The health-promoting family: a conceptual framework for future research

Social Science & Medicine 59 (2004) 377–387

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doi:10.1016/j.so

The health-promoting family: a conceptual framework forfuture research

Dr. Pia Christensen*

The National Institute of Public Health, Svanem^llevej 25, 2100 Copenhagen Ø, Denmark

Abstract

There has so far only been little research attention given to how families actively engage in promoting their health in

everyday life. In this paper a theoretical framework is proposed for studies of the ‘health-promoting family’ with

particular focus on children’s health and well-being. This paper sets out a conceptual model for understanding how the

family can play a part in promoting both the health of children and children’s capacities as health-promoting actors. It

draws on contemporary social science approaches to health, the family and children, suggesting a new emphasis on the

family’s ecocultural pathway, family practices and the child as a health-promoting actor.

r 2003 Elsevier Ltd. All rights reserved.

Keywords: Family health; Child health; Health promotion; Health-promoting family

Introduction

This paper addresses what has remained a somewhat

neglected area: how, in their everyday life, families

engage in promoting the health of their members

(Sindal, 1997). To date only a small amount of research

has been directly concerned with how family members

(including children) actively engage in promoting,

developing and sustaining their health (Hogg, Barker,

& McGuire, 1996). My aim is to present a theoretical

model for future studies of the ‘health-promoting family’

with particular focus on children’s health and well-

being. This paper will be restricted to discussion of the

main theoretical components for such a model, thus

identifying a framework within which future methodo-

logical and empirical work can be located.

The health-promoting family

The model (see Fig. 1) is analytically divided into two

parts in order to distinguish factors external to the

family and factors internal to it. The external factors are

920-7777x226; fax: +45-392-08010.

ess: [email protected] (P. Christensen).

e front matter r 2003 Elsevier Ltd. All rights reserve

cscimed.2003.10.021

further divided into societal and community level

factors. The societal factors provide the material base

for the family and will therefore to a large degree shape

the resources available to the family. These include, for

example, income and wealth, education and knowledge,

family structure and housing, ethnicity, social networks

and time. The community level is the configuration of

social spheres that contribute to child health. These

include the consumer society, the local community,

schools, the health services, the mass media, peer groups

and day care institutions.

The components of the model central to the concep-

tion of the family and the processes that may be thought

of as going on ‘inside’ it are indicated with a semi-

permeable boundary—a broken circle line. These are

linked to and influenced by the processes and factors

‘outside’ the family. The internal level has the ‘family

ecocultural pathway’ and ‘family health practices’ as the

main elements in shaping the processes from and

through which both individual and collective patterns

of health action, practice and forms of knowledge of

health are produced. An important feature of the model

is that it will allow differences between families to be

revealed by identifying the conditions for a family to act

in an optimal way for health. It also highlights the

obstacles for families in promoting the health and

d.

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Fig. 1. Model of the health-promoting family.

P. Christensen / Social Science & Medicine 59 (2004) 377–387378

well-being of children and the barriers to enabling the

child’s development as a health-promoting actor during

their growing up.

At the centre of the model, and a primary concern of

research, are the health practices of the family. By this is

meant all those activities of everyday life that shape and

influence the health of family members. These include

the traditional health practices around food and healthy

eating, physical activity, alcohol and smoking, care and

connection, and in addition other key factors that can be

shown to affect young people’s health and well-being.

WHO (2001) suggested five factors important to young

people’s health. These include: meaningful relationships

with adults and peers; parental structure and boundaries

for behaviours; encouragement of self-expression; op-

portunities for participation with their contributions

being valued; educational, economic and social oppor-

tunities and minimal risk of injury, exploitation, or

disease. Childhood research supports these findings

whilst stressing children’s own experiences, perspectives

and actions. For example, Christensen (1998) suggests

that children wish for families in which they have

opportunities to participate in everyday life, and in

which they feel that they are able to contribute

to and manage their own health and well being, as well

as that of other family members. De Winther, Baerveldt,

and Kooistra (1999) have argued that ‘child participa-

tion’ needs to be linked with ‘enablement’. They argue

for the importance of gaining meaningful social

experiences (e.g. at school and in their neighbourhood)

for children to develop the self-respect and social

competence that allows them to work better for their

own health and well-being. Important work by Burton

(Skinner, Burton, & Manlove, 2000) points out the value

of ‘mattering’ for children, the experience that they

matter to other people, and Christensen (2002) has

highlighted the importance of ‘someone being there for

you’ for children and young people in their relationships

with parents and friends. Work on children and risk (for

example, Green, 1997) suggests putting an emphasis on

‘risk management’ as well as risk behaviour, acknowl-

edging how children and young people (including their

families) actively balance and handle different risks in

their everyday life.

The model suggested in this paper focuses on the

health of children. It suggests two main outcomes of the

health-promoting practices of families: the health status

of children (as measured, for example, by morbidity

rates); and the child as a health-promoting actor. Whilst

child health status is a traditional outcome measure of

health research, the idea of the child as a health-

promoting actor is new. The model suggests that the

ARTICLE IN PRESSP. Christensen / Social Science & Medicine 59 (2004) 377–387 379

degree to which children act in ways that promote (or

demote) their own health is an important aspect of

family life. It suggests that children should be seen as

actors in their own right and that research should ask

how children become involved in and, indeed, pro-active

in health practices during growing up.

This is currently work in progress and for the scope of

this paper only the main elements of the child as a

health-promoting actor are indicated here. For the child

to develop independent agency in relation to their own

(and others) health and well-being the key aspects

suggested are: self care (physically, emotionally and

socially), personal care and hygiene, keeping fit and

active (physically and mentally), developing and main-

taining connections (including relations of care, respon-

sibility and obligation) with parents and peers,

balancing and managing everyday risks, developing

knowledge and health-related skills and competencies,

developing positive values and meaningful goals for own

health, well being and health behaviours, and the ability

to consult and use health care services.

The ecocultural pathway

The model suggests a way of looking at family health

practices within the broad range of activities that

families engage in. This part of the model is referred

to as ‘the family ecocultural pathway’. This concept is

drawn from Weisner and his colleagues and is a method

of conceptualising the ways in which families engage

with and utilise the resources at their disposal (see, for

example, Weisner, 1998, 1996; Gallimore, Weisner,

Kaufman, & Bernheimer, 1989). The ecocultural ap-

proach suggests that families have their own goals and

values that they pursue through their daily routines.

Through daily practices and activities they may be more

or less successful in meeting their goals. These goals may

or may not include health or may balance health against

other goals. However the daily routines followed by

families have implications for the health of each family

member. Some families will follow routines that to a

greater extent than other families will support their

health and well being. This ecocultural approach is an

important step forward in looking at family health.

Instead of being concerned to link health to different

types of family (e.g. one or two parent families), it rather

concentrates on what families actually do in their

everyday life—their practices. The ecocultural pathway

includes all the family goals, values and practices and

thus forms the broad milieu within which health

practices take place. Health-related practices are there-

fore only a part of the picture and have to be understood

in this broader context. Families have to balance the

individual and shared goals and needs of family

members with health and well being, and integrate these

in the overall goals of the family. For example, the

business of earning a living may influence diet or

exercise.

Influences on the family

Of course families in different socio-economic situa-

tions have very different resources at their disposal and

this may also result in different ecocultural pathways.

To a large degree socio-economic position may shape

the resources available to the family, including, for

example, income and wealth, education and knowledge,

social networks, time, and emotional energy. Thus

factors such as occupation and whether the family has

one or two working parents are important in determin-

ing the level of resources available. However, it is also

crucial to look at how the family makes use of the

resources available to them and how this forms part of

their cultural pathway to health. Different families

construct their ecocultural pathway in different ways,

even though their socio-economic situation may be

similar. It is important therefore to look at both the

resources available to families and how families handle

these resources—that is how they construct their

ecocultural pathway. This ecocultural pathway thus acts

as a mediator between family health practice and the

socio-economic position of the family. Another factor

that shapes family health practices is their history across

generations. A child’s health status is also determined by

the child and family history of health and illness and

genetic dispositions of the parents. The model therefore

also draws attention to the importance of investigating

the family history of health practices, for example family

eating patterns, involvement in physical activity, atti-

tudes to health services and so on. Finally, there is a host

of community spheres that influence and shape chil-

dren’s health. These include the consumer society, the

local community, schools, the health services, the mass

media, peer groups and day care institutions. These

enter into family life in two ways. Sometimes they are

mediated through parents but in contemporary society

children also have independent access to such spheres.

These may be important also in their peer relationships.

Overall then this model sets out a way of looking at

the family as a health-promoting environment. In the

following section I will further develop its theoretical

underpinnings.

Health promotion and the family

I take as my starting point the problem identified in

more recent studies of child health. This is the tendency

of conventional approaches to child health to focus on

negative rather than positive factors and outcomes for

children and young people’s health and well-being. De

ARTICLE IN PRESSP. Christensen / Social Science & Medicine 59 (2004) 377–387380

Winther (1997) argues that concerns about the well-

being of children over time have given prominence to

explanations of causality on an individual rather than on

a societal level. This is coupled with seeking to identify

health-damaging effects and negative outcomes for

children rather than identifying those factors that

promote their health or reduce the risk of negative

outcomes. A number of researchers have made similar

calls for the need to uncover positive indicators of child

well-being and place these alongside the medical and

epidemiological questions about child health outcomes.

Ben-Arieh and Wintersberger (1997) and Zubrick,

Silburn, Vimpani, and Williams (1999), for example

argue for the importance of an ecological perspective

that take into account factors operating within the

family household and the neighbourhood as well as

those operating on a broader societal level. In relation to

this debate Barnes (2001) argues that research needs to

develop indicators that relate to children’s well-being in

the present. This in turn will allow children’s own

subjective experiences of well-being to be reflected in the

development and shaping of the concepts that are used

to measure their well-being.

This issue is salient to the broader debate within

health promotion about whether health should be

defined negatively or positively. An important distinction

has to be drawn between disease prevention and health

promotion (Breslow, 1999). Health debates have been

marked by both of these dimensions, especially in relation

to the WHO’s broad definition of health (WHO, 1986).

Over the years this definition has been marked by a pull

and push effect that has taken various forms and reflected

different interests. The importance of a positive approach

to health is now generally recognised and it is given a

prominent position in current thinking. Breslow (1999)

has very importantly suggested the need to pay particular

attention to the Ottawa Charter’s explicit definition of

health as a resource for everyday life, and consequently

the need to shift the focus of health-promoting strategies

to ‘capacity building for health’ He argues:

To reach the full potential of living, it is becoming

clear the specific capacities must be developed and

maintained. This is clearly beyond disease prevention

and illustrates the importance of considering the

nature of health promotion (Breslow, 1999, p. 1031).

The notion of ‘the health-promoting family’ can be

usefully understood within Breslow’s advocacy of the

idea of ‘capacity building for health’. Whilst parents are

not the only ones involved in building children’s

capacity for health, they are nevertheless key mediators

in the process. In understanding the health-promoting

family it will, therefore, be important to identify the

factors that act as key resources in child health. This

involves looking at the health-related practices of

parents as they are embedded in their everyday life. It

also involves working through how children engage in

their own health and well-being, how they develop the

skills that enable them to do so, and how children

contribute to the health and well-being of their family

and others to whom they socially relate. Taken together

this approach would explore the environment in which

children live, looking at the base it forms for their health

choices and also, perhaps, how it may be improved and

changed (cf. Kickbusch, 2002), to take into account

children’s perspectives and active participation in their

own and their family’s health.

The family

The family and family life has long been recognised as

a complex historical, social and cultural phenomenon.

As a context defining a multiple set of everyday living

arrangements and different ways of organising personal

intimate relationships, the trend in family studies has

been away from the use of the family as a generic term

towards more fluid conceptualisations of the family (e.g.

Holland, Mauthner, & Sharpe, 1996; Carsten, 1998;

Simpson 1998; Cheal, 2002). This is of importance when

considering the family as a health-promoting environ-

ment. In an in-depth study of the nature of, and

processes involved in, the communication of health

messages to and within families Holland, et al. (1996,

p. 83) conclude that:

The family is clearly a complex site for the reception,

transmission and communication of health informa-

tion...individual health beliefs and health-related

behaviour are related to a number of factors related

to family life.

They suggest that these determining factors include

family structure, employment patterns, gender and age

role differences, the stage of parenting, family dynamics

and parenting styles, communication patterns, power

relations and decision-making processes.

Their findings suggest that understandings of the

health-promoting family must work with a concept of

the family that can handle great complexity and

diversity. Recent developments within the sociology of

the family have taken up the challenge both of

representing greater family complexity and employing

wider notions of what the family is. They do this by

focusing more attention on what families actually do

(Cheal, 2002; Silva & Smart, 1997). This can be

contrasted to previous research that has centred mainly

on two approaches: family structure and family func-

tions. The structural approach led to identifying

different ‘types’ of family defined by social positions or

roles. A family structure is typically defined by who the

family members are and by their relationship to each


other, for example in terms of marriage and parenthood

(Cheal, 2002, p. 7). However this approach cannot

account very well for the activities that family members

do together, or for the meanings and results of these

activities. The second approach, by focusing on family

functions, offered a way of looking at the activities that

families do together in order to meet their needs within a

context of assumed mutual responsibility. Within this

approach family functions could be based on externally

observed and defined activities, such as involvement in

food production, distribution and consumption or in the

care of children or elderly family members. However,

this approach tended to stress the positive benefits of

families (that is what people do together and especially

what they do to support each other), but left more or

less unanswered questions about why not all families

function well (ibid).

Recognition of the shortcomings of both the structur-

al and functional approaches to the family signalled an

important step forward for the study of the family: the

move toward studying the interactions and transactions

of family life through the study of family practices

(Morgan, 1996, 1997). The family is no longer to be

conceived of as a static or concrete social unit. The

notion of family practices carries with it a sense of

‘action’ and ‘doing’ rooted in the everyday. In their

everyday character these practices also carry a sense of

regularity and repetition. Family practices are linked to

wider notions of parenthood, kinship and marriage and

the expectations and obligations associated with these.

They link history and biography because practices are

historically constituted and shaped at the same time as

they are woven into and constituted from elements of

individual biographies (Mills, 1959, in Morgan, 1996).

This theoretical approach is a very promising one for

the study of family and child health (1). One especially

useful way of focusing on family practices is provided by

the ‘ecocultural’ view of the family developed by

Weisner and colleagues in USA. This is designed as a

flexible tool for understanding a wide range of different

family circumstances in different social and cultural

settings. At its heart is a concern with everyday routines:

‘Cultural pathways are made up of everyday routines

of life and routines are made up of cultural activities

(bedtime, playing video games, home work, watching

TV, cooking dinner, etc.). Activities are useful units for

cultural analysis because they are meaningful units for

parents and children to understand, they are amenable

to ethnographic fieldwork, systematic observation and

interviewing methods. They are what children and

adults experience and they crystallize the important

aspects of culture’ (Weisner 2002, p. 276).

The ecocultural approach places a strong emphasis on

how families sustain their everyday routines. It therefore

asks in detail how the resources available to families and

the constraints and opportunities faced by families are

managed and how they contribute to sustainability. It

suggests that three factors are especially important. The

first is termed ‘ecological fit’. It refers to the relationship

of the family to important matters such as earning a

living, neighbourhood safety and transportation, etc. It

recognises the effect that each of these can have on

aiding or disrupting the daily routines of a family and

the goals they are pursuing through them. It draws

particular attention to how families are able to balance

issues of income, neighbourhood, transport etc. with the

effort of sustaining their daily routines. The second

factor is termed ‘meaningfulness’. This refers to the

moral and cultural significance of the daily routines to

the family members. If these ‘make sense’ and are valued

by family members, this helps them to sustain routine

everyday activities. Finally, there is a factor termed

‘congruence’. This refers to the balance between the needs

and goals of family members. If there is congruence then

they will be met not completely but sufficiently. No one

person’s needs will dominate the others (2).

It is notable that this approach to the family is very

compatible with the idea of health as a resource for

living. Health practices are woven into the everyday life

of families as they try and establish sustainable routines.

In the flow of everyday life, health practices may or may

not be separated out as distinct, however, from a

research viewpoint it is necessary to foreground health

practices analytically whilst simultaneously recognising

that they are woven into family routines. This allows for

recognition that, for example, some families may be able

to establish routines that allow for the successful

integration of health practices and goals into their

everyday life. However, health may also come into

conflict with other goals and needs. For example, getting

the material resources needed for the family may disrupt

everyday health practices.

This approach, then, enables a detailed view of the

processes involved in promoting health in families

because it assumes that all families, whatever their

background or circumstances, can be involved in health-

promoting activities. This takes an important step away

from the conventional emphasis on family type and

notions of the ‘problem family’. It allows a focus on the

dynamics and family practices, asking whether they

promote or hinder the development of good health and

well-being in children. This is underscored by a concern

with children’s own part in shaping themselves as

health-promoting actors. It is of course expected that

families with fewer resources (biologically, socially,

culturally and materially) may have the most difficulties

or obstacles in achieving and sustaining health and well-

being for its members. However, the approach taken

allows the health practices of the family to be

analytically separated from the issue of resources (3).

Furthermore, within this approach the notion of the

family ceases to be seen as a bounded unit and is


recognised as constituted not only through sets of

ongoing relations between family members—through

internal connections—but also through connections

external to the family. These are the social relations

that cut across the family and connect its members to

work, school and other social and material settings.

Both adults and children (women and men, boys and

girls) establish such networks of connections. The

importance of connections across these boundaries was

shown in a study of farming families in the UK

(Christensen, Hockey, & James, 1997, 1998). Men and

women drew up the boundaries of family and commu-

nity in different ways. This revealed a complexity

around the relation between self, family and community

that became articulated at times of family crisis such as

the onset of illness. This perspective proved an

important one to understand the ways in which families

provide help and support in case of illness.

Health socialisation and the place of children

During industrialisation (1800–1900) the notion of

child socialisation changed dramatically. Childhood

became constituted through notions of the intimate

and private sphere of the family and ideas about the

importance of children’s learning and nurturing. Mod-

ern childhood was constituted through the formation of

specific social worlds, such as the way motherhood

pivoted around the dyadic relationship between mother

and child during infancy. It also included the separation

of play, school and work and the exclusion of children

from the work force (Alanen, 1988). Childhood became

a quarantine period when particular protective care was

necessary. Since the child was seen as not yet part of

society he/she was on the receiving end of care, learning

and protection. Emergent notions of this new social

world developed into a number of practices and schemes

to monitor child health and well-being, childcare and

Fig. 2. The social settings involved in children’s

training. This involved the development of particular

professional expertises in relation to children, such as in

the emergence of pediatrics (Armstrong, 1983). At the

same time the family became a key social institution in

society with the primary task of undertaking the proper

development and sustenance of both child and parental

health and well-being (Crawford, 1994). This gave

emphasis to the importance of primary socialisation

and the transmission of health knowledge and behaviour

from the mother (or parents) to the child. This

positioned mothers as especially responsible in provid-

ing for the child. At the same time childhood was

characterised by relations of dependency, constituting

children as the more or less passive recipients of care.

In contemporary, post-industrial times socialisation

theories have shifted, stressing the interactive character

of the socialisation process. This constitutes the child as

developing through active engagement with the

health knowledge and actions of adults. The increased

institutionalisation of modern childhood, which has

taken place over the last decades, has led to the

recognition of the school and other day care institutions

as contributing to children’s health and well-being

through the stake that educators and pedagogues have

in the socialisation of children. However, as recent

detailed research has shown, the discrepancies between

health socialisation practices at home and those at

school have important implications for children’s

acquisition of self-care practices (Mayall, 1993, 1996).

What goes on in one context is not necessarily carried

over and built on in the other, and vice versa. More

recently, children’s health has been recognised as a

plural construct, produced at the interface between the

child, family, friendships and peer groups, school, day-

care institution, media (especially TV), the consumer

society, and health care services (see Fig. 2). This

interplay of many different social actors and contexts

creates a health universe of competing values and

standards that renders outmoded the idea of a one-

development as health-promoting actors.


way transmission of health, practices and values. This

underlines the idea that contemporary societies require

children to create meanings for themselves.

Although the family can still be seen as central, when

it comes to health more recent research has emphasised

the pluralistic character of children’s health. As a

consequence the view of children as primarily dependent

in the different contexts of their everyday life such as

that of the family, school and after school institution is

changing (Corsaro, 1997). Recent important work

within health promotion is exploring new directions

for child health practice and policy through adopting the

notion of the social ecology of child health and well-

being. This refers to the nested arrangement of family,

school, neighbourhood and community contexts (Earls

& Carlson, 2001).

Children and young people are growing up in a

society undergoing great change. This has created

environments where they meet with many different and

often contradictory health and life quality values and

practices. Parents cease, therefore, to be regarded as

having the only, or perhaps even the primary, influence

on children’s health and successful development in

youth. Of course parents retain a central role in

providing care and support, and in strengthening and

monitoring children/young people in their growing up.

However, the interactive and pluralistic character of

health means that children have in a larger measure than

before to create meaning for themselves and to develop

their own positive health practices. In this process

parents may now be seen as very important mediators in

children’s health actions rather than being seen as

having the main direct influence upon them.

Shifting perspectives on children and child health

When considering the move towards understanding

the child as an health-promoting actor we are dealing

not only with understanding how children’s socialisation

take place but also with how children are seen.

Traditionally in child health research the perspective

has been to understand the child as an object, that is as a

person acted upon by others and broadly shaped by

influences in its social and material environment, rather

than as a subject acting in the world (Kalnins, McQueen,

Backett, Curtice & Currie, 1992; Christensen, 1998;

Woodhead & Faulkner, 2000). This notion of the child is

still widely persuasive in studies that see child health and

well-being primarily as an outcome of external influ-

ences, including genetic disposition/composition, passive

socialisation and specific structural factors.

This approach emphasises children’s dependency in

their relations with adults and renders them relatively

passive in relation to external influences. The tendency

to neglect children’s own experiences, understandings

and actions, and the failure to see children as social

persons in their own right, has led to an emphasis on

what could be called an ‘‘adultist’’ perspective in child

health research (Ridge, 2002). In the first place, this has

emphasised the key role of adults in children’s health.

Although research has argued for the greater scope in

recognising children’s agency and subjectivity in health,

children are primarily seen as modelling parental

behaviour (Jackson & Henriksen, 1997). Real agency

in health has been delegated to responsible adults and is

closely associated with parental roles. As primary

models for their children, it is mothers’ health status,

beliefs, behaviour and practices that are usually linked

with those of the child. This may be extended to include

other significant adults (such as fathers and teachers)

who through their engagement and care are designated

as active, responsible agents. Adults status, and in

particular the parental child/adult relationship, is seen in

normal circumstances as the guarantor of children’s

health and welfare. Indeed parenting has been identified

as the single largest variable implicated in childhood

illnesses and child accidents. Much important work

investigating the impact of risk factors on children’s

academic and psychological functioning (Rutter, 1979;

Sameroff, Bartko, Baldwin, Baldwin, & Seifer, 1998) has

shown that it is a number of risk factors that best

explains individual differences in children’s develop-

mental outcomes, i.e. it is the cumulative effect rather

than the unique effects of any particular factor.

Second, this ‘adult’ view is reflected in the epidemio-

logical concern with child health as a precursor to the

future general health of the population. Renewed

interest in a life-course perspective on health thus

recognises human health as shaped over time through

genetic factors, family, socio-economic and material

living conditions and personal lifestyles (Barker, 1992;

Ross & Wu, 1995; Power & Hertzman, 1997; Lynch,

Kaplan, & Salonen, 1997). In this vein the health

characteristics of childhood are employed as statistically

predictive of adult health (McCarthy, 2002), just as

paternal living conditions and lifestyle can be shown

statistically predictive of the health of the next genera-

tion. The prenatal period is seen to play an important

role in diseases being clinically detected later in life.

Research findings published during the last decade

suggest the scope for exploring such links in more detail

(Kuh & Ben-Shlomo, 1997; Ben-Shlomo & Kuh 2002;

Berkman & Kawachi, 2000).

However, in this perspective children’s health and

well-being appear primarily as serving the need to

understand the natural course of adult illness better.

Whilst this clearly expresses a legitimate concern with

the future health of children as adults, it draws attention

away from the value of children’s health and well being

for children—as living in the present and in their

transitions from childhood to adulthood. Indeed the

implications of specific factors for children’s health in


the present are met with the argument that these may be

serious in themselves but are even more important as

precursors of problems in adulthood and for the next

generation (see, for example, Hoghughi, 1998; Kolvin,

Muller, Scott, Gatzanis, & Fleeting, 1990).

This problem is reflected in the conventional focus on

young people’s risk-behaviour and is highlighted by the

rather sparse literature on the health, well-being and

health behaviours of middle childhood. This conven-

tional focus neglects children and young people’s

positive health behaviours and fails to recognise them

as a base which could be built upon by health

promotion. The potential for this approach is shown

in Nichter’s (2000) large scale, in-depth study of

American teen-age girls and dieting. She argues that

health promotion needs to support the strategies that the

girls employ for maintaining their health in the present

and suggests that this will be conducive to long term

success. For example, she suggests that the girls’ idea of

‘watching what you eat’ forms a positive counter to the

dieting messages and programmes that dominate the

media.

A third problem flowing from seeing children as

objects rather than subjects is the over-reliance in

research on objective measures of child health. Too

little attention is paid to the processes that lie behind the

statistical associations found. Research evidence shows

that it is necessary to look at children’s own active role

in forming and shaping their lives. For example, Joshi,

Cooksey, Wiggins, McCullock, Verropoulou, and

Clarke (1999) have recently argued that a reliance on

the statistical analysis of longitudinal data is insufficient

for an understanding of why some children do well and

some do badly even when the social and economic

circumstances of their lives are very similar. In their

study Joshi and colleagues wished to quantify the impact

of changing family forms of Britain through investigat-

ing their outcome for children’s development and well-

being. The study used longitudinal data on children aged

5–17 years old. A particular focus was how children

living in families with a single parent compared to

households with two parents. The researchers did find

significant difference on several dimensions of children’s

well-being when they made a crude comparison between

children who lived with both their biological parents and

children living in other family arrangements. However

the relationship between family type, housing and

children’s well being was mediated in complex ways by

levels of human, economic and social capital. For

example, low income was one of the most powerful

associations with children doing badly. But low income

was both a precursor to and a consequence of marital

breakdown (and thus of children not living with both

their biological parents).

Furthermore, the research found great variations

within the same family types. Some children seemed to

be badly affected by family breakdown but many were

not. The researchers concluded that although they did

not wish to argue that divorce was a life event that did

not affect children, they warned against conventional

assumptions that children from broken homes are

necessarily vulnerable or victims. They found that

children’s resilience was an important aspect of how

and why some children did well when others were

observed to be more vulnerable even within the same

family. This was an aspect that could not be explained

by the family type that the child lived in (see also

McMunn, Nazroo, Marmot, Boreham, & Goodman,

2001). This latter point indicates the importance of

exploring in more detail the differences among children

and in particular the influence of their own agency for

maintaining their well-being, including the resources

that children who do well are able to draw upon for their

support through hardship and difficulties.

Such a refocusing will undoubtedly require more

qualitative and ethnographic work allied to quantitative

investigation, resulting in a mixed method approach in

child health. For example, much previous research has

both assumed and emphasised the important role of

parents for children’s health, well-being and behaviour.

It thus reflects the main concerns of developmental

research with investment in children (and their prospec-

tive futures) at home, school and in the community

rather than with how children contribute to their

families and communities through ‘the flows of moral

and material capital between the generations from child

to parents as well as parents to children’ (Weisner,

2001). More recent research, in particular ethnographic

and qualitative work, has, however, helped to illuminate

how a focus on children’s specific contributions can

provide important insights into the dynamics of family-

based health and health care (Christensen, 1998; Back-

ett, 1992a). Such studies have begun to demonstrate that

even early in their lives children actively contribute to

health-promoting activities in the family (Backett,

1992a, b; Backett-Milburn, 2000; Brannen & Storey,

1996; Brannen, Heptinstall, & Bhopal 2000), at school

(Prout, 1988; Mayall, Bendelow, Barker, Storey, &

Veltman, 1999; Christensen, 1993, 2000), in contact with

the health care system (Bluebond-Langner, 1978;

Strong, 1979; Davis, 1982) and through health-promot-

ing activities in their local community (Kalnins et al.,

2002; Wallerstein, 2002; Gibbs, Mann, & Mathers,

2002).

Conclusion: the family and the child as health-promoting

actors

This paper presents a theoretical model for under-

standing the ‘health-promoting family’, which is in-

tended to encourage discussion. As a framework for


further empirical studies the different elements in the

model and the relationships between them can be

explored, tested and modified. The health-promoting

family can ideally be seen as an ecocultural milieu that

works to promote children’s health, well-being and

development and reduces children’s risk behaviour (cf.

WHO, 2001; Weisner, 1998). I suggest the family can

also be seen as a support for the development of the

child as a health-promoting actor. Children’s

health, well-being and agency in health are treated as

the main outcomes of the model. The child as health-

promoting actor is a concept that requires further

definition and exploration including developing ways

to study and measure it. An important part of research

will involve understanding the child’s active participa-

tion in and level of information and skills in making

health choices in a life-course perspective. This process

needs to be placed within both intergenerational (for

example, parent–child relations) and intra-generational

relationships (children’s relationships with their peers).

Through this it should be possible to trace the

conditions and processes that facilitate (or hinder)

children’s health and health-promoting action in their

families.

Notes

1. This approach does not reject looking at family

structure rather it places family structure as part of

the societal context and focuses especially on the

implications of family type for the economic,

material, cultural and social resources available to a

particular family. Governmental policies about the

family, for example, can have a great influence on

how different family forms are seen and the resources

that are available to them.

2. From this point of view the approach in this paper is

sensitive to the gender division of labour highlighted

by feminist health researches. In particular they point

to an asymmetrical division of labour between men

and women in family health care and a high level of

unpaid health work carried out by women (see

Graham, 1984; Lewin and Olesen, 1985; Stacey,

1988; Charles and Kerr, 1988).

3. This approach will allow for Prout’s (1996)

suggestion in a study of family and household

health that class be treated with attention to

divisions within as well as between social class

groupings, to focus also on class trajectories

and its relationship to cultural habitus rather

than more static notions of class position

and to look at health practices in terms of different

cultural capital and their transmission between

generations.

Acknowledgements

I wish to thank Mette Madsen for her engagement,

enthusiasm and helpful comments on earlier drafts of

this paper. I am indebted to Niels Kristian Rasmussen

for his sharp insights and supportive criticism that

helped me to clarify many ideas in developing the

conceptual model. I also wish to thank Alan Prout for

continual support and contribution to refining the final

version of this paper.

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The health-promoting family: a conceptual framework for future research