Health
Association. (2001). The value
of immunization in the future
of Canada’s health.
Submission to the
Commission on the Future of
Health Care in Canada.
[online]. Retrieved from
http://www.immunize.cpha.ca.
National Forum on Health.
(1997). Canada health action:
Building on the legacy.
(Synthesis Reports and Issue
Papers, Vol. 2). Ottawa,
Ontario, Canada: Author.
Plotkin, S. A., & Orenstein, W. A.
(1999). Vaccines (3rd ed.).
Philadelphia: W. B. Saunders.
Stoto, M. A., Evans, G., & Bostrom
A. (1998). Vaccine risk
communication. American
Journal of Preventive
Medicine, 14, 237-239.
W0115-12.qxd 9/30/03 2:20 PM Page 328
328
III Family Nursing Practice
Family nurses, as well as other health care
providers, share much of the responsibility for
ensuring that families know their risk factors and
are able to provide themselves with adequate health
protection. A number of community resources
are available to assist families in meeting their
health protection needs. For example, local
chapters of organizations such as Planned Parent-
hood, the American Cancer Society, the American
Heart Association, and the American Lung Asso-
ciation, worksite health programs, neighborhood
health centers, and school-based clinics all
provide health and wellness information relevant
to families. Families seeking health information
can consult a variety of sources: local libraries,
hospitals and clinics, self-help groups, health
information centers, national health organizations,
and U.S. government clearinghouses and infor-
mation centers. Many of these resources are easily
accessible on the Internet. The Website Resources
box at the end of the chapter provides the URLs
for several of the family health-related websites
available to health care professionals and to
the public.
Assessment
Assessment of family health protective behaviors
involves the collection of data from which family
strengths, concerns, and actual or potential
problems can be identified. A thorough family
assessment and genogram are excellent ways to
assess and teach families and are covered in
greater detail in other chapters. The first step in
family health protection is identification of the
family’s health risks.
One way to assist families in identifying risk is
through the use of a health risk appraisal. Health
risk appraisals are commonly used by nurses and
other health care professionals as a means of
assessing individual and family risk factors and
providing families with a realistic estimate of the
major health hazards to which they are particu-
larly vulnerable. Family members may be more
amenable to recommended lifestyle changes if
they are shown specific risk factors and under-
stand that their risk of developing specific health
conditions is moderate or high. A number of risk
appraisals for specific conditions are available
online at the Healthfinder website and other
websites, listed with their URLs in the Website
Resources box. Appendix 12-1 at the end of the
chapter presents a sample risk appraisal tool that
is organized by family developmental stages.
Planning and Implementation
Families must have an active voice in the planning
process for a health protection plan to be effec-
tive. Family nurses need to consider themselves
as partners in the family’s health; therefore the
steps in developing a family health protection
plan involve both the nurse and the family.
Pender, Murdaugh, and Parsons (2002) describe
the common steps necessary for the nurse and
family together to develop a health protection
plan. These steps are as follows:
1) Review family assessment data and family
health status.
2) Identify and reinforce strengths of the family
that provide the basis for health protection
actions.
3) Identify family health goals.
4) Identify behavior or health outcomes that will
indicate the plan has been successful.
5) Develop a health protection/behavior plan that
incorporates the family’s readiness to change
and assess their knowledge of health protection
strategies.
6) Address social, environmental, and inter-
personal factors that are barriers to change.
7) Determine the time frame for implementation.
8) Commit to the family’s health protection goals
and the structure and support needed to
accomplish them.
The role of the nurse in health protection and
health protection planning varies according to
the developmental stage and needs of the family.
The use of “interventive questions” as described
by Wright and Leahy (2000) can be very helpful
as the family nurse works with a family to identify
health risks and behavior changes to reduce the
risks. Interventive questions elicit family expla-
nations of cause and effect, but more importantly,
also explore the relationships between family
members, events, beliefs, and behaviors. Two
examples of interventive questions are: “How
would your mother feel about you or your sister
helping to increase the servings of fruit and
vegetables in your meals?” and “What is the best
W0115-12.qxd 9/30/03 2:20 PM Page 329
advice you have had on how to approach your
son about using alcohol and driving or being
with someone who is drinking and driving?”
These types of questions can lead the nurse to
interventions such as offering education, making
referrals to community support agencies, vali-
dating emotional responses, and devising rituals
and family routines that are specific to the
family’s needs.
Although the family is ultimately responsible
for carrying out the prescribed plan of action, the
family nurse continues to play an active role in
health protection. Feeley and Gottlieb (2000)
advocate an approach building on family strengths
such as family capacity, competency, and resources
in working with families. Strengths can be iden-
tified in one area and applied from one domain
or area to another with the aim of successfully
reinforcing new health protection behaviors. The
expanding family strengths are then nurtured and
supported by identifying and mobilizing resources.
The family nurse plays a number of important roles
in supporting families’ health protection function.
Evaluation
Evaluation is the ongoing process between the
nurse and the family or its members that measures
the progress that has been made toward goal
achievement. Because most health protective
measures are self-directed, behavior change evalu-
ation is largely based on the family’s perception of
progress. Periodic revision of goals and the plan
of action may be necessary because of the family’s
CASE SCENARIO
The Norton family consists of Bruce (48), Cheryl (47),
and three daughters—Jesse (10), Penny (13), and Kelly
(15). Cheryl’s mother, Arlene (81), has just moved into
their home because she could no longer live
independently. The family is a working-class family.
Bruce works as a sales representative and Cheryl was
working as a secretary until Arlene moved in. She has
quit her job to care for her mother.
The family is generally healthy. Arlene has limited
mobility and pain because of rheumatoid arthritis.
However, the principal reason Cheryl insisted she move
in is that Arlene has become increasingly forgetful
Chapter 12 Family Health Protection
329
mastery of behavior changes, changes in risk, or
changes in family priorities and values; revision
may also be needed when new options become
available to the family.
The family health nurse can play a vital role
in working with families to identify risk and
adopt strategies to reduce the family’s risk. Much
remains to be learned about family health
protection practices. More research is needed in
understanding how families identify risk and
adopt protective behaviors. As families age, there
is an increasing need to understand the protective
activities of elder family members and family
caregivers. Further research on the unique pre-
vention needs and strategies of the many types
of families—single-parent families, two- or three-
generation families living under one roof, and gay
and lesbian families—is needed. Given the aging
of the population, there is a significant absence in
the literature of research and discussion of the
health protection strategies for families in later
life. Additional research should focus on the family
characteristics and family dynamics that support
families’ changing old beliefs and behaviors to
health conscious and health protective behaviors.
In this chapter, the role of the family nurse has
been described as working with families to support
their risk identification, education, and behavior
changes. The role of the family nurse is also
being expanded to include strategies for helping
families interpret the overwhelming volume of
health information available and newly emerging
information regarding genetic risk and the impli-
cations of genetic screening.
since her husband died almost a year ago. Cheryl has
recently begun complaining of joint stiffness. Bruce’s
parents are both alive and live in a different state.
Bruce smokes half a pack of cigarettes a day and has
hypertension.
The girls are active in their schools and the
community. Their busy schedules create considerable
stress in the family. Bruce and Cheryl have a complex
schedule of driving the girls to and picking them up
from various activities. As a result, the family seldom
has meals together. The girls spend several hours a
day on the Internet, “chatting.” Kelly started smoking,
Continued
W0115-12.qxd 9/30/03 2:20 PM Page 330
330
III Family Nursing Practice
CASE SCENARIO—cont’d
mostly because of peer pressure and social inter-
actions. Cheryl keeps track of where the girls are and
with whom they spend time. She often invites their
friends over for dinner and sleepovers as a way of
keeping track. Cheryl has become more interested in
using the Internet to order things, visit health-related
websites, and explore her mother’s “forgetfulness.”
MAJOR FAMILY STRESSORS
The family has two significant stressors related to its
developmental stage. The situation of the family with
teenagers is inherently stressful as the family balances
the need for autonomy with the need for structure
and risk taking of adolescence. In addition, Cheryl’s
mother has recently moved into the house. The
responsibilities of providing care to Cheryl’s mother
and parenting the teenage girls are not being shared
by Cheryl and Bruce. There is little family time, and the
girls’ activities have been overscheduled.
FAMILY STRENGTHS
The family is generally healthy, and there is open
communication in terms of both listening and express-
ing needs among family members. Although it creates
stress, there is closeness with the older generation as
Arlene has been welcomed into the home. The family
demonstrates a willingness to take care of themselves
and each other, best demonstrated by Cheryl closely
monitoring her daughters’ activities.
LIFESTYLE CHANGES INDICATED
There are a number of areas in which the nurse can
focus on improving the family’s health protective
EBSITE RESOURCES
ORGANIZATION
Department of Health and Human Services
Centers for Disease Control and Prevention
Agency for Healthcare Research and Quality (AHRQ)
National Institutes for Health (NIH)
Healthfinder
Healthy People 2010
Parenting Resources for the 21st Century
American Academy of Family Physicians
behaviors. Because of Arlene’s and the girls’ ages,
safety is the first health protection issue. Home safety
measures are essential for Arlene. Removing area rugs
is one example. Safety is also an issue for the girls as
they enter adolescence. Cheryl’s efforts to monitor
their activities are positive and need to be supported.
Encourage the family to use the open communication
they have established to discuss delayed and safe sex,
discourage drug and alcohol use, emphasize not riding
with friends who have been drinking, and discuss
family rules related to using the Internet. Second,
Bruce’s smoking exposes everyone in the house to
second-hand smoke and could imply to the girls
parental approval of smoking. The nurse could work
with Bruce to quit or form a habit of smoking outside
and encourage both parents to express their wishes
and concerns about smoking with their daughters.
Third, Cheryl needs respite. Start by exploring how
existing family roles could be expanded to contribute
to better balance. Preventive health care behaviors
such as exercise, diet, sleep, and routine preventive
health care such as annual physicals, Pap smears, and
mammograms are important for protecting Cheryl’s
health because of the increased risk associated with
caregiving. Fourth, Arlene needs pneumonia and
influenza vaccinations. Bruce and Cheryl should
consider annual influenza vaccinations.
WEBSITE ADDRESS
http://www.hhs.gov
http://www.cdc.gov
http://www.ahrq.gov
http://www.nih.gov
http://www.healthfinder.gov
http://www.health.gov/healthypeople
http://www.parentingresources.ncjrs.org/
http://www.familydoctor.org
W0115-12.qxd 9/30/03 2:20 PM Page 331

Chapter 12 Family Health Protection
331

EBSITE RESOURCES—cont’d

American Academy of Pediatrics http://www.aap.org

American Association of Retired Persons http://www.aarp.org
Kaiser Family Foundation http://www.kff.org/
Spry Foundation http://www.spry.org
Children’s Defense Fund www.childrensdefense.org
American Heart Association http://www.americanheart.org
American Lung Association http://www.lungusa.org
American Cancer Association http://www.cancer.org
Family Violence Prevention Fund http://www.endabuse.org
PAX Real Solutions to Gun Violence http://www.paxusa.org
National Center for Complementary and http://www.nccam.nih.gov/health/
Alternative Medicine
National Cancer Institute http://www.nci.nih.gov/cancerinfo/ten-
things-to-know
National Domestic Violence Hotline http://www.ndvh.org
National Women’s Health Information Center www.4woman.gov/violence/index.cfm
Department of Justice Violence Against http://www.ojp.usdoj.gov/vawo
Women Office
Family Violence Prevention Fund http://www.endabuse.org

CHAPTER HIGHLIGHTS

• Health protection behaviors aim to eliminate or
minimize threats to health related to risk factors
for specific illnesses.
• The family plays a critical role in the development
and practice of health protective patterns by
members.
• A number of family characteristics such as open
communication and parental monitoring support
successful adoption of health protective behaviors.
• Families experience specific health risks as they
move through family developmental stages.
• Families are using alternative health care as a
means of enhancing health protection and are
better informed about health as a result of
access to a wealth of information through the
Internet.
• Family nurses have a vital role in assisting
families to identify potential threats to health
and to develop effective plans for health
protection for individual members and the
family unit throughout the family life cycle.
W0115-12.qxd 9/30/03 2:20 PM Page 332
332
III Family Nursing Practice
CRITICAL THINKING ACTIVITIES
1. How do cultural beliefs affect a family’s
perception of risk? For example, what might
family health protection behaviors look like if a
family believed that respect and treatment of
their ancestors was related to good health?
2. It has been argued that the increase in focus
on health protection and health promotion by
REFERENCES
Acton, G. J. (2002). Health-promoting self-care in family care-
givers. Western Journal of Nursing Research, 24, 73-86.
Ahmann, E. (2001). Guns in the home: Nurses’ role. Pediatric
Nursing, 27, 587-605.
Allen, F. M., & Warner, M. (2002). A developmental model of
health and nursing. Journal of Family Nursing, 8, 96-135.
Bashir, S. A. (2002). Home is where the harm is: Inadequate
housing as a public health crisis. American Journal of Public
Health, 92, 733-738.
Bennett, L. A., Wolin, S. J., Reiss, D., & Teitelbaum, M. A.
(1987). Couples at risk for transmission of alcoholism:
Protective influences. Family Process, 26, 111-129.
Berland, G. K., Elliott, M. N., Morales, L. S., Algazy, J. I.,
Kravitz, R. L., Broder, M. S., et al. (2001). Health infor-
mation on the Internet: Accessibility, quality, and readability
in English and Spanish. Journal American Medical
Association, 285, 2612-2621.
Bigbee, J., & Jansa, N. (1991). Strategies for promoting health
protection. Nursing Clinics of North America, 26, 895-913.
Borzekowski, D. L. G., & Rickett, V. I. (2001). Adolescent
cybersurfing for health information: A new resource that
crosses barriers. Archives of Pediatric and Adolescent
Medicine, 155, 813-17.
Campaign for Tobacco-Free Kids, American Cancer Society,
American Heart Association, & American Lung Association.
(2002, January 15). Show us the money: An update on the
states’ allocation of the tobacco settlement dollars. Retrieved
October 11, 2002, from http://www.tobaccofreekids.org/
reports/settlements/
Campbell, J., Jones, A. S., Dienemann, J., Kub, J.,
Schollenberger, J. O’Campo, P., et al. (2002). Intimate
partner violence and physical health consequences.
Archives of Internal Medicine. 62, 1157-1164.
Carter, B., & McGoldrick, M. (1999). The expanded family life
cycle: Individual, family and social perspectives (3rd ed.).
Boston: Allyn and Bacon.
Ceballo, R., Dahl, T. A., Aretakis, M. T., & Ramirez, C. (2001).
Inner-city children’s exposure to community violence:
How much do parents know? Journal of Marriage and
Family, 63, 927-940.
Centers for Disease Control and Prevention. (2002, June 28).
Youth risk behavior surveillance—United States, 2001
[Electronic version]. Morbidity and Mortality Weekly
Report, 51(SS04), 1-64. Retrieved October 11, 2002, from
families is a middle and upper socioeconomic
class phenomenon because of its relationship
to time, money, and access to health care.
How can principles of health protection and
promotion be made available to families of
lower socioeconomic status?
http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5104a1.
html
Centers for Disease Control and Prevention. (2002, May).
Trends in cigarette smoking among high school students—
United States, 1991-2001 [Electronic version]. Morbidity
and Mortality Weekly Report, 51(19). Retrieved October
11, 2002, from http://www.cdc.gov/tobacco/research_data/
youth/mmwr5119.highlights.html
Centers for Disease Control and Prevention. (2002). The
burden of chronic disease and their risk factors: National
and state perspectives. Retrieved October 11, 2002, from
http://www.cdc.gov/nccdphp/burdenbook2002/index.html
Centers for Disease Control and Prevention. (n.d.). Injury
fact book, 2001-2002. Retrieved October 11, 2002, from
http://cdc.gov/ncipa/fact_book/factbook.html
Coffield, A. B., Maciosek, M. V., McGinnis, J. M., Harris, J. R.,
Caldwell, M. B., Teutsch, S. M., et al. (2001). Priorities
among recommended clinical preventive services.
American Journal of Preventive Medicine, 21, 1-9.
Committee on Injury and Poison Prevention, American
Academy of Pediatrics. (2000). Firearm-related injuries
affecting the pediatric population. Pediatrics, 105, 888-895.
Committee on Substance Abuse, American Academy of
Pediatrics. (2001). Alcohol use and abuse: A pediatric
concern. Pediatrics, 108, 185-189.
Compan, E., Moreno, J., Ruiz, M. T., & Pascual, E. (2002).
Doing things together: Adolescent health and family
rituals. Journal of Epidemiology and Community Health, 56,
89-95.
D’Alessandro, D. M., & Dosa, N. P. (2001). Empowering
children and families with information technology. Archives
of Pediatric and Adolescent Medicine, 155, 1131-1136.
D’Alessandro, D. M., Kingsley, P., & Johnson-West, J. (2001).
The readability of pediatric patient education materials on
the World Wide Web. Archives of Pediatric and Adolescent
Medicine, 155, 807-812.
Denham, S. A. (1999). Part I: The definition and practice of
family health. Journal of Family Nursing, 5, 133-160.
Denham, S. A. (2003). Family health: A framework for nursing.
Philadelphia: Davis.
DiClemente R. J., Wingood G. M., Crosby R., Sionean C.,
Cobb B. K., Harrington K., et al. (2001). Parental
monitoring: Association with adolescents’ risk behaviors.
Pediatrics, 107, 1363-1368.
W0115-12.qxd 9/30/03 2:20 PM Page 333
Elders, M. J., Perry, C. L., Eriksen, M. P., & Giorano, G. A.
(1994). The report of the Surgeon General: Preventing
tobacco use among young people. American Journal of
Public Health, 84, 543-547.
Fallon, B. J., & Bowles, T. P. V. (2001). Family functioning and
adolescent help-seeking behavior. Family Relations, 50,
239-245.
Farah, M. M., Simon, H. K., & Kellermann, A. L. (1999).
Firearms in the home: Parental perceptions. Pediatrics,
104, 1059-1063.
Feeley, N., & Gottlieb, L. N. (2000). Nursing approaches for
working with family strengths and resources. Journal of
Family Nursing, 6, 9-24.
Fiese, B. H. (2000). Family routines, rituals, and asthma
management: A proposal for family-based strategies.
Families, Systems, and Health: The Journal of Collaborative
Family Healthcare, 18, 405-418.
Ford-Gilboe, M. (1997). Family strengths, motivation, and
resources as predictors of health promotion behavior in
single- and two-parent families. Research in Nursing and
Health, 20, 205-217.
Friedman, M. M, Bowen, V. R., & Jones, E .G. (2003). Family
nursing: Research, theory, and practice (5th ed.). Upper
Saddle River, NJ: Prentice Hall.
Gaffney, K. F. (2001). Infant exposure to environmental
tobacco smoke. Journal of Nursing Scholarship, 33, 343-347.
Gershoff, E. T. (2002). Corporal punishment by parents and
associated child behaviors and experiences: A meta-
analytic and theoretical review. Psychological Bulletin, 128,
534-579.
Gielen, A. C., McDonald, E. M., Wilson, M. E. H., Hwang, W.,
Serwint, J. R., Andrews, J. S., et al. (2002). Effects of
improved access to safety counseling, products, and home
visits on parents’ safety practices: Results of a randomized
trial. Archives of Pediatric and Adolescent Medicine, 156,
33-41.
Gielen, A. C., O’Campo, P. J., Campbell, J. C., Schollenberger, J.,
Woods, A. B., Jones, et al. (2000). Women’s opinions about
domestic violence screening and mandatory reporting.
American Journal of Preventive Medicine, 19, 279-285.
Grant, B. F. (2000). Estimates of US children exposed to
alcohol abuse and dependence in the family. American
Journal of Public Health, 90, 112-115.
Harris, D. M., & Guten S. (1979). Health protective behavior:
An exploratory study. Journal of Health and Social Behavior,
20, 17-29.
Health Canada. (2000). Leading causes of deaths and
hospitalizations, 2000. Population and Public Health
Branch. Retrieved October 11, 2002, from http://www.hc-
sc.gc.ca/hpb/lcdc/publicat/pcd97/index.html
Hughes, M. E., & Waite, L. J. (2002). Health in household
context: Living arrangements and health in late middle
age. Journal of Health and Social Behavior, 43, 1-21.
Humphreys, J. C. (2001a). Turnings and adaptations in
resilient daughters of battered women. Journal of Nursing
Scholarship, 33, 245-251.
Humphreys, J. C. (2001b). Growing up in a violent home:
The lived experience of daughters of battered women.
Journal of Family Nursing, 7, 244-260.
Hunt, K., Davison, C., Emslie C., & Ford G. (2000). Are
perceptions of a family history of heart disease related to
Chapter 12 Family Health Protection
333
health-related attitudes and behavior? Health Education
Research, 15, 131-143.
Hunt, K., Emslie, C., & Watt, G. (2001). Lay constructions
of a family history of heart disease: Potential for misunder-
standings in the clinical encounter? Lancet, 357, 1168-1171.
Institute of Medicine. (2002). Is soccer bad for children’s heads?
Summary of the IOM Workshop on Neuropsychological Con-
sequences of Head Impact in Youth Soccer. Washington, DC:
National Academy Press.
Jackman, G. A., Farah, M. M., Kellermann, A. L., & Simon, H.
K. (2001). Seeing is believing: What do boys do when they
find a real gun. Pediatrics, 107, 1247-1250.
Jain, A., Sherman, S. N., Chamberlin, L. A., Carter, Y.,
Powers, S. W., & Whitaker, R. (2001). Why don’t low-
income mothers worry about their preschoolers being
overweight? Pediatrics, 107, 1138-1146.
Johnson, K., Davy, L., Boyett, T., Weathers, L., & Roetzheim, R.
(2001). Sun protection practices for children: Knowledge,
attitudes, and parent behaviors. Archives of Pediatric and
Adolescent Medicine, 155, 891-896.
Kaler, M., & Ravella, P.C. (2002). Staying on the ethical high
ground with complementary and alternative medicine.
Nurse Practitioner 27, 38-42.
Kegler, M. C., McCormick, L., Crawford, M., Allen, P.,
Spigner, C., & Ureda, J. (2002). An exploration of family
influences on smoking among ethnically diverse adoles-
cents. Health Education and Behavior, 29, 473-490.
Keltner, B. R. (1992). Family influences on child health status.
Pediatric Nursing, 18, 128-131.
Kulbok, P., & Baldwin, J. H. (1992). From preventive health
behavior to health promotion: Advancing a positive con-
struct of health. Advances in Nursing Science, 14, 50-64.
Kulbok, P. A., Baldwin, J. H., Cox, C. L., & Duffy, R. (1997).
Advancing discourse on health promotion: Beyond main-
stream thinking. Advances in Nursing Science, 20, 12-20.
Lane, W. G., Liu, G. C., & Newlin, E. (2000). The association
between hands-on instruction and proper child safety seat
installation. Pediatrics, 106, 924-929.
Langford, D. R. (1998). Social chaos and danger as context
of battered women’s lives. Journal of Family Nursing, 4,
167-182.
Lantz, P. M., Jacobson, P. D., Warner, K. E., Wasserman, J.,
Pollack, H. A., Berson, J., et al. (2000). Investing in youth
tobacco control: A review of smoking prevention and
control strategies. Tobacco Control, 9, 47-63.
Lavoie, F., Herbert, M., Tremblay, R., Vitaro, F. Vezina, L., &
McDuff, P. (2002). History of family dysfunction and
perpetration of dating violence by adolescent boys:
A longitudinal study. Journal of Adolescent Health, 30,
375-383.
Lehr, S. T., DiIorio, C., Dudley, W. N., & Lipana, J. A. (2000).
The relationship between parent-adolescent communi-
cation and safer sex behaviors in college students. Journal
of Family Nursing, 6, 180-196.
Liaschenko, J. (2002). Health promotion, moral harm, and the
moral aims of nursing. In L. E. Young & V. Hayes (Eds.),
Transforming health promotion practice: Concepts, issues and
application (pp. 136-147). Philadelphia: F. A. Davis.
Loveland-Cherry, C. J. (2000). Family interventions to prevent
substance abuse: Children and adolescents. Annual Review
of Nursing Research, 18, 195-218.
W0115-12.qxd 9/30/03 2:20 PM Page 334
334
III Family Nursing Practice
Maney, D. W., Higham-Gardill, D. A., & Mahoney, B. S. (2002).
The alcohol-related psychosocial and behavioral risks of a
nationally representative sample of adolescents. Journal of
School Health, 72, 157-163.
Mantle, F. (2002). Complementary therapies and health
promotion. British Journal of Community Nursing, 7, 102-
107.
Martin, S. G. (2002). Children exposed to domestic violence:
Psychological considerations for health care practitioners.
Holistic Nursing Practice, 6, 7-9.
Mayhew, M. (1991). Strategies for promoting safety and
preventing injury. Nursing Clinics of North America, 26,
885-893.
McNeely, C., Shew, M. L., Beuhring, T., Sieving, R., Miller, B. C.,
& Blum R. W. (2002). Mothers’ influence on the timing of
first sex among 14- and 15-year-olds. Journal of Adolescent
Health, 31, 256-265.
Mellin, A. E., Neumark-Sztainer, D., Story, M., Ireland, M., &
Resnick, M. D. (2002). Unhealthy behaviors and psycho-
social difficulties among overweight adolescents: The
potential impact of familial factors. Journal of Adolescent
Health, 31, 145-153.
Messecar, D. C., Archbold, P. G., Stewart, B. J., & Kirschling, J.
(2002). Home environmental modification strategies used
by caregivers of elderly. Research in Nursing and Health, 25,
357-370.
Miller, K. E., Sabo, D. F., Farrell, M. P., Barnes, G. M., &
Melnick, M. J. (1998). Athletic participation and sexual
behavior in adolescents: The different worlds of boys and
girls. Journal Health and Social Behavior, 39, 108-123.
Mitchell, K. J., Finkelhor, D., & Wolak, J. (2001). Risk factors
for and impact of online sexual solicitation of youth. Journal
of the American Medical Association, 285, 3011-3014.
Murray, R., & Huelskoetter, M. M. (1991). Psychiatric mental
health nursing: Giving emotional care (3rd ed.). Norwalk,
CT: Appleton Lange.
National Center for Complementary and Alternative
Medicine (NCCAM), National Institutes of Health. (2002,
September 20). What is complementary and alternate
medicine (CAM). Retrieved October 11, 2002, from
http://nccam.nih.gov/health/whatiscam
National Center for Health Statistics. (2001, October 12).
Deaths: Leading causes for 1999. Retrieved October 11,
2002, from http://www.cdc.gov/nchs/data/nvsr/nvsr49/
nvsr49_11.pdf
Naumann, P. A., Langford, D. R., Torres, S., Campbell, J. C.,
& Glass, N. (1999). Woman battering in primary care
practice. Family Practice: An International Journal, 16,
343-352.
Pender, N. J., Murdaugh C. L., & Parsons M. A. (2002).
Health promotion in nursing practice (4th ed.). Upper Saddle
River, NJ: Prentice Hall.
PEW Internet Project. (2002, May 22). Vital decisions: How
Internet users decide what information to trust when they or
their loved ones are sick. Retrieved October 11, 2002, from
http://www.pewinternet.org/reports/toc.asp?Report=59
Pinderhughes, E. E., Nix, R., Foster, E. M., & Jones, D. (2001).
Parenting in context: Impact of neighborhood poverty,
residential stability, public services, social networks, and
danger on parental behaviors. Journal of Marriage and
Family, 63, 941-953.
Ponder, M., Lee J., Green J., & Richards M. (1996). Family
history and perceived vulnerability to some common
diseases: A study of young people and their parents.
Journal of Medical Genetics, 33, 485-492.
Romero, A. J., Robinson, T. N., Kraemer, H. C., Erickson, S. J.,
Haydel, K. F., Mendoza, F., et al. (2001). Are perceived
neighborhood hazards a barrier to physical activity in
children? Archives of Pediatric and Adolescent Medicine,
155, 1143-1148.
Rose, L. E., Campbell, J., & Kub, J. (2000). The role of social
support and family relationships in women’s responses to
battering. Health Care for Women International, 21, 27-39.
Ruffing-Rahal, M. A. (1991). Rationale and design for health
promotion with older adults. Public Health Nursing, 8,
258-263.
Sargent, J. D., & Dalton, M. (2001). Does parental disapproval
of smoking prevent adolescents from becoming established
smokers? Pediatrics, 108, 1256-1262.
Schuster, M. A., Franke, T. M., Bastian, A. M., Sor, S., &
Halfon, N. (2000). Firearm storage patterns in U.S.
homes with children, American Journal of Public Health,
90, 588-594.
Smith, C. A. (1999). Family life pathfinders on the new
electronic frontier. Family Relations, 48, 31-34.
Spector, R. E. (2000). Cultural diversity in health and illness
(5th ed.). Upper Saddle River, NJ: Prentice Hall.
Stahl, C., & Fritz, N. (2002). Internet safety: Adolescents’
self-report. Journal of Adolescent Health, 31, 7-10.
Swanson, J. R., & Pearson, T. A. (2001). Screening family
members at high risk for coronary disease: Why isn’t it
done? American Journal of Preventive Medicine, 20, 50-55.
Task Force on College Drinking. (2002, April). A call to action:
Changing the culture of drinking at U.S. colleges. Retrieved
October 11, 2002, from http://www.collegedrinking prevention.
gov/Reports/#task
U. S. Department of Commerce. (2000, October). Falling
through the Net: Toward digital inclusion. Retrieved October
11, 2002, from http://www.ntia.doc.gov/ntiahome/fttn00/
contents00.html
U. S. Department of Health and Human Services, Office of
Disease Prevention and Health Promotion. (n.d.).
Healthy People 2010. Retrieved October 11, 2002, from
http://www.health.gov/healthypeople/document/
U. S. Preventive Services Task Force. (n.d.). Preventive care
guidelines—adult, children. Retrieved September 10, 2002,
from the Agency for Healthcare Research and Quality
website, http://www.ahrq.gov/clinic/ppipix.htm#tools
Vessey, J. A., & Rechkemoner, A. (2001). Natural approaches
to children’s health. Pediatric Nursing, 27, 61-64.
Williamson, D. L., & Drummond, J. (2000). Enhancing low-
income parent’ capacities to promote their children’s
health: Education is not enough. Public Health Nursing,
17, 121-131.
Winkelstein, M. (1992). Adolescent smoking: Influential
factors, past preventive efforts, and future nursing impli-
cations. Journal of Pediatric Nursing, 7, 120-127.
Wright, L. M., & Leahy, M. (2000). Nurses and families:
A guide to family assessment and intervention (3rd ed.).
Philadelphia: F. A. Davis.
W0115-Appendix 12-1.qxd 9/30/03 2:20 PM Page 335

Chapter 12 Family Health Protection
335

APPENDIX 12-1 Family Health Protective Behaviors

The nurse should indicate for each item whether the family member accomplishes the item according to criteria indicated in
the columns. If an item or section does not apply, the points represented by that item should be so indicated by marking the
“not applicable” column. In scoring at the end of each section, the category “total points possible” means the total number of
points that could be attained if every item applied. The “total not applicable” category shows the total points for items or
sections that do not apply to the family at this time; this number should be subtracted from the “total points possible” to
obtain the “total applicable” score. When comparing “total applicable” with the “total points attained,” the nurse and family
can see the numerical difference in what should or could be achieved and what does exist at the present time.

Yes No Not
(2 pts) (0 pts) Applicable
I. Family Health Protective Behaviors
A. The Expectant Family
1. Expectant mother receives adequate
prenatal care
2. Adequate nutritional intake maintained
throughout pregnancy
3. Expectant mother abstains from alcohol,
drug, or tobacco use throughout
pregnancy
4. Expectant mother avoids environmental
hazards during pregnancy
Total points possible 8
Total not applicable
Total applicable
Total points attained
B. Families with Infants
1. Infant screened for inherited metabolic
disorders
2. Ongoing health supervision arranged
for immunizations and growth and
developmental assessment
3. Parents actively seek information related
to infant care skills, normal growth and
development, and parenting
Total points possible 6
Total not applicable
Total applicable
Total points attained
C. Families with Preschool Children
1. Parents are aware of accident hazards
2. Parents are aware of symptoms and
management of common childhood
illnesses
3. Parents provide for and encourage:
a. Good nutrition
b. Adequate sleep
c. Adequate exercise
d. Dental health practices

Adapted from Kandzari, J.H., and Howard, H.R. (1981). The Well Family: A Developmental Approach to
Assessment. Boston: Little, Brown. Adapted with permission.
W0115-Appendix 12-1.qxd 9/30/03 2:20 PM Page 336

336
III Family Nursing Practice

4. Parents provide for ongoing health

supervision
5. Immunizations completed prior to school
entry
6. Vision and hearing screening prior to school
entry
7. Preschool facility provides healthy environment
a. Proper light
b. Adequate heating
and cooling
c. Free of accident hazards
d. Ample room for vigorous physical activity
8. Preschool caregiver has philosophy congruent
with that of family
9. Preschool program promotes physical health,
proper nutrition, and cognitive and social skill
development
Total points possible 30
Total not applicable
Total applicable
Total points attained
D. Families with School-Age Children
1. Family teaches safety and accident prevention
2. Child demonstrates safe behaviors in play and
daily activities
3. Child demonstrates increasing responsibility
for self-care
4. Family provides for and encourages preventive
dental care
5. School has comprehensive health program
a. Routine vision/hearing screening
b. Health education
6. School sports programs promote mental and
physical wellness
7. Working parents provide appropriate
after-school supervision of child
8. Parents monitor and limit television viewing
by children
9. Family effectively deals with everyday stress
Total points possible 20
Total not applicable
Total applicable
Total points attained
E. Families with Adolescents
1. Adolescent assumes nearly total responsibility
for self-care
2. Adolescent is actively involved in physical
fitness program
3. Dietary patterns adequately meet the nutritional
needs of the adolescent
4. Adolescent is aware of the health hazards related
to drug, alcohol, and tobacco use
5. Family members are aware of the early signs
of drug abuse among children or adolescents
6. Family members discuss aspects of responsible
sexual behavior
7. Adolescent receives accurate information about
contraceptive methods and where to obtain them
8. Adolescent demonstrates effective problem-
solving skills
W0115-Appendix 12-1.qxd 9/30/03 2:20 PM Page 337

Chapter 12 Family Health Protection
337

9. Adolescent completes drivers education course

Total points possible 20
Total not applicable
Total applicable
Total points attained
F. Families with Young Adults
1. Young adult assumes total responsibility for
self-care
2. Reviews and updates immunization status
3. If female:
a. Performs regular BSE
b. Obtains Pap smear as indicated
4. If male, performs regular examination of
the testes
5. Engages in responsible,“safe” sexual
practices
6. Refrains from alcohol, drug, and tobacco use
7. Obtains and records baseline blood pressure
8. Develops effective decision-making skills for
career, marriage, and parenthood
Total points possible 18
Total not applicable
Total applicable
Total points attained
G. Families with Middle-Aged Adults
1. Performs monthly breast or testicular self-
examination
2. Obtains routine Pap smear
3. Obtains mammogram as indicated
4. Obtains screening for occult blood
5. Performs visual inspections of body monthly
for lumps and changes in moles
6. Refrains from alcohol, drug, or tobacco use
7. Obtains screening for diabetes
8. Obtains screening for hypertension
9. Obtains screening for glaucoma
10. Modifies nutrition practices as necessary
according to caloric needs
11. Maintains physical exercise program
12. Identifies normal changes due to aging and
adapts accordingly
Total points possible 24
Total not applicable
Total applicable
Total points attained
H. Families with Older Adults
1. Maintains good oral hygiene practices
2. Plans for expected stressful situations such
as retirement or relocation
3. Family aware of potential accident hazards due
to sensory and mobility changes
4. Maintains good nutritional practices
5. Practices safe use of medications
6. Obtains recommended immunizations
7. Obtains physical examinations
as necessary
8. Performs self-screening for cancer
9. Maintains physical exercise program
10. Obtains screening for diabetes
W0115-Appendix 12-1.qxd 9/30/03 2:20 PM Page 338

338
III Family Nursing Practice

11. Obtains screening for glaucoma

12. Identifies normal changes due to aging and
adapts accordingly
Total points possible 26
Total not applicable
Total applicable
Total points attained
I. Families Self-Care
1. Family maintains appropriate medical
equipment and supplies in the home
2. Family members demonstrate knowledge of
proper use of equipment and supplies
3. Family members state signs and symptoms
of physical conditions that warrant medical
attention
4. Family evaluates the credentials of health
care providers
5. Family considers personal characteristics and
wellness attitude when choosing health
professional
6. Family seeks information on health services
and reasonable costs
7. Family effectively utilizes available self-care
resources in the community
Total points possible 14
Total not applicable
Total applicable
Total points attained

Assessment Tool Summary

Subtotal Subtotal Subtotal
points not Subtotal points
possible applicable applicable attained
I. Family Health Protective Behaviors
A. The Expectant Family 8

B. Families with Infants 6

C. Families with Preschool Children 30

D. Families with School-Age Children 20

E. Families with Adolescents 20

F. Families with Young Adults 18

G. Families with Middle-Aged Adults 24

H. Families with Older Adults 26

I. Family Self-Care 14

Total points possible 166

Total not applicable
Total applicable
Total points attained